[Long-term results of thrust plate prostheses: comparison of patients younger than and older than 50 years]. / Langfristige Analyse der Druckscheibenendoprothese: Vergleich von Patienten unter und über 50 Jahren.

BACKGROUND: Hip replacement in patients younger than 50 years old is no longer an exception in view of the increasing necessity for care. The aim of the present study was to analyze whether the results after implantation of thrust plate prosthesis (TPP) with metaphyseal anchorage are equal for patients below 50 years compared to older patients. PATIENTS AND METHODS: The investigation comprised 465 TPP implantations. In 149 TPP the patient age was below 50 years (group A) und in 316 TPP cases above 50 years (group B). Clinical and radiological evaluation of the results for both groups was carried out as well as a differentiated survival analysis with defined endpoints. RESULTS: Survival analysis of group A (96%/13.2 years) showed a significantly improved survival rate compared to group B (86%/12.5 years). Additionally, the risk of prosthesis and/or radiological signs loosening of was significantly lower in group A than in group B (p <0.05). CONCLUSION: Comparison of long-term results of prostheses with intramedullary fixation shows that the anchorage principle of TPP with bone-saving implantation to the proximal femur is justified especially for patients below 50 years of age.

[Antigranulocyte scintigraphy of septic loosening of hip endoprosthesis: effect of different methods of analysis]. / Antigranulozytenszintigraphie bei septischer Hüft-Endoprothesen-Lockerung: Einfluss unterschiedlicher Auswertemethoden.

AIM: Diagnosis of infection with help of antigranulocyte scintigraphy near body stem is difficult because of contemporary visualisation of bone marrow. Therefore, we investigated, whether it is possible to improve the accuracy in diagnosing septic loosening of hip endoprosthesis by changing the analyzing methods. METHODS: In 28 patients, the results of a visual interpretation of late scan, a visual interpretation and a quantitative interpretation of time-activity-course were compared. These results were verified by histology respectively microbiology. RESULTS: Histological and microbiological verification found 14 septic loosening and 14 aseptic loosening of the hip prothesis. Therefore, sensitivity, specificity, negative and positive predictive value for the visual interpretation of late scan were 0.86, 0.57, 0.80 and 0.67. For visual and quantitative interpretation of time-activity-course we found 0.86, 0.79, 0.85 and 0.80 respectively 1, 0.93, 1, 0.93. For interobserver agreement we found kappa coefficients of 0.28 +/- 0.2 for visual interpretation of late scan, 0.48 +/- 0.17 for visual interpretation and 1.0 +/- 0 for quantitative interpretation of time-activity-course. CONCLUSION: In all investigated values quantitative interpretation of time-activity-course was superior to the other analyzing methods. Therefore, antigranulocyte scintigraphy for septic loosening of hip endoprosthesis should be interpreted quantitatively.

Indication for lumbosacral fusion and reduction in spondylolisthesis.

The indication for operative treatment in spondylolisthesis results from pain, progressive sliding and, in up to 60 % of the patients with progressive dislocation, from radicular malfunction. The posterolateral fusion in situ is a safe procedure, but the deformation remains and in spondyloptosis plastic deformation of the fusion mass can lead to further dislocation. With the external fixator as an instrument for reduction and the internal fixator for stabilization the reduction of even serious spondyloptosis and the recovery of a normal spine alignement and posture is possible, with an acceptable neurological risk. Therefore a concept of treatment is suggested, which as a rule is aiming at the anatomical reduction of the dislocated vertrebra beside stabilization and nerveroot decompression. Depending on the extent of the slip, reduction and stabilization is to be performed in one, two or three stages. An anterior or posterior fusion is sufficient in grade I dislocation. In grade II-V a combined posterior and anterior surgical proceedure is recommended.

[Arthroplasty of the knee - result after 33 years (author's transl)]. / Kniearthroplastik - Spätergebnis nach 33 Jahren.

