A prospective, randomized comparison of 3 types of proximal interphalangeal joint arthroplasty.

PURPOSE: For surface replacement arthroplasty in proximal interphalangeal joint osteoarthritis, titanium-polyethylene (TI) and pyrocarbon (PY) implants are frequently used. However, their superiority in comparison to the silicone (SI) spacer has not been established. The purpose of this study was to compare these 3 types of implants with regard to outcome. METHODS: A prospective, randomized, multicenter trial was performed. A total of 43 patients (62 proximal interphalangeal joints) had surgery in the 3 participating centers, and each patient was randomly allocated to one of the 3 groups (TI, PY, SI). Range of motion (ROM) and strength were measured before surgery; pain and disability self-assessment and radiographic analysis were also completed. The same examination protocol was planned for 3 months, 6 months, and 1, 2, and 3 years after surgery, but some follow-up visits did not take place due to patient death or poor compliance. RESULTS: The mean follow-up time at the final follow-up was 35 ± 3 months (range, 30-41 mo). All implant types led to significant pain reduction at rest and at load. Tip pinch strength was slightly improved by all 3 devices at the 3-year follow-up. No significant improvement in ROM for silicone or resurfacing implants was found. However, when comparing the highest ROM values reached after surgery, the resurfacing devices tended to show superior joint motility compared to silicone spacers, albeit only temporarily and not significantly. Sixteen explantations were necessary: 2 of 18 SI (11%), 7 of 26 TI (27%) and 7 of 18 PY (39%) implants had to be removed. An additional 4 secondary surgical procedures were performed in group TI. CONCLUSIONS: Surface replacement arthroplasty devices showed a tendency for a temporarily superior maximum postoperative ROM, but markedly higher postoperative complication and explantation rates were observed compared to the silicone spacer implantation.

[Results after arthroplasty of the metacarpophalangeal joints with uncemented, unconstrained HM prosthesis in rheumatoid patients]. / Ergebnisse nach Arthroplastik der Fingergrundgelenke mittels zementfreier, ungekoppelter HM-Prothese beim Rheumatiker.

PURPOSE: In 80 % of patients with rheumatoid arthritis, the metacarpophalangeal (MP) joints are involved with increasing destruction and loss of function. Silicone arthroplasty of the MP joints leads to a limited range of motion, an increase in osteolysis and fractures of the implants. The cementless, unconstrained design of the HM prosthesis is a new concept for replacing the MP joints of rheumatoid patients. Short-term and midterm results are shown. METHOD AND MATERIAL: In a prospective study, 38 HM prostheses were implanted, 28 in patients with rheumatoid arthritis, four with osteoarthrosis, five with polyarthrosis and one after revision of a silicone implant. The patients were reexamined clinically and radiologically after an average follow-up of 16 months (6 - 37 months). RESULTS: The average active range of motion for extension, flexion increased from 0/15/65 degrees before surgery to 0/9/65 degrees after surgery. The remaining ulnar drift was 12 degrees (preoperative 18 degrees ). The average grip strength after surgery was 80 % of the opposite side. Pain in the verbal analog scale improved from 2.3 to 1.7 postoperatively. One palmar subluxation of an implant of the little finger was recognized. No infection occurred. The X-rays showed complete osteointegration in all metacarpal components. Radiolucent zones were found in progress only at the basis on the phalangeal components without radiological signs of loosening or sinking. CONCLUSION: The short- and midterm results after implantation of the cementless, unconstrained HM prosthesis show an improved hand function and pain relief. The design of the implant may solve the accepted postoperative problem of instability of the MP joints. Until now, no prosthesis had to be exchanged.

Biterminal tenotomy for the treatment of congenital muscular torticollis. Long-term results.

Fifty-five patients who, in a twenty-eight-year period, had been managed with a biterminal open release because of congenital muscular torticollis, were re-examined at an average of fifteen years and a minimum of five years after the operation. Forty-eight patients reported no functional or cosmetic impairment. Palpable soft-tissue strands remained in twenty-nine patients, but bending toward the untreated side was limited more than 10 degrees in only one patient. The rate of recurrence was 2 per cent. Facial asymmetry improved or resolved in more than one-half of the patients. We recommend that biterminal release be performed at the age of three to five years in all patients who do not respond to non-operative treatment.

