[Amputation of the leg with impaired circulation. The orthopaedic surgeon's view]. / Die Amputation der durchblutungsgestörten Extremität aus der Sicht des Orthopäden.

Despite therapeutic improvements in the treatment of arterial circulatory problems of the leg, several tens of thousands of amputations are performed every year. The amputation is not the end of the treatment but is the beginning of the rehabilitation. Decisive criteria for a successful rehabilitation are the quality of the leg-stump, the immediate and early care, and an adequate artificial leg.

Development of osteoarthritis in the knee joints of Wistar rats after strenuous running exercise in a running wheel by intracranial self-stimulation.

The influence of excessive running load on the development of knee osteoarthritis (OA) was investigated in male Wistar rats. Running exercises were performed in a running wheel using intracranial self-stimulation to motivate Wistar rats to run daily distances of 500 m at 5 days/week. Hereby, ten rats ran a distance of 15 km within three weeks while a further ten rats run a total of 30 km within six weeks. Thirteen Wistar rats without running exercises served as controls. Complete knee joint sections of all rats were evaluated histologically using MANKINs grading system with categorization of the findings into non, mild moderate, and severe osteoarthritis. In addition, immunoreactivity of the chondrocytes to MMP-3 as an important cartilage degrading enzyme in OA was assessed by immunostaining with monoclonal MMP-3 IgG antibodies. Histological assessment of the knee joint sections revealed a significant increase in osteoarthritic changes with higher running load. While in rats with 15 km running all but two knee joints showed mild OA, moderate OA was the predominant finding in rats with 30 km running. In contrast, no OA was found in the controls. Immunostaining for MMP-3 revealed a significant increase in immunoreactivity of the chondrocytes to MMP-3 with higher running load, indicating a running load-depending production of this cartilage-degrading enzyme in the course of increasing OA. Compared to 47.4% immunoreactive chondrocytes to MMP-3 in the controls, this ratio rose to 70.4% in rats with 15 km running and even up to 89.9% in rats with 30 km running. In conclusion, in Wistar rats, excessive running load leads to marked, running distance-depending osteoarthritic changes which are caused, at least in part, by an increase in MMP-3 production rising with greater running distance. Within this exercise model of OA, intracranial self-stimulation is an effective method to motivate Wistar rats to extremely excessive running in a running wheel. This model offers a wide range of further approaches to studying different processes of the development of OA.

Detailed analysis of proprioception in normal and ACL-deficient knees.

We assessed proprioception using threshold levels for the perception of knee movement at slow angular velocities (0.1 degrees/s to 0.85 degrees/s) in 20 patients with unilateral tears of the anterior cruciate ligament (ACL) and 15 age-related control subjects. Failure to detect movement was also analysed. The threshold levels of detection did not differ between the damaged and undamaged knees in the patients or between the patients and the control group. Failure to appreciate movement, however, was significantly greater in knees with ACL loss compared with the undamaged knees of patients and the control group. Our findings show a proprioceptive deficit in the absence of the ACL. Measurements of threshold levels of detection of passive movement alone are not suitable for the evaluation of proprioceptive loss in ACL deficiency; assessment of failure to appreciate movement is essential.

[Changes in proprioceptive capacities of the shoulder joint in ventral shoulder instability. A comparative study before and after arthroscopic labrum refixation]. / Veränderungen propriozeptiver Fähigkeiten am Schultergelenk bei ventraler Schulterinstabilität. Eine vergleichende Untersuchung vor und nach arthroskopischer Labrumrefixation.

Measurements of movement sense determined by threshold levels for the perception of motion of the shoulder were performed in 10 patients with unilateral posttraumatic shoulder instabilities, in 30 patients who underwent arthroscopic labrum repair for recurrent anterior shoulder instability, and in 15 age-related controls. In patients with anterior shoulder instabilities threshold levels for the perception of motion were higher. In addition, movement sense measurements revealed a marked, but time dependent improve of proprioceptive abilities in patients who underwent arthroscopic labrum repair. While in the shoulders of patients with an postoperative period shorter than 18 months elevated threshold levels for the perception of motion still could be observed, after a postoperative period of 18 moths or more movement sense was not different from normal, uninjured shoulders. In conclusion, our study gives evidence for a proprioceptive deficit with anterior shoulder instability which improves significantly after arthroscopic labrum repair. The restitution of proprioceptive abilities, however, seems to be a time dependent process.

