Articulating spacers compared to fixed spacers for the treatment of infected knee arthroplasty: A follow-up of 37 cases.

BACKGROUND: The standard treatment of a periprosthetic infection after TKA involves a two-stage reimplantation with the intermittent implantation of spacers. Different designs of spacers have been described; currently articulating spacers and fixed spacers are used. The aim of the present study is to compare the advantages/disadvantages of the different spacers. PATIENTS AND METHODS: In this retrospective study we analyzed 37 cases after revision surgery of infected TKA. All patients that received spacers as part of the two-stage reimplantation were included. Exclusion criteria were massive bone loss prior to revision, because the implantation of a mobile spacer would not have been possible. RESULTS: The average ROM was 98.0 (± 14.9) degrees in the articulating spacer group (group 1) and 79.3 (± 22.5) in the group that received the fixed spacers (group 2) before revision surgery started. At a late follow up the average ROM for group 1 was 102.0 (± 8.4) and 79.0 (± 26) for group 2. CONCLUSION: The use of articulating spacers in the two-stage revision for infected total knee arthroplasty is a safe alternative to fixed spacers, that equally preserves ligament balancing and has equal infection eradication rates. A long term improvement of the range of motion following reimplantation of the new joint was, however, not observed.

Mechanical principles of compressive interbody fusion.

STUDY DESIGN: A biomechanical study on cadaveric lumbar spines was performed measuring interfragmentary forces and contact areas between intercorporal bone blocks and vertebral endplates. OBJECTIVES: To show the correct application of internal fixators to achieve interfragmentary compression between bone blocks and adjacent endplates. SUMMARY OF BACKGROUND DATA: Several researchers have previously tried to compress interbody bone blocks by internal fixator systems. Knowledge of the correct way to use the internal fixator systems for this purpose has been lacking. METHODS: Ten cadaveric lumbar spines were analyzed by instrumenting each motion unit with an intercorporal bone block and a dorsal transpedicular arbeitsgemeinschaft osteosynthesefragen internal fixator. Interfragmentary load and compression surface and their distribution were measured with a capacitive measuring mat. The internal fixator was loaded in compression in two different ways to determine the optimum mode of application. RESULTS: Simple compression of an internal fixator did not achieve sufficient interfragmentary forces and compression surfaces. Usually lordotic contouring of the instrumented spinal motion unit with a decrease in interfragmentary forces and width of compression surfaces developed. Preloading the fixator in slight kyphosis and compressing it in a second step achieved significantly improved interfragmentary forces and sufficient compression surfaces. CONCLUSIONS: Preloading an internal fixator in kyphosis and secondary compression is mandatory to get sufficient interfragmentary forces and compression surfaces between interbody bone blocks and adjacent vertebral endplates. The technique described provides a compressive interbody fusion and can be performed preserving the physiological shape of the spine.

Harman and norharman plasma levels in weaned alcoholics: correlations with depression and tobacco smoking.

Based on the hypothesis that ß-carbolines are involved in the pathogenesis of alcohol-related mood disturbance, harman and norharman levels were assayed in the blood plasma of alcoholics and correlated to the Hamilton Depression (HAM-D) scores after 3 and 5 weeks post-admission. Tobacco smoking was co-evaluated since it is known to influence ß-carboline levels. After a 3-week period, plasma harman but not norharman was increased in depressed alcoholics and positively related to the HAM-D sum-score (r = 0.47; p < 0.04) and to tobacco smoking (r = 0.56; p < 0.02). Since no correlation between depression and smoking was found, these data could account for the higher incidence of depressive symptoms in withdrawn alcoholics with increased harman levels. The partial correlations support this hypothesis.

[Sonographic evaluation of the rotator cuff following reconstruction of complete ruptures]. / Sonographische Beurteilung der Rotatorenmanschette nach Rekonstruktion kompletter Rupturen.

