Management of acute knee dislocations: anatomic repair and ligament bracing as a new treatment option-results of a multicentre study.

PURPOSE: The literature shows no consensus regarding the best method and timing for the treatment of acute knee dislocations. Studies indicate that a one-stage procedure performed in the early stages of injury can lead to superior results. The aim of this study was to evaluate the results after performing early surgical repair with additional suture augmentation (ligament bracing) of all torn ligaments in acute knee dislocations. METHODS: In this prospective multicentre study, 73 patients with an acute type III or IV knee dislocation were treated with one-stage ligament bracing within 10 days. Twenty-six patients sustained a type III medial dislocation, thirty-nine patients sustained a type III lateral dislocation, and eight patients presented a type IV dislocation. Four patients were lost to follow-up. Within the follow-up evaluation, various scores were collected (International Knee Documentation Committee IKDC Score, Tegner Score and Lysholm Score). Additional stress radiography was performed (Telos™) postoperatively. RESULTS: Sixty-nine knee dislocations (Schenck III and IV) with a follow-up at a mean of 14 ± 1.6 months were evaluated. The average IKDC score was 75.5 ± 14.5, the average Lysholm score was 81.0 ± 15.5, and the median loss of activity in the Tegner score was 1 (range 0-3) point. Stress radiographs showed side-to-side differences at a mean of 3.2 ± 1.3 mm for the anterior cruciate ligament (ACL) and of 2.9 ± 2.1 mm for the posterior cruciate ligament (PCL). The operative revision rate (early and late) was 17.4%. In the early stage, one wound infection and one case of transient common peroneal nerve (CPN) paresis were successfully revised. In the later stage, four patients with knee stiffness and six cases with symptomatic knee instability needed reoperation. Patients without ultra-low velocity (ULV) dislocations or CPN showed good or excellent results in 87.5% according to the Lysholm score. CONCLUSION: In cases of acute knee dislocation, primary ACL and PCL transosseous sutures with additional suture augmentation predominantly lead to good and excellent clinical results. Obese patients sustaining ultra-low velocity (ULV) dislocations and patients following injury to the CPN show inferior outcomes. In patients without ULV and CPN intraoperative and postoperative complications occurred in 10.1%. The obtained results and revision rates show that early primary suture repair is a promising option. LEVEL OF EVIDENCE: Prospective multicentre study, II.

[Clinical results following conservative and surgical treatment of osteoporotic distal radius fractures in the elderly : Overview of best available evidence]. / Klinische Ergebnisse nach konservativer und operativer Therapie der distalen Radiusfraktur beim älteren Patienten : Übersicht der besten verfügbaren Evidenz.

Fractures of the distal radius in elderly patients increasingly contribute to the workload in emergency departments worldwide. There is still no consensus about the best treatment option, e. g. closed reduction and cast stabilization, percutaneous pinning, external fixation or open reduction and internal fixation with volar locking plates (ORIF). In addition, the influence of pharmacological antiosteoporotic treatment (e. g. bisphosphonates) is unclear. In this overview five comparative studies were analyzed, which had been identified in a previous systematic review. The evaluation included 3 cohort studies and 2 randomized trials enrolling a total of 515 patients. A clinical or statistical advantage of ORIF over conservative treatment with respect to DASH scores 12 months after the index fracture event could not be demonstrated with a mean difference of 0.25 (95 % confidence interval CI -0.57-1.07). According to current best scientific evidence from preclinical and clinical investigations, antiosteoporotic medication does not have an unfavorable influence on fracture healing and should be continued due to its proven effectiveness in reducing subsequent osteoporotic fractures. Following distal radius fractures in elderly patients with clinical risk factors, an osteoporosis screening should be routine practice and a specific therapy should be initiated if the fracture risk is increased.

[Evidence-based trauma and orthopedic surgery : 20 years after Sackett]. / Evidenzbasierte Unfallchirurgie und Orthopädie : Zwanzig Jahre nach Sackett.