[Medium-term results of the cementless femoral neck prosthesis CUT]. / Mittelfristige Ergebnisse der zementfreien Schenkelhals-Endoprothese Typ CUT.

AIM: The present work aims at evaluating the clinical and radiological midterm results of the femoral neck prosthesis CUT. METHOD: 67 femoral neck prostheses of the type CUT were implanted in 63 patients between 4/1999 and 5/2003 (average age 56 years). At an average follow-up time of 5.1 years (min.: 2.9; max.: 6.9) 53 patients with 57 CUT prostheses were examined clinically with the Harris hip score and radiologically. All together we determined the state of 64 CUT prostheses (96%). RESULTS: The mean Harris hip score improved from 55 points preoperatively to 90.4 points at the last follow-up and is assessed as a good result. A total of 7 CUT prostheses (11%) had been revised. 3 CUT prostheses (4.7%) had been revised because of aseptic loosening, 2 (3.1%) because of persisting postoperative thigh pain, 1 (1.6%) because of vertical migration of an unsuitable CUT prostheses a few days after the operation and 1 (1.6%) because of septic loosening. The survival rate according to Kaplan-Meier was 89.1% at 5.1 years. If the femoral neck was resected too widely there was an increased rate of horizontal migration with aseptic loosening of the CUT prostheses. CONCLUSION: In the midterm follow-up the CUT prosthesis shows a higher loosening rate as compared with cementless standard stems.

[The femoral neck prosthesis CUT. Three- to six-year results]. / Schenkelhalsendoprothese Typ CUT. 3- bis 6-Jahres-Ergebnisse.

BACKGROUND: As the number of younger patients undergoing total hip arthroplasty is growing steadily, bone-saving implantation techniques are increasingly gaining in importance. METHODS: Fifty-six femoral neck prostheses (type CUT, ESKA Implants, Lübeck, Germany) were implanted in 50 patients between 1999 and 2002 (average age 49 years). After a mean follow-up of 4.9 years (min.: 3.2, max.: 6.5), we determined the state of all the prostheses. Forty-four patients with 50 prostheses were examined clinically with the Harris hip score and were assessed radiologically. RESULTS: The average Harris hip score improved from 48 points preoperatively to 93 points at the most recent follow-up examination. Of the 56 CUT prostheses, 6 (10.7%) had been revised. Four of these six cases (7.1%) required revision because of aseptic loosening. The radiological evaluation of these four cases revealed in three cases progressive horizontal migration with varization of the prosthesis, although the stem had been correctly positioned in primary surgery, with the femoral neck resected too widely or completely. After 4.9 years, the survival rate of the CUT prostheses is 88.4% according to Kaplan-Meier for a necessary exchange of the CUT prostheses as an endpoint. CONCLUSION: The use of the CUT prosthesis can lead to good clinical and radiological results, but shows a higher loosening rate as compared with cementless standard stems. Further studies are necessary to determine if the CUT prosthesis is a real alternative to cementless standard stems.

[Long-term results with the Harris-Galante press-fit-cup]. / Langzeitergebnisse der Harris-Galante Press-fit-Pfanne.

AIM: The present work aims at evaluating the clinical and radiological long-term results of the Harris-Galante press-fit cup. METHOD: At an average follow-up time of 9.5 years (min. 9, max. 10.3) 123 patients with 138 Harris-Galante press-fit cups (HGP) were examined clinically and radiology. The clinical evaluation was done with the Harris hip score. Together with the HGP, which was inserted in all cases, five different femoral stems were implanted. A lateral approach, according to the technique of Watson-Jones, was used in all cases. RESULTS: The mean follow-up Harris hip score was 89 of 100 points and is assessed as a good result. 7 cups (5%) were classed as being radiological loose, but only one case had also clinical symptoms. A total of 10 cups (6.8%) had to be revised. 3 cups (2 %) had to be revised because of aseptic loosening. This result represents a survival rate of 93.2% according to Kaplan-Meier. CONCLUSION: The long-term clinical and radiological results of the Harris-Galante press-fit cup and there fixation method can assessed as good.