This is a report on the results of a clinical and sonographical re-examination of 66 shoulder joints after reconstruction of complete rotator cuff tears. One-third of the patients were asymptomatic, in more than half of them pre-operatively existing complaints had improved, and in 15% no improvement was seen. Clinical findings were without abnormalities in half of the patients. In as many patients indications were found of a still existing rotator cuff syndrome. Sonographically, in 49 out of 66 cases the continuity of the rotator cuff was maintained. In 17 cases indications of tears were found. Remarkable features were, in rotator cuffs with maintained tendon continuity, in 50% of the shoulder joints a thinning out of the tendon and/or echogenic patterns. Tears in the non-operated opposite side were found in 7 cases and thinning out and/or enhanced echogenicity in 12 cases.

Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment.

Plantar fibromatosis is a rare, benign lesion involving the plantar aponeurosis. Eleven patients (13 feet) underwent 24 operations, including local excision, wide excision, or complete plantar fasciectomy. Clinical results were evaluated retrospectively. There were no differences among the subgroups in postoperative complications. Two primary fasciectomies did not recur. Three of six revised fasciectomies, seven of nine wide excisions, and six of seven local excisions recurred. Our results indicate that recurrence of plantar fibromatosis after surgical resection can be reduced by aggressive initial surgical resection.

[Use of a capacitive measuring mat for recording inter-fragment pressures and pressure distribution in ventral inter-corporal spondylodesis]. / Die Anwendung einer capacitiven Messmatte zur Darstellung interfragmentärer Drücke und Druckverteilungen bei ventralen intercorporellen Spondylodesen.

With respect to ventral interbody fusion, rates of pseudarthrosis of up to 30% are reported. With the aim of reducing this figure, the use of dorsal fixation systems to stabilise the fused spinal units is recommended by a number of authors. The aim of these osteosynthetic procedures is to elevate the interfragmentary compression between the ventral bone block and the adjacent vertebrae. In order to measure the pressure achievable, and its local distribution, an experimental investigation involving the use of a capacitive measuring mat has been designed. The system of capacitive measurement and its application to the spine is described. The simple mode of measurement and mechanical stability, combined with high accuracy, are the specific advantages of capacitive systems of measurement. Especially in the documentation of interfragmentary pressure and pressure distribution, capacitive measuring mats are superior to comparable systems.

[Post disc surgery syndrome: indications for surgery and conservative and operative treatment possibilities]. / Postnukleotomiesyndrom: Operationsindikation, konservative und operative Behandlungsmöglichkeiten.

Post disc surgery syndrome is characterised by the presence of persistent disabling pain in the hip, thigh, or lower back. Persistent or recurrent pain may be related to neurologic compression, incomplete discectomy with retained disc fragments, recurrent disc herniation, or altered biomechanics of the operated segments. Early failure is usually due to poor patient selection, incorrect diagnosis, incorrect procedure, or infection. A new onset of pain following a good surgical result may be due to recurrent disc herniation, instability of the operated segment, or disease at a different disc level. It can also be the result of a chronic pain syndrome. Therapy depends on exact diagnostics and can include conservative as well as surgical treatment.

Long-term results of ventro-dorsal versus ventral instrumentation fusion in the treatment of spondylitis.

This study examines prospectively the randomised, long-term, clinical and radiological results of the treatment of spondylitis patients by ventro-dorsal or ventral spine fusion. Group 1 consisted of 12 patients who (after ventral removal of the focus of infection and autologous bone grafting) were treated by dorsal instrumentation. Group 2 consisted of ten patients who, after similar ventral removal and bone interposition, were stabilised by ventral instrumentation. The patients prospectively underwent clinical and radiological studies. In addition, they were asked to fill in self-assessment questionnaires such as the short-form (SF)-36 health survey, the Oswestry questionnaire, and the visual analog scales (VAS). The postoperative follow-ups were at 6 months, 2 years and 5.4 years. It proved possible to demonstrate clinically that patients with an isolated ventral spondylodesis feel significantly better and experience significantly less pain in the area of spinal fusion than patients with ventro-dorsal fusion 2 and 5.4 years after the operation. Over a number of years a stable fusion can be achieved through either operation. Ventral stabilisation yields more advantages than dorsal instrumentation in the long term. These advantages result in a clinically smoother course after the operation. If, in the individual case, ventral instrumentation is feasible, this method should be used.