[Scintigraphic research on patellar changes after endoprosthetic replacement of the knee joint]. / Szintigraphische Untersuchungen zur Veränderung der Patella nach endoprothetischem Kniegelenksersatz.

A clinical and x-ray review of 118 GSB-Knee-Protheses without resurfacing the patella--mean time of follow-up 4 years--was performed. In 50 knees of these an additional quantifying bone-scan with 99mTc-MDP ("ROI-method") indicated new aspects of the pathomechanics of the patella after knee replacement. Comparing 42 healthy knee joints and 82 knees with osteoarthrosis principles for early diagnosis of patellar changes could be set up. According to these findings the quantifying scans show the development of dystrophic patellar changes after knee replacement.

[Method for in vivo measurement of intraosseous pressure of the patella]. / Methode zur In-vivo-Messung des intraossären Druckes an der Patella.

During the development of degenerative joint disease (osteoarthritis, chondropathy), a diagnostic or even pathogenetic role is attributed to the phenomenon of intraosseous pressure (IOP). Owing to technical problems and a lack of systematic experimental or clinical studies on the control mechanisms of the IOP, the actual importance of this factor is still not known with certainty. Now, a measuring method that enables correct recording of the IOP and standardized on-line processing of the measured signal minimize artefact-related problems. The technique is evaluated for reliability in an in vitro model of the human patella and in a limited clinical study of the IOP in patients undergoing knee surgery for various reasons. Factors such as intra-articular effusion, joint position or changes in intra-articular soft tissue are examined for their influence of the primary signal.

[Does excessive stress play a role in the development of osteochondrosis dissecans tali?]. / Spielt bei der Entstehung der Osteochondrosis dissecans tali Uberlastung eine Rolle?

At the follow-up examination of 61 patients with Osteochondrosis dissecans tali (OD) we found at 48 of them one or more injuries in the anamnesia. More than 70 percent of them had as an injury mechanism a supination trauma. In case of medial OD the possible cause of an OD is given by the ratio 34 to 12 of trauma and non-trauma. The ratio in case of a lateral OD is 14 to 1 and it almost definitely points to overstress being a cause of it. Primary reasons may be here sports, especially football.

[Multilocular myositis ossificans--damage caused by excessive stress in performance sports?]. / Die multilokuläre Myositis ossificans--ein Uberlastungsschaden im Leistungssport?

This is a report of a girl of 16 years of age who complained of pain in both legs after intensive competitive sports, the main event being the 800 m race. Radiologically visualised were periostal reactions and new periostal bone formations at the femur and lower leg. Diagnosis was extremely difficult due to generalised signs and symptoms, such as temperature, associated with inappetence and a "run-down" feeling, increase of alkaline phosphatase and liver enzyme levels and of the blood sedimentation rate. Differential diagnosis of heterotopic ossifications is dealt with in detail.

[Thromboembolism complications in orthopedics and traumatology. A prospective study of 598 operated patients]. / Thromboembolische Komplikationen in der Orthopädie und Traumatologie. Eine prospektive Studie bei 598 operierten Patienten.

From 1.10.-31.12. 1989, 598 patients who underwent orthopaedic surgery in the Staatliche Orthopädische Klinik were examined by a pre-, intra- and postoperative questionnaire up to 3 months from the date of operation. All patients were separated into 4 groups corresponding to the calculated risk and duration of the operation. 46 patients in Group I, who underwent minor surgery, received 3 x 5000 I.E. Heparin subcutaneously. 243 patients in Group II received besides 3 x 5000 I.E. Heparin, 500 ml HAES 6% preoperatively. They underwent operations of greater intensity and duration at the upper and lower extremities. 302 patients of Group III were given 3 x 5000 I.E. heparin and 500 ml 6% dextrane 60 preoperatively because of severe operations (pelvis, hip). 7 high-risk patients received apart from 3 x 5000 I.E. Heparin subcutaneously 500 ml 6% dextrane 60 preoperatively and 250ml 10% dextrane 40 postoperatively for 5 days. In Group I we had 2.2% thromboembolic complications, whereas in Group II 1.7% and in Group III 3.3% complications with thrombosis and pulmonary embolism occurred. This was proved by pulmonary scintigraphy and phlebography. No such complications were seen in Group IV. The total incidence of deep vein thrombosis was 2.0% and of pulmonary embolism 0.5%. These results show the importance of preoperative risk check and individual prophylaxis of thromboembolic complications in orthopaedic and traumatologic surgery.