[Influence of retropatellar arthrosis on the proprioceptive ability of patients with gonarthrosis]. / Einfluss der Retropatellararthrose auf die Propriozeptionsfähigkeit von Gonarthrosepatienten.

Degenerative changes of the retropatellar articular surface contribute to a great extent to functional disability in patients with osteoarthritic knees. Therefore, in the present study we examined the influence of retropatellar osteoarthritis (OA) on proprioception in patients with knee OA. Comparison of movement sense determined by threshold levels for the perception of knee motion was performed in 10 patients with severe, in 10 patients with moderate, and in 9 patients with mild retropatellar OA. In addition, detection failures occurring during movement sense measurements were analysed. At correct movement detections, threshold levels did not differ between the three groups of patients regardless the extent of retropatellar OA. In contrast, analysis of detection failures occurring during movement sense measurements revealed significantly higher failure rates with greater severity of retropatellar OA. In conclusion, our study gives evidence for increased proprioceptive deficits with greater severity of retropatellar articular surface damage. Hereby, analysis of detection failures occurring during movement sense measurements proved to be a feasible tool for the assessment of proprioceptive deficits.

[Functional changes in the quadriceps femoris muscle in patients with varus gonarthrosis]. / Funktionelle Veränderungen des Quadriceps Femoris Muskels bei Patienten mit Varusgonarthrose.

In osteoarthritis (OA) of the knee, arthrogenous muscle inhibition (AMI) is considered to be one of the reasons of quadricep muscle weakness. Its influence on functional impairment such as gait alterations, however, still remains unclear. Fourty-seven patients with knee OA (mean age 64 +/- 5.2 years, 36 women, 11 men) and 47 age- and gender-matched healthy controls were investigated for voluntary activation (VA) and maximum voluntary contraction (MVC) of the quadricep muscle. In addition, these two parameters of AMI have been correlated with the extent of gait alterations. Measurement of VA and MVC were performed by a twitch interpolation technique; for gait analysis an optoelectronic motion analysis system (ELITE, Italy) was used. Quadricep MVC and VA were significantly lower in OA than in control knees. Moreover, in addition to reduced walking velocity and step cadence, gait analysis revealed significantly lower stance phase re-extension angles in OA patients (mean 2.7 degrees +/- 2.6) than in control knees (mean 10.7 degrees +/- 4.9). Hereby, in OA knees there was a significant correlation between MVC and VA deficits and the reduction of re-extension angles. The work shows that knee OA is characterized by severe alterations of the quadricep motor function due to arthrogenous muscle inhibition. Hereby, quadricep AMI represents one major reason for functional impairment in knee OA.

[Measuring knee joint kinesthesis for determining proprioceptive deficits in varus gonarthrosis]. / Messung der Kniegelenkskinästhesie zur Bestimmung von Propriozeptionsdefiziten bei Varusgonarthrose.

Studying knee osteoarthrosis proprioceptive deficits play a growing role. However, the methods for the detection of these deficits using joint position sense measurements have been criticized recently. Therefore, we developed a new method for the measurement of knee-joint kinaesthesia. At 5 different angular velocities of passive knee movement both movement and stop detection were tested. Tests were performed both in 25 patients with osteoarthrosis of the knee and in a control group of 20 age related normal subjects. In addition to the measurements of movement detection and stop-detection thresholds, a specific detection-failure analysis was performed in our study. In addition to a significant improvement of proprioceptive abilities with increasing angular velocities, detection failure analysis brought about significant differences between patients with knee osteoarthrosis and normal subjects yielding a significant proprioceptive deficit in osteoarthrosis of the knee. In contrast, in case of correct movement detection or stop-detection there were no significant differences in the detection-threshold values between normal and ostheoarthrotic knees. In conclusion, both the lack of differences in detection thresholds between the arthrosis and the control-groups and the increased detection failure rates in arthrosis patients gave evidence for these proprioceptive differences being a result of central nervous dysregulation in knee osteoarthrosis.

[Treatment of recurrent traumatic shoulder dislocations with coracoid transfer--Latarjet-Bristow operation]. / Die Behandlung der rezidivierenden traumatischen Schulterluxationen mit der Coracoid-Transfer--Operation nach Latarjet-Bristow.