[Material removal after anterio-posterior spondylodesis -- necessity of posterior instrumentation removal after osseous fusion]. / Implantatentfernung bei ventro-dorsalen Spondylodesen. Ist eine Entfernung des dorsalen Implantats nach knöcherner Durchbauung sinnvoll?

BACKGROUND: The present study on spondylitis patients with anterio-posterior spondylodesis was carried out to get a recommendation whether material removal is necessary after osseous fusion. METHODS: A total of 12 patients with spondylitis were operated on at the Orthopaedic Department of Ludwig-Maximilians-University Munich with posterior instrumentation after debridement and fusion with autologous bone transplant. In a prospective clinical investigation we examined our patients regarding clinical and radiological outcome preoperatively, 2 weeks, 12 months and 4.9 years after operation. We paid special attention on complications and loss of correction in leaving posterior instrumentation. RESULTS: Compared with the advanced clinical signs of spondylitis, minor intra- and postoperative complications were seen. Two patients showed superficial wound infections with fistulization because of the posterior implants 3 years postoperatively. Both cases closed after revision and material removal without complications. 12 months and 4.9 years postoperatively the average loss of correction was constant 2 degrees . CONCLUSION: Generally material removal of posterior spinal instruments results in a significant loss of correction in the spondylodesis segment. Our study shows, that persisting posterior instrumentation could prevent loss of correction. On the other hand we recommend material removal in case of spondylodesis after osseous fusion to prevent wound healing complications.

[Value of heterologous bone transplants in the surgical therapy of habitual shoulder dislocation]. / Die Wertigkeit heterologer Knochentransplantate in der operativen Therapie der habituellen Schulterluxation.

45 heterologous bone grafts of "Kiel Bone" were radiologically examined after operative treatment of recurrent shoulder dislocation in the technique of M. Lange. The postoperative period differed between 1 and 17 years. Bony consolidation was achieved in 80% of the cases. Signs of resorption were postoperatively found in 14 cases. Five of them consolidated secondaryly. The results of our study show the usefulness of "Kiel Bone" in the treatment of recurrent shoulder dislocation. It should not be used as a bone graft in cases which require quick an secure consolidation. In these cases autologous bone grafts are superior.

[The spine as an unusual location for a malignant synovioma]. / Die Wirbelsäule als ungewöhnliche Lokalisation eines malignen Synovialoms.

The authors report on a case of malignant synovioma of the spine, a rare condition. A general review of the literature on the pathogenesis and localization, and the histologic and immunohistochemical investigation possibilities for differential diagnosis is given. The surgical and radiotherapeutic treatment possibilities are pointed out.

[Differentiated surgical and conservative treatment of spondylitis and spondylodiscitis]. / Differenzierte operative und konservative Therapie der Spondylitis und Spondylodiscitis.

In the time from 1980 to 1987 58 patients underwent a conservative or operative treatment of spondylitis and spondylodiscitis according to the individual clinical and radiological features. In early or moderately advanced stages of the disease conservative therapy was performed. Under bedrest and antibacterial or tuberculostatic drug therapy bony fusion of the affected vertebral bodies was achieved in 50% of the pyogenic cases. In tuberculous spondylitis fusion rate was 83%. Persistent septic changes, progressive neurological symptoms and gross vertebral damage are indications for surgery. In those cases removal of the focus and intercorporal spondylodesis was performed. Bony union occurred in every cases. At follow-up examination, 3 years after the onset of therapy on an average, 42 patients had no complaints according to the vertebral column. As the results of our study show spondylitis and spondylodiscitis should according to the clinical and radiological features be lead to a differentiated operative or conservative treatment. Then good clinical results are to be supposed.