The article "Evidence based medicine: what it is and what it isn't" published in the BMJ in 1996, is regarded as the foundation of the evidence-based medicine (EbM) movement. Approximately 5 years later David L. Sackett, one of the leaders of the movement, requested all experts to voluntarily abandon their position to make way for young researchers and fresh ideas. Since the term was first coined and the establishment of organizations and platforms fostering the idea, EbM has polarized clinicians and scientists around the world. Clinical and methodological developments during recent years have, however, overtaken the original principles of EbM. This review highlights the core concepts of EbM which have remained unchanged and valid for the current practice of trauma and orthopedic surgery and where revision is needed.

[Current prevention and treatment strategies for osteoporosis. Fracture-oriented, effective, low side effects and inexpensive]. / Aktuelle Osteoporoseprophylaxe und -therapie. Frakturorientiert, effektiv, nebenwirkungsarm, kostengünstig.

Osteoporosis is still an underdiagnosed and insufficiently therapied widespread disease in Germany. Of the estimated 7 million osteoporosis patients only 1.5 million receive a guideline conform diagnosis and even less receive appropriate treatment. Some 90 % of patients are provided with analgesics but only 10 % receive an effective therapy, although efficacious, well-tested and affordable medications are available. In addition, approximately one half of the patients terminate treatment after only 1 year although according to the results of recent studies the duration of therapy should be at least 3-5 years. In view of the increasing average life expectancy, a consistent management for prevention of fractures associated with osteoporosis is always most important for society, even if only for reasons of costs. Achievement of this target depends on four circumstances: clarification of the origin of osteoporosis and fractures (bone consciousness), prophylaxis of bone loss and fractures (primary prevention), consistent guideline conform diagnostics and therapy (secondary and tertiary prevention) and cooperation of all disciplines in medicine (bone is everybody's business). This article describes the current state of diagnostics (bone density measurement with dual X-ray absorptiometry, FRAX®), prophylaxis of fractures (screening program) and therapy (use of economic and effective medications with low side effects). Novel medications are already undergoing clinical testing and a "healing" of bone reduction with restoration of the normal bone structure is to be expected.

[Secondary osteoporosis: pathogenesis, types, diagnostics and therapy]. / Sekundäre Osteoporosen: Pathogenese, Formen, Diagnostik und Therapie.

Due to increasing knowledge on pathogenetic factors causing osteoporosis and increasingly more detailed investigations, the diagnosis of secondary osteoporosis is being made increasingly more often. A rational search for the underlying disease or the bone-damaging medication is indicated particularly in adolescents, premenopausal women, men and postmenopausal women with rapidly decreasing bone tissue. The early detection of the causative disease in the preclinical stage of osteoporosis and the current therapeutic options allow not only normalization of the bone structure and the risk of fracture but also targeted therapy of the cause of the osteoporosis. The focal point in the diagnostics of secondary osteoporosis is still dual energy X-ray absorptiometry (DXA) measurement together with the manifold imaging procedures in radiology and additional clinical, laboratory chemical and bioptic findings.

[Drug-induced osteopathies. Drugs, pathogenesis, forms, diagnosis, prevention and therapy]. / Medikamenteninduzierte Osteopathien. Medikamente, Pathogenese, Formen, Diagnostik, Prävention und Therapie.

A number of drugs can have "side effects" on bone metabolism and formation, causing bone atrophy, impaired mineralisation, as well as osteonecrosis. In both clinical and general practitioner settings, these forms of bone damage have been hitherto considered as adverse drug side effects and have received insufficient attention; moreover, they have not been the subject of patient information. Preventive measures are not instigated prior to initiation of medication and even after onset of bone damage, therapeutic strategies are poorly implemented. Even fracture healing with its complex, staged course can be both positively and negatively influenced by a number of drugs and these effects require monitoring. Recommendations regarding practical screening and therapy of drug-induced osteopathies are presented.