We reviewed 31 patients with recurrent traumatic anterior shoulder dislocations, being operated with the Latarjet-Bristow procedure consecutively between March 1991 and March 1994. The average follow-up time was 31.2 months. According to the Rowe-score results were estimated as excellent in 45.1% and as good in 38.7%. New shoulder dislocations occurred in one case, resulting in a new shoulder dislocation rate of 3.2 per cent. Deficits in the external rotation of more than 5 degrees compared with the not operated side were seen in 15 patients. In two patients 7 respectively 9 months after the operation loosenings of the screws happened, but were without any effect on the functional outcome of the operation. The Latarjet-Bristow procedure proved to be a very safe method with a low redislocation rate, few complications and good functional results. Because of limitations in external rotation, however, this method should only be performed in cases in which an anatomic labrum reconstruction is hardly possible.

[Correlation of pathological clinical hip symptoms in the sonographic study of infant hips]. / Korrelation von pathologisch klinischen Hüftbefunden zur sonographischen Untersuchung von Säuglingshüften.

The relevance of clinical signs of infant hip dysplasia and the importance of a sonographic newborn-hip screening are often discussed. Between 1984 and 1990 at our department 6532 infant hips were examined both clinically and sonographically. Sonographic hip findings were pathological in 71.7% of the hips with positive clinical Roser-Ortolani sign and in 100% of the hips with positive Hilgenreiner sign. In contrast, pathological hip types according to Graf were seen only in 18% of the hips with limitations of the abductions of the hip joint. Examining other clinical signs for infant hip dysplasia within this study, as well we can conclude, that only the Roser-Ortolani sign and that of Hilgenreiner showed a high specificity for infant hip dysplasia, while most of the clinical signs e.g. limitation of abduction in the hip joint are rather unspecific.

[Is unicondylar knee prosthesis a current possibility in primary management of varus gonarthrosis?--A prospective matched-pair study]. / Ist die unikondyläre Knieprothese eine zeitgemässe Möglichkeit der Primärversorgung bei Varusgonarthrose?--Eine prospektive matched-pair-Studie.

AIM: In the present study, we performed a follow-up investigation comparing middle-term results after unicompartmental and bicompartmental knee arthroplasties. MATERIAL AND METHODS: We used matched pairs with 18 patients in each group. The first group was treated with the unicompartmental slegde prosthesis (Type Wessinghage), the second with the cementless nonconstrained bicondylar prosthesis (Type Natural knee). The mean time of follow-up was 4.5 years. (SD +/- 0.6). The average age of the patients in both groups was 59 years (SD +/- 3). Both groups included 12 female and 8 male patients. All patients suffered from primary medial osteoarthritis of the knee. In all cases, the contralateral knee also had signs of manifest osteoarthritis. The determination and evaluation of the results of the investigation were made according to the score of the American Knee Society. We also reviewed the radiological findings concerning placement of the prosthesis, radiolucent lines, and patella position in the femoral shield. RESULTS: At follow-up examination, there were no significant differences in the knee score between the patients undergoing unicompartmental or total knee replacement. However, patients with the Wessinghage sledge tended to show better results. The mean knee score was 94.3 +/- 4.9 in the Wessinghage group and 91.9 +/- 8.3 in the Natural knee group. Evaluation of the radiographs revealed radiolucent lines in the group with total replacement. In contrast, in 7 of 18 patients with the unicompartmental prostheses we found radiolucent lines at the tibial component of 1 mm or more, which, however, did not cause clinical symptoms. CONCLUSION: Our results show, that the unicompartmental arthroplasty is still an effective method for the treatment of the osteoarthritis, especially concerning the conditions for possibly needed revisions.

[Calcifications after operations of the subacromial space]. / Verkalkungen nach Operationen im Subakromialraum.