Mutational and functional analyses of xylosyltransferases and their implication in osteoarthritis.

OBJECTIVE: The hallmark in osteoarthritis (OA) is the loss of proteoglycans (PGs) in articular cartilage (AC). Xylosyltransferase I (XT-I) catalyzes the transfer of xylose to serine residues in the core protein and initiates the biosynthesis of PGs in AC. The XYLT-II gene encodes a highly homologous protein but its biological function is not yet known. Here we investigate for the first time genetic variations in the XYLT-genes and serum XT-I activities and their implication in OA. METHODS: Denaturing high-performance liquid chromatography (DHPLC) was used for the screening of the XYLT-genes in 49 OA patients. For a detailed characterization of XT-I amino acid exchanges we performed recombinant expression of XT-I mutants in insect cells. Furthermore, the XT activity was measured in the patients' serum. RESULTS: The variation c.1569C>T (XYLT-II) occurs with a significantly higher frequency in younger OA patients in comparison with the older ones (P<0.001) and the controls (P<0.02). Furthermore, significantly higher serum XT activities were found in patients with a long disease duration of OA (P<0.04). The recombinant XT-I mutants p.P385L and p.I552S had reduced enzymatic activity (85% and 74%) compared with the wildtype (wt). CONCLUSIONS: Our findings indicate a correlation of the c.1569 T-allele in XYLT-II with an earlier manifestation of OA and that the serum XT activity is a potential biochemical marker for staging and monitoring the progression of AC damage in OA. Comparison of XT-I activity in mutant enzymes in vivo and in vitro revealed that heterozygous mutations are not involved in OA.

[The knee joint]. / Das Kniegelenk.

The knee is very important in the treatment of rheumatic diseases. Differentiating between the indications for different forms of therapy is dependent upon knowledge of the prospects for success. Synovectomy, preventive and palliative procedure, is the most important joint-saving measure, as confirmed by the long-term results presented here. Synoviorthese and arthroscopic operative procedures are alternatives and have expanded the spectrum. However, their long-term effectiveness has not yet been proved. Rheumatic, recurring synovitis has not yet been defined satisfactorily. Additional soft tissue operations should always be included in preoperative planning and determine the form of therapy. Alloarthroplasty of the knee is the foremost reconstructive measure, and excellent long-term results have already been achieved in some cases. It should be remembered, however, that modifications of individual models occasionally have a considerable influence on the results. Particularly for rheumatic knee joint deterioration, knee prosthesis models that guarantee long-term success should be given preference if the time and effort expended are justifiable. Continuous passive mobilization seems to be the most valuable postoperative measure.

[Development of rheumatoid arthritis orthopedics in German-speaking countries]. / Die Entwicklung der Rheumaorthopädie in den deutschsprachigen Ländern.

In the realization that the cause of and thus an appropriate curative systemic therapy for rheumatoid arthritis did not and does not exist, surgical treatment of this usually destructive disease emerged as a major field in orthopedics in collaboration with internists specialized in rheumatology. The establishment of working groups within the scientific society initiated by the German Association for Orthopedics and Traumatology (DGOT) in 1971 to improve efficiency was a decisive factor for the further development in the German-speaking countries. A significant role was played by the fact that the Swiss N. Gschwend from Zurich was entrusted with the formation of the working group. This ensured that other German-speaking colleagues in Austria as well as Scandinavia also had the opportunity to add their input and influence rheumatoid orthopedics to a large extent. The DGOT also supported the creation of the ARO, which was founded as an independent association within the DGOT in 1992. The growth of rheumatoid orthopedics received considerable impetus from the fact that it was recognized in 1981 as the only subspecialty of orthopedics granted equal footing, as was the case for rheumatology in internal medicine. At the start of the 1970s, interest was focused on synovectomy for joint preservation, also with regard to its techniques and the possibility for preventive indications. Influenced by the experience gained from the development of endoprosthetic replacements, arthrodeses for rheumatic patients, e.g., in the region of the shoulder and knee joints, were almost completely ignored. The special field of reconstructive surgery on the hand and wrist employing implantation of finger joints and limited arthrodeses yielded impressive subjective and partially functional improvement for the patients. New impulses in the surgical treatment of foot deformities with joint-saving techniques for toe joints and endoprosthetic reconstruction of the ankle have brought about new trends in rheumatoid orthopedics in the past 10 years. Operative stabilization of cervical instabilities represents a special aspect in the development of rheumatoid orthopedics. Both the differential indication and the surgical technique have changed. The development of magnet resonance tomography and new implants for the cervical spine has played a significant role. Rheumatoid arthritis surgery has shown preference to integrating physical measures including in particular ergotherapy and special hand therapy into local surgical interventions. Functional treatment measures, care of braces and aids, and training in joint protection have become a firm part of the therapeutic concept. It is significant that in the German-speaking countries a treatment plan focused solely on the joints has thus far not gained general acceptance as is the case in Anglo-American countries. Preference is given to working as a team with subspecialties for upper and lower extremities and the spinal column. This guarantees that the priorities of the patients who usually present with multiple joint alterations can be dealt with by one group.