[Praying for the hunchback man. On the cultural history of scoliosis and kyphosis]. / Beten fürs bucklicht Männlein. Zur Kulturgeschichte der Skoliose und Kyphose.

Numerous ancient burial sites contain spines with scoliotic deformities. However, very little is known about the lives of these people, the "hunchbacks". Their everyday life, how they saw themselves and were seen by others, their social status and perspectives can usually only be deduced indirectly from a variety of sources. These include fairy-tales and myths, beliefs and superstitions, classical and light literature, and accounts by theological and philosophical writers. The present paper proves that severely deformed scoliosis patients were generally burdened with a pitful fate in ancient times and during the Middle Ages. There was no effective treatment, healthy citizens showed little compassion, hunchbacks were said to have a vile and base character, and they were usually stigmatised outsiders. The sociopsychological situation for these patients did not improve until modern times, beginning with increased public awareness during the last century, in parallel with the slow development of orthopaedic treatment methods for scoliosis.

[Radiologic changes of the bones following cement-free implantation of hip joint prosthesis in inflammatory rheumatic diseases]. / Radiologische Veränderungen am Knochen nach zementfreier Implantation von Hüftgelenksendoprothesen bei entzündlich rheumatischen Erkrankungen.

The postoperative x-rays of 34 patients with rheumatoid arthritis or spondylitis who had received a cement-free fixed total hip endoprosthesis were examined. The postoperative period ranged from 3 months to four years. In the region of the acetabular component an increasing rate of osseous integration in relation to the postoperative time was observed. Adaptive modeling changes in the area of the femoral stem were found as radiolucent lines parallel to the implant. Also a densification of cancellous bone and cortical hypertrophy as well as cortical rarefaction was noticeable. The bone in rheumatoid arthritis or spondylitis reacts to the implantation of a cementless fixed total hip prosthesis similar as the bone in osteoarthritis.

[Patellar dislocation as a cause of osteochondral fracture of the femoro-patellar joint]. / Die Patellaluxation als Ursache osteochondraler Frakturen im femoropatellaren Gleitlager.

Acute traumatic dislocation of the patella may be associated with osteochondral fractures. Clinical examination invariably shows a tense effusion. A detailed radiographic examination including antero-posterior, lateral and skyline views of the patella is usually necessary to establish an exact diagnosis. Once diagnosis is made open reduction and fixation of the osteochondral fracture should be carried out if it is possible. Out of 78 patients of our own with patella dislocation 24 cases suffered an osteochondral fracture. In ten cases refixation of the osteochondral fragment was achieved. Intraoperatively the alignment of the patella was controlled in any case. In cases of lateral subluxation lateral release and medial reconstruction was performed. In two cases medial transfer of the tibial tuberosity was carried out. Osteochondral fractures of the femoro-patellar groove represent an important injury in the course of acute patellar dislocation. With exact diagnosis and correct treatment congruity of the femoro-patellar joint can be restored in many cases.

[Indications and results of intertrochanteric reconstructive osteotomy in coxa profunda and protrusio coxae]. / Indikation und Ergebnisse der intertrochanteren Aufrichtungsosteotomie bei Coxa profunda und Protrusio coxae.

Coxa profunda often connected with coxa vara lead to an increasing stress on the medial part of the acetabulum. Secondary degenerative alterations with painful limited motion are the result. In 20 hip joints with coxa profunda a valgus intertrochanteric osteotomy was carried out in order to modify the direction of the resulting force from the depth to the roof of the acetabulum. A relief of pain was achieved in 18 of 20 cases. Therefore the valgus intertrochanteric osteotomy has to be considered an effective method in the treatment of coxarthrosis in coxa profunda.

[Differences between anteroposterior and posterior spondylodesis in clinical scores]. / Vergleich ventrodorsaler und ventraler Spondylodese bei Patienten mit Spondylitis anhand klinischer Scores.