[Drug-induced osteopathies. Drugs, pathogenesis, forms, diagnosis, prevention and therapy]. / Medikamenteninduzierte Osteopathien: Medikamente, Pathogenese, Formen, Diagnostik, Prävention und Therapie.

A number of drugs can have "side effects" on bone metabolism and formation, causing bone atrophy, impaired mineralisation, as well as osteonecrosis. In both clinical and general practitioner settings, these forms of bone damage have been hitherto considered as adverse drug side effects and have received insufficient attention; moreover, they have not been the subject of patient information. Preventive measures are not instigated prior to initiation of medication and even after onset of bone damage, therapeutic strategies are poorly implemented. Even fracture healing with its complex, staged course can be both positively and negatively influenced by a number of drugs and these effects require monitoring. Recommendations regarding practical screening and therapy of drug-induced osteopathies are presented.

Endogenous kappa-opioid systems in opiate withdrawal: role in aversion and accompanying changes in mesolimbic dopamine release.

The kappa-opioid receptor antagonist nor-binaltorphimine (nor-BNI) was recently shown to potentiate certain overt withdrawal signs in morphine-dependent rats. The present study sought to further assess this phenomenon by examining the influence of nor-BNI treatment upon the conditioned place aversion associated with the naloxone-precipitated withdrawal syndrome. In addition, in vivo microdialysis studies were conducted in morphine-dependent rats to determine whether nor-BNI treatment can modify withdrawal-induced changes in basal dopamine (DA) release within the mesolimbic system. Rats were pretreated with either saline or a single dose of nor-BNI and then received ascending doses of morphine for 10 days. A withdrawal syndrome was then precipitated by the administration of naloxone (1 mg/kg SC). In rats which received chronic morphine injections, administration of naloxone produced a characteristic withdrawal syndrome and a marked aversion for an environment previously associated with naloxone-precipitated withdrawal. Nor-BNI treatment potentiated most overt signs of physical dependence. This treatment also resulted in a greater withdrawal-induced place aversion. Morphine-dependent rats exhibited a marked reduction in basal mesolimbic DA release. An even greater decrease in basal DA release was observed in nor-BNI treated rats. These results suggest that endogenous kappa-systems are important in the modulation of mesolimbic DA release and the accompanying place aversion which occurs during opiate withdrawal.

Osteochondral autologous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder.

We performed eight osteochondral autologous transplantations from the knee joint to the shoulder. All patients (six men, two women; mean age 43.1 years) were documented prospectively. In each patient the stage of the osteochondral lesion was Outerbridge grade IV with a mean size of the affected area of 150 mm2. All patients were assessed by using the Constant score for the shoulder and the Lysholm score for the knee. Standard radiographs, magnetic resonance imaging and second-look arthroscopy were used to assess the presence of glenohumeral osteoarthritis and the integrity of the grafts. After a mean of 32.6 months (8 to 47), the mean Constant score increased significantly. Magnetic resonance imaging revealed good osseointegration of the osteochondral plugs and congruent articular cartilage at the transplantation site in all but one patient. Second-look arthroscopy performed in two cases revealed a macroscopically good integration of the autograft with an intact articular surface. Osteochondral autologous transplantation in the shoulder appears to offer good clinical results for treating full-thickness osteochondral lesions of the glenohumeral joint. However, our study suggests that the development of osteoarthritis and the progression of pre-existing osteoarthritic changes cannot be altered by this technique.

Dynamic aspects during the cylinder grip--flexion sequence of the finger joints analyzed using a sensor glove.

The purpose of this study was to assess whether there is a universal pattern of movement of the finger joints while performing a cylinder grip. A sensor glove was used to record the finger joint motion of 48 participants. Our observations showed that when examining the fingers, flexion motion began either at the metacarpophalangeal (MP) or proximal interphalangeal (PIP) joints, with the distal interphalangeal (DIP) joints always last to move (p = 0.0052). The sequence of the joints at the end of the gripping motion was different than at the beginning. Here, the only statistically significant observation was that the DIP joints fully flexed only once the MP joints had flexed fully. Apart from that, it was completely variable which joint reached its final position first or last. The analysis also revealed that synchronization of four identical joints (i.e. the four PIP joints) was significantly higher than synchronization of the 12 finger joints. Although synchronization was already high at the beginning of the flexion motion, it increased significantly by the time the joints completed their movement.