[Radio-synoviorthesis with yttrium 90 of the knee joint in polyarthritis]. / Die Radio-Synoviorthese mit Yttrium 90 am Kniegelenk bei chronischer Polyarthritis.

The radio-synoviorthesis with yttrium 90 in the knee-joint in rheumatoid arthritis was performed and controlled in 106 knees of patients with rheumatoid arthritis over a span of time between 6 and 49 months. The results are similar to those of other authors. As compared to synovectomy radio-synoviorthesis seems less successful as far as long-term results are concerned. As local treatment radio-synoviorthesis seems a good supplementory element in the therapeutic plan of rheumatoid arthritis. The indication to alternative procedures has to be considered carefully for each individual case and joint.

[Solitary bone cysts with expansion throughout the complete humerus (author's transl)]. / Juvenile Knochenzysten mit Ausdehnung über den gesamten Humerus.

The paper contains two case reports of solitary bone cysts of the humerus, which expanded throughout the complete bone from the upper end to the lower. This unusual size was seen in a 12 year old boy after subtotal resection of an active cyst at the age of 6 years, with recurrence of the cyst. In the other case an 18 year old female patient felt pain in her left arm after sports. The X-ray picture showed a cystic transformation of the complete humerus. The histodiagnosis of the disease was made by multiple, repeated biopsy. Other cystic bone lesions, which are important concerning differential diagnosis, were excluded by detailed examination. No further pathological findings were made in both cases.

Pathomechanics of the femoropatellar joint following total knee arthroplasty.

Persistent discomfort in the femoropatellar joint is still one of the most disappointing aspects following total knee arthroplasty (TKA). Especially, TKA without patellofemoral replacement has a significant incidence of patellofemoral problems with a frequency between 5% and 45%. Pathomechanical factors in the development of retropatellar problems are loss of patellar thickness and retropatellar erosions. In 157 TKAs using Gschwend, Scheier, Bähler (GSB) joints without patellar resurfacing, pathomechanically postoperative vertical patellar malposition appeared to be the main cause of dysfunction. In many cases, the implantation technique leads to an artificial form of patella alta. This altered knee anatomy results in pathologic biomechanics, thus leading to reduced function. The combination of altered anatomy and reduced function leads to extensive patellar destruction and ultimately to intractable retropatellar pain.

[The possibilities of osteoplastic measures in mid-foot amputation and osteomyelitis of the tarsus]. / Möglichten knochenplastischer Massnahmen bei der Mittelfussamputation und Fusswurzelosteomyelitis.

Osteomyelitis after trauma or after operations and amputations at the midfoot or tarsus leads to a disadvantage in terms of motion and of weightbearing on the foot. Once local fistula, exophytic bone growth, skin defects and instability of the metatarsus have arisen, hygiene and recovery of joint function are difficult. Four patients were treated by reamputation at the midfoot and bone autografts. The osteomyelitic part was excised and the tarsal and metatarsal bones stabilized. The result at follow up showed painfree stumps without recurrence of infection within 3 years. Little support is needed in the way of orthopedic appliances, and all four patients can walk easily with no pain. This operation is recommended for the primary surgical procedure.

Retropatellar forces after rupture of the PCL and patello-tibial transfixation: an in vitro study.