OBJECTIVE: Although there are several studies on the development of periarticular calcifications after different operation procedures of the joints, such calcifications have only seldomly been described in connection with operations in the subacromial space. Therefore, the present study was aimed at investigating the incidence of periarticular calcifications after operations in the subacromial space and to assess their clinical relevance. PATIENTS AND METHODS: In a retrospective study we examined 152 patients (51 female, 101 male) who had been operated on for primary shoulder impingement by open or arthroscopic procedures. The average follow-up time was 32.5 months. The assessment of the outcome of the treatment was performed using the criteria of the Constant score, different shoulder tests, a visual-analog scale for the evaluation of pain, and by evaluation of radiographs. RESULTS: Our study revealed good clinical results in the operative treatment of different stages of primary shoulder impingement and thus confirmed the results of similar studies before. However, in 25.6% of all patients we found periarticular calcifications. Hereby, calcifications occurred significantly more often after open procedures (56.8%) than after arthroscopic procedures (12.9%). There was non correlation between the occurrence of such calcifications and the stage of the disease. Moreover, comparison of the clinical results and the Constant scores at follow-up did not reveal any differences between patients with and without periarticular calcifications. CONCLUSION: Our study shows that the presence of periarticular calcifications after operations in the subacromial space is not necessarily associated with clinical symptoms. Therefore, routine prophylactic measurements against such calcifications are not justified.

[History of German orthopedics 1989-2001]. / Geschichte der deutschen Orthopädie von 1989-2001.

The present article describes essential aspects of the development of German orthopedics from 1989 to 2001. Special attention is given to the unification of the two German orthopedic groups after the political turnaround in the German Democratic Republic and the resultant changes in the landscape of German orthopedics. In addition, further milestones in the development of German orthopedics during the last 10 years are presented, e.g., the formation of the Alliance of German Orthopedists, the establishment of various sections of the DGOT (German Association of Orthopedics and Traumatology) as well as the main focus of scientific activity in the past few years.

[3-dimensional image analysis of the shoulder joint--a new method for characterizing parameters of shoulder joint function]. / Dreidimensionale Bewegungsanalyse am Schultergelenk--Ein neues Verfahren zur Charakterisierung von Parametern der Schultergelenksfunktion.

OBJECTIVE: An exact assessment of shoulder movement is of special importance both in the diagnosis of and in the therapy for different shoulder diseases. Therefore, we developed a feasible method for the analysis of shoulder movement. METHODS: On the basis of an ELITE system and 6 skin markers (marker positions. acromion, humerus, olecranon, proc. styloideus ulnae, cervical and thoracic spine), movement analysis was performed during continuous abduction of the arm over 15 s. With the help of a purpose made software we determined the exact angle of abduction and, in addition, the acceleration (+aAC) and the deceleration (-aAC) of the acromion. We evaluated 12 normal subjects (10 male, 2 female, average age 29 yrs) without shoulder conditions and 8 patients (6 male, 2 female, average age 46 yrs.) with unilateral impingement syndrome stage II according to Neer. RESULTS: In addition to a significantly diminished abduction ability in patients with impingement syndrome, our results also revealed significantly decreased acceleration values for the acromion in impingement patients. In contrast, deceleration values for the acromion were not altered in patients with impingement syndrome. CONCLUSION: The presented method allows exact measurements of shoulder movement. In addition, measurements of acromion acceleration and deceleration seem to offer two parameters for the assessment of shoulder function in pathological conditions. Further investigations are required to prove the advantages and limitations of this method.

[Arthroscopic repair of the glenoid labrum using the 3-point knot technique. Early results with consideration to different postoperative immobilization time periods]. / Arthroskopische Refixation des Labrum glenoidale in der transossären 3-Punkt-Knoten-Technik. Frühergebnisse unter Betrachtung unterschiedlich langer postoperativer Immobilisationszeiten.

There are different opinions on the duration of post-operative shoulder immobilisation following arthroscopic repair of labrum tears. Between 1993 and 1994 at our department arthroscopic repairs of the glenoid labrum as described by Habermeyer (15, 16) have been performed in 38 patients. In 20 of these patients postoperative treatment included immobilisation of the operated shoulder in a Gilchrist-bandage for 3 weeks, while in the remaining 18 patients this postoperative immobilisation period was decreased to only 1 or 2 weeks. Physiotherapy started the day after the operation, using a device for passive-motion exercises. The mean follow-up time of our examinations was 15.4 month. The mean score by Rowe rose significantly from 20.0 preoperatively to 82.6 at the follow-up examination. Results were excellent or good in 89.4% of all cases, new shoulder dislocations did not occur in any case. Patients having their shoulders immobilised for 3 weeks reached significantly higher Rowe-scores at our follow-up than those patients, whose shoulders were immobilised for only 1 or 2 weeks. Therefore, postoperative management following arthroscopic repair of labrum tears should include immobilisation of the operate shoulder for 3 weeks and an early start of passive-motion exercises.