[The isolated subscapularis tendon tear: arthroscopic and open repair]. / Die isolierte Subskapularisruptur : Arthroskopische und offene Operationstechnik.

OBJECTIVE: Arthroscopic or open reconstruction of isolated subscapularis tendon tears with the use of suture anchors to restore the glenohumeral function and joint biomechanics. INDICATIONS: Traumatic full-thickness tears, chronic tears with a functional deficit or decentration of the humerus head, anterosuperior rotator cuff insufficiency, symptomatic reruptures after prior arthroscopic or open surgical procedures. CONTRAINDICATIONS: Frozen shoulder, atrophy > grade II (Thomazeau) or fatty infiltration > grade III (Goutallier/Fox) of the muscle, high-grade omarthrosis. SURGICAL TECHNIQUE: Diagnostic arthroscopy and careful tendon release. If the inferior edge of the rupture is reliable visible and the tendon-mobilisation works proper, the repair is performed arthroscopically. The footprint is decorticated lightly and 1-4 suture anchors (depending on the lesion-size) are placed from inferior to superior. Knots are tied starting from caudal in a modified Mason-Allen technique (alternative: single or double mattress stitches) with a slipknot and three half hitches in opposite directions. In case of larger tears, a double-row technique for better reconstruction of the trapezoidal footprint is performed. For open reconstruction, a deltopectoral approach is used to reattache the tendon in an analogous fashion. RESULTS: Arthroscopic or open repair of isolated subscapularis tendon tears (Fox type II-IV) was performed in 35 patients. The Constant score increased significantly after 36 m, with no difference between these two groups. The majority of subscapularis tests were postoperatively negative, 6% in both groups showed a rerupture. A symptomatic period of > 6 m prior to the operation and a high grade atrophy and fatty infiltration of the muscle was correlated with poorer results.

[Use of bisphosphonates in orthopedic surgery]. / Einsatz der Bisphosphonate in der Orthopädie und Unfallchirurgie.

Over the past three decades, the members of the substance group called bisphosphonates (BP) have been employed with growing success to manage osteopathies caused by increased osteoclastic activity. The following developments in BP are responsible: Modern BP are now already 20,000 times more potent than the first preparation approved for use. Their biochemical and cellular mechanisms of action have meanwhile been elucidated. They have no effect on hormones so that they are open for all patients. They are well tolerated and can be administered orally or intravenously. They have admirably been thoroughly studied in multinational trials. They are the "gold standard" in the treatment of osteoporosis, a widespread disease. Rare but serious side effects such as osteonecrosis of the jaw or acute renal insufficiency can be avoided to a large extent. BP also have tumoricidal properties and are used to suppress tumor growth in bones. Their anti-inflammatory activity is also successfully used in the treatment of bone marrow edema and bone pain.

[Management of isolated subscapularis tendon tears]. / Die isolierte Subskapularissehnenruptur.

Isolated subscapularis tendon tears are rare and often of traumatic origin. Despite specific clinical tests and exact radiological tools (ultrasound, magnetic resonance imaging), these tendon ruptures are often overlooked. For restoration of normal biomechanical joint function, immediate operative reconstruction is recommended. Tears of the upper subscapularis and partial articular-side tendon can be safely managed arthroscopically. The biceps tendon is often involved, and adequate treatment with tenotomy or tenodesis must be given to prevent postoperative pain. Complete subscapularis tendon avulsions should be reconstructed with an open repair technique. Immediate surgical management provides better results than delayed repair.

Intra-articular volume assessment in glenohumeral instability.