The present study on spondylitis patients was carried out to compare prospectively results of clinical scores of patients treated with anteroposterior or anterior spondylodesis. A total of 22 patients with spondylitis were enrolled in the randomized trial to undergo an operation with anteroposterior or posterior spondylodesis. For quality of life adjustment, the SF-36 health survey was applied. Pain and disability were measured using the Oswestry low-back pain disability questionnaire and visual analogue scales (VAS). Twelve patients were assigned to undergo anteroposterior spondylodesis and ten patients anterior spondylodesis. Postoperative improvement of spinal function, general health, well being, back pain, and mobility could be observed in both groups of patients. Better results of patients treated with anterior spondylodesis compared with anteroposterior spondylodesis were seen. No statistical difference was found between the two groups at any time. The less invasive nature of anterior spondylodesis could be responsible for that result.Anterior spondylodesis should used if possible and deemed adequate because it causes less discomfort.

[First results of anterior versus posterior instrumentation-fusion in the treatment of spondylodiscitis]. / Erste Ergebnisse ventraler versus dorsaler Instrumentation nach Ausräumung und intervertebraler Fusion bei Spondylodiszitis.

AIM: The present study on spondylodiscitis patients was carried out to compare prospectively and randomized the results of clinical and radiological outcomes of anterior versus posterior instrumentation after debridement and grafting. We aimed to make a recommendation concerning the optimum treatment of spondylodiscitis. METHOD: A total of 22 patients with spondylodiscitis were enrolled in the randomized trial to undergo an operation with anterior or posterior instrumentation after debridement and fusion with autologous bone transplant. 12 patients (group 1) were assigned to posterior Universal Spine System stabilization. 10 patients (group 2) were treated with anterior VentroFix instrumentation. In a prospective clinical investigation we have examined both operative therapies with regard to clinical and radiological outcome. The follow-up was one year. RESULTS: In patients with ventral Spondylodesis (group 2), prior recreation of patients was achieved in clinical examination and blood tests. Radiological results are even equivalent in both groups. Therefore we recommend ventral instrumentation as the superior surgical procedure. But the individual local situation has to enable ventral stabilization. CONCLUSION: We found advantages with anterior instrumentation in comparison to posterior stabilization in patients with spondylodiscitis. Advantages of ventral stabilization cause early mobilization postoperatively without any increase in complication rates. Except for operation time and intraoperative blood loss, no statistical difference were was seen. Important is the individual indication for each method depending on anatomical and clinical signs. Ventral instrumentation should be restricted to cases with sufficient bone stock.

[The wrist joint]. / Das Handgelenk.

The wrist joint is involved in a great majority of cases of rheumatoid arthritis. Tenosynovitis and synovitis can lead to severe destruction of the joint and to spontaneous ruptures of the tendons. Therefore, early tenosynovectomy and wrist-joint synovectomy are required. At the advanced stage of the disease, arthroplasty is necessary. Arthrodesis is rarely indicated in the treatment of severe wrist destruction in rheumatoid arthritis.

[Ventral compression spondylodesis using internal fixator instrumentation--a biomechanical study]. / Die ventrale Kompressionsspondylodese mit Fixateur-interne-Instrumentation--eine biomechanische Untersuchung.

Pseudarthrosis is said to be a main complication in anterior interbody fusion. It is usually the result of an insufficient mechanical stability which hinders bony incorporation of intervertebral bone grafts. In order to improve stability dorsal transpedicular instrumentation should be carried out to achieve interfragmentary compression between bone block and adjacent vertebral endplate. Using human lumbar spine cadavers and a capacitive measuring mat an experimental study was completed to find out in which way an internal fixator has to be used to achieve this goal. The collected data showed that simple compression of the fixator by reducing the distance between the Schanz-screws did not produce sufficient interfragmentary compression. Preloading the fixator in kyphosis and compression in a second step improved the results significantly. Using this technique a compressive interbody fusion can be attained.