[Revisions after arthroscopic interventions in the subacromial space]. / Revisionen nach arthroskopischen Eingriffen im Subakromialraum.

PROBLEM: In the present study, we evaluated the failure and revisions rates after arthroscopic subacromial decompression (SAD). METHOD: We examined 83 patients who were treated with arthroscopic subacromial decompression for primary shoulder impingement (stage II and stage III according to Neer) at an average follow-up time of 30 months. Hereby, special attention was paid to the revision operations resulting from our treatment. RESULTS: In patients with impingement stage II, the mean follow-up Constant-score was 84.7 (SD +/- 16.7) while in patients with impingement stage III it was 78.0 (SD +/- 21.8). In ten patients (12%) revision operation had to be performed, nine of them with initial stage II impingement and one with initial stage III impingement. Reasons for revisions were persisting or increasing pain as well as functional dissatisfaction. At the follow up examination, six of these revised patients (60%) were satisfied with the result. The mean follow up Constant-score in the revised patients was 77.3 (SD +/- 17.4). In 60% of the revised patients the necessity for the revision operation was directly related to the technical problems at the primary operation, in 40% we found reasons not related to the primary SAD. CONCLUSIONS: Technical falls are the most common cause for the need of revision operations after SAD. This demonstrates how demanding this kind of operation procedure is. In case of revision operations individual strategies should be developed in which the decision whether to perform arthroscopic or open revision procedures is of special importance.

[Experiences with the GSB (Geschwend-Scheier-Bähler) III total endoprosthesis in the elbow joint]. / Erfahrungen mit der GSB (Gschwend-Scheier-Bähler) III-Totalendoprothese am Ellenbogengelenk.

Studies on the results with elbow prostheses published in the seventies reported on marked problems such as high loosening rates and instabilities of the joints. However, enormous progresses in elbow replacements have been made in the meantime. Therefore, we analyzed the results of the GSB III-elbow-prostheses that were implanted in our department for 9 years. Between January 1, 1987 and April 1995 at our department 34 total elbow replacements were performed in 32 patients. In this study, we reviewed 25 patients with elbow replacements both clinically and radiologically. The clinical outcome was rated according to the score of INGLIS and PELLICI. The mean follow-up time was 3.7 years. Our follow up examination revealed a total complication rate of 22%. Septic prosthesis loosening with explantation of the prostheses occurred in 3 patients resulting in a prosthesis survival-rate of 88%. However, clinical assessment revealed 80% excellent or good results. While the range of motion could only be improved to a small degree, a marked reduction of the preoperative pain could be achieved. Patients were satisfied with the outcome of the operation in 97%. Although the results of total elbow arthroplasties cannot be compared with those of hip or knee arthroplasties, in selected patients with rheumatoid arthritis and osteoathrosis the use of elbow replacements proved to be a successful procedure with satisfactory results. The implantation of elbow prostheses should mainly be considered when debilitating pain, strongly limited range of motion and instability of the joint are the main problems.

[Comparison of 2 surgical techniques in isolated supraspinatus rupture. A matched-pair study]. / Vergleich von 2 Operationstechniken bei isolierter Supraspinatusruptur. Eine Matched-pair-Studie.

The comparison of results after open surgery methods in the repair of rotator cuff ruptures needs homogen patient groups. We compared 34 patients in 2 groups who were treated with open surgery for isolated ruptures of the supraspinatus muscles (lesion type III). Patients in group I were treated with transosseous suture refixation of the supraspinatus, in group II suture anchors (type: Corkscrew) were used. Both groups were age and gender paired. Preoperatively, all patients had the same clinical status. For the evaluation of the clinical results at follow-up we used the Constant-Score. In addition, strength and pain measurement and oblique X-rays of the shoulder were performed. The follow-up time was 18 months. In all patients, the mean Constant-Score improved significantly with increase in muscle strength and marked pain reduction. Significant differences between both groups could not be observed. The mean time of surgery in group II (suture anchor) was significantly lower than in group I. In conclusion, with the anchor techniques the same good results can be achieved as with bone refixation. The shortening of the surgery time should, however, be seen in relation to the higher costs with this technique.