It is commonly claimed that instability of the shoulder is associated with an enlarged joint volume. The purpose of our study was to assess the intra-articular volume in acute and chronic glenohumeral dislocation. Sixty-seven patients were examined by intra-articular infusion of saline solution. Three groups could be formed. Group 1 (n = 51) consisted of patients with first time traumatic dislocation, group 2 (n = 8) of cases with recurrent post-traumatic dislocation. The patients of group 3 (n = 8) suffered from impingement syndrome and served as the control group. The joint volume was correlated to the body surface area (BSA). We found a strong correlation between height, sex and intra-articular joint volume. There was no statistically significant difference in joint volume correlated to BSA between the three groups. There is no statistically significant difference in joint volume correlated to BSA in patients with traumatic anterior instability, chronic instability and individuals without glenohumeral instability.

[Emergency surgery for chest injuries in the multiply injured: a systematic review]. / Operative Versorgung von Thoraxverletzungen innerhalb der ersten Operationsphase: Eine systematische Literaturübersicht.

OBJECTIVE: Severe chest injuries are still associated with significant morbidity and mortality. This systematic review assesses the early operative management of severe chest trauma in multi injured patients with special regard to the priority of the operative therapy. METHODS: Clinical trials were systematically sought and collected (MEDLINE, Cochrane and hand searches). Of 618 abstracts, 46 articles were selected for detailed appraisal and were classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: Penetrating chest injuries in haemodynamically instable patients require emergency operative therapy. A thoracotomy is also indicated in excessive chest tube output (>1500 ml). An aortic rupture can be treated either by open suture or-in borderline patients-by endovascular stenting. In selected haemodynamically stable patients delayed treatment is also possible. Lesions of the tracheobronchial system should be treated urgently with primary surgical repair. Diaphragmatic ruptures should be closed urgently. Surgical stabilisation of rib fractures with an associated flail chest reduces the ventilator days and the length of intensive care unit stay. CONCLUSION: A large part of early surgery for chest injuries is justified because it averts immediate threats to life (level 1c evidence). No randomised and only a few controlled trials have examined the relative value of the different surgical options so far. Long-term data are lacking especially on the safety of endovascular stenting.

[Diagnosis and therapy of osteoporosis. Strategy for effective treatment after fragility fractures]. / Diagnostik und Therapie der Osteoporose. Strategie für eine effiziente Prävention von Folgefrakturen.

Until about 20 years ago osteoporosis was considered an inevitable disease of ageing. Now the situation has completely changed and osteoporosis is classified as a disorder which is easily diagnosed and treated in the early stages of its development that is,before a skeletal fracture has occurred. Two types of medication are available today for prophylaxis and therapy of osteoporosis: the antiresorptive and the osteoanabolic drugs whose efficacy has been demonstrated in large randomized clinical trials (RCTs). These drugs are effective not only in the early stages of osteoporosis i.e. for prevention, but also when fractures have already occurred, to reduce the risk of further skeletal fractures. However, in this setting only about 7% of patients in Germany are being treated although all are at significant risk of sustaining additional fractures. Consequently all patients with osteoporosis-related fractures should be thoroughly investigated during their hospitalisation and effective treatment instituted. In addition, treatment should be continued and monitored by the family doctor. The strategy for the administration of therapy for successful prevention of secondary fractures in osteoporosis is presented.

[Arthroscopic treatment of shoulder instability]. / Arthroskopische Verfahren in der Behandlung der Schulterluxation.

Arthroscopic treatment of glenohumeral instability has become more common over the last years. Compared with open reconstruction which still is the gold standard in the treatment of glenohumeral instability the arthroscopic techniques show several advantages but also disadvantages that must be proved for every single case. Careful patient selection with regard of prognostic preoperative and intraoperative factors is substantial for successful treatment. When indicated using clinical, radiological and arthroscopic findings the results of arthroscopic stabilization could be improved over the last years and failure rates could be decreased.