Compared to injuries of the other knee ligaments, a rupture of the posterior cruciate ligament (PCL) is relatively rare. Treatment may be conservative or operative. A rupture that has been operated on temporarily can be stabilised using a Grammont patello-tibial transfixation (olecranisation). Flexion and extension between 30 degrees and 60 degrees are allowed. The advantage of this method is that it avoids complete immobilisation of the joint and also the reduction of pull on the PCL. However, patients treated with this method show long-term osteoarthritis of the retropatellar joint area. Our study aimed to show the distribution of forces at the dorsal patellar surface in the following: (1) knee with intact ligaments; (2) knee with PCL rupture; (3) knee with PCL rupture plus olecranisation. Fourteen fresh knee specimens were investigated in a Plitz/Wirth knee kinemator. The femur was fixed while the tibia was flexed between 5 degrees and 120 degrees. Pull was placed on the patella and on the dorsal side of the tibia with weights over the tendons of the quadriceps and the roots of the ischio-crural muscles. With the aid of a special measurement device in the patella, the medially laterally, proximally and distally acting forces in a movement cycle could be measured as well as the total retropatellar force in the above experimental setups.(ABSTRACT TRUNCATED AT 250 WORDS)

[A tumorous chondrocalcinosis]. / Tumoröse Chondrokalzinose.

Calcium pyrophosphate dihydrate (CPPD) deposits are an accidental finding or they can be responsible for destructive osteoarthritis. Seldom they create a periarticular soft tissue tumour with or without bony destruction. We present a case of tumoral chondrocalcinosis that could have been mistaken for a malignant tumour without knowledge of the clinical course due to the high vascularity of the tumour.

[Postoperative evaluation of osteochondrosis dissecans of the talus with special reference to medial malleolar osteotomy]. / Die postoperative Bewertung der Osteochondrosis dissecans tali unter besonderer Berücksichtigung der Innenknöchelosteotomie.

58 out of 69 patients after open operation for osteochondritis dissecans (OD) of the upper ankle joint were reexamined retrospectively. In 44 cases the medial talar edge was concerned, in 15 the lateral one. Pain in activity resisting conservative treatment led to the operations. 31 excisions, 16 drillings, 10 autogenous bone graftings (2 external) and 2 diagnostic arthrotomies had been carried out. Medial malleolar osteotomy had to be performed in 22 cases, mainly concerning excisions and graftings to maintain sufficient survey of the lesion. Follow-up examination took place an average 67 months postoperatively. The results were obtained through a new scoring system with special regard to subjective and clinical criteria. 13 excellent, 29 good, 10 fair and 7 bad results were obtained. Results depended mainly on operative approach, location of the lesion and in lateral OD time of operation. Medial malleolar osteotomy frequently led to local osteoarthritis and less favourable clinical findings. No significant difference could be realized for size of the lesion and the applied operative technique. Stage and age at time of operation did not clearly influence the outcome. The indication for operation must be made dependant on individual complaints. Even in the era of arthroscopy medial malleolar osteotomy sometimes is necessary, but goes along with higher morbidity and worse prognosis. Operations have to be carried out according to stage and followed by proper rehabilitation to render proper assessment. Lateral lesions result from sprains and should be operated early.

[Tribologic investigation of a metacarpophalangeal prosthesis]. / Tribologische Untersuchungen einer metakarpophalangealen Prothese.

It is the goal of this paper to introduce modern tribological investigations into the development of a new finger prosthesis, with the particular aim of optimising the material component.A new, unconstrained metacarpophalangeal prosthesis restoring the anatomy of the joint has been developed in two versions (UHMWPE-metal and PEEK-metal). In order to determine the version having better wear behaviour, these two versions were tested on a Joyce finger simulator. As the UHMWPE-metal version showed a lower amount of wear in vitro, this version was chosen to conduct a clinical study. This investigation showed the importance of conducting an in vitro wear test before any clinical studies. Such tests allow the optimisation of the wear behaviour of the tested metacarpophalangeal prosthesis and therefore permit a minimisation of the possible risks to the patients.

The cruciate ligaments in knee replacement.

The cruciate ligaments were resected with their bony insertions during total knee arthroplasty carried out in 12 patients with severe rheumatoid or osteoarthritis. The ligaments were examined histologically and biomechanically, using ten specimens from healthy adults as a control. A significant difference was found in the tensile stiffness and viscoelastic properties of the ligaments between the arthritic and the control group. The ligaments in the rheumatoid knees had a distinctly inferior tensile strength compared with the osteoarthritic knees. Total knee replacement, which also replaces ligament function, should therefore be considered in severely damaged rheumatoid knees.