The case report of an arthroplasty of the knee joint with observation during 33 years after operation is given as an example ofl the efficiency of a classical orthopedic operation. The literature is briefly recorded and the special indications for this treatment are pointed out. In these selected cases the modern alloarthroplastic joint replacement only seldom has a better long time prognosis and a more satisfactory result.

[Comparative study after hamstring ACL plasty with RigidFix (pin fixation) and EndoButton (anchor fixation)]. / Vergleichende Studie nach vorderer Hamstring-Kreuzbandplastik mit RigidFix (Pinfixation) und EndoButton (Ankerfixation).

AIM: Within a prospective case group study, two hamstring fixation techniques, a pin fixation with RigidFix (RF) and an anchor fixation with EndoButton (EB), were compared. METHOD: 67 patients were followed clinically and by MRI preoperatively (t0), at six months (t6) and at twelve months (t12). In one group (N = 21), EB was used for representing a juxta-articular graft fixation. The second group (N = 46) with RF was used to represent the ab-articular fixation. KT-1000 stability measurement, IKDC, Lysholm and Tegner scores were used to determine the clinical outcomes. Reflux and tunnel widening (TW) were investigated by MRI. RESULTS: The KT-1000 values were slightly more stable at t6 (EB: 2.1 +/- 4.1 mm, RF: 1.0 +/- 2.5 mm) in the RF group (p = 0.044) but equalised later at t12 (EB: 0.5 +/- 3.1 mm, RF 1.0 +/- 2.4 mm). The median Tegner score at t6 (EB: 4.3 +/- 1.2, RF 4.1 +/- 1.7) and t12 (EB: 5.9 +/- 1.8, RF 5.4 +/- 2.0) were comparable (p = 0.692). The mean Lysholm score at t6 (EB: 90 +/- 11, RF: 91 +/- 8.9) and t12 (EB: 95 +/- 7.5, RF: 95 +/- 7.4) was comparable in each group (p = 0.589). The same was valid in the median of the IKDC score at t6 (EB: II, RF III) and t12 (EB: II, RF III). The category "femoral reflux" showed slight minimal fringe in the EB group at t6 but aligned to "no reflux" together with the RF group at t12 (NS, p = 0.550). A tunnel widening was not detectable in either of the groups.

[Long-term results of the cementless conical balgrist expansion cup--comparison analysis to the Zweymüller-Alloclassic screw cup]. / Langzeitergebnisse der zementfreien konischen Balgrist-Spreizpfanne--Vergleichsanalyse zur Alloclassic-Schraubpfanne.

AIM: The press-fit fixation of the conical Balgrist expansion cup (Allo Pro, Baar, Schweiz) is realised by the help of a (titanium alloy) split ring and a metal-backed inlay. The results and fixation principles of the cement-free Balgrist hip socket are analysed within a clinical and radiological long-time study and compared with those of the conical Zweymüller-Alloclassic CFS (Zimmer-GmbH, Winterthur, Schweiz) screw cup for a concluding evaluation. METHOD: Between 1993 and 2003, 277 Balgrist hip sockets and between 1994 and 2000 130 Alloclassic-Zweymüller screw cups were performed consecutively in 364 patients considering similar indications with an average age of 54.6 years and 51.9 years, respectively. The clinical investigation was carried out with the Harris hip score (HHS). Radiological evaluation included a manual migration analysis according to Sutherland et al., Nunn et al. and Effenberger et al.; radiolucent lines were registered according to the zones of DeLee and Charnley. The survival rate of both cups was calculated on the basis of the Kaplan-Meier and the life-table analyses. RESULTS: Besides 4 (1.4%) aseptic loosenings, 5 Balgrist cups (1.8%) had to be replaced because of infection and another 1 (0.8%) because of persisting pain. Three Balgrist sockets (1.1%) showed a migration > 2 mm. In the Alloclassic group 1 cup (0.8%) was considered as being migrated, another cup (0.8%) had to be replaced due to infection. Considering aseptic loosening and radiological migration as an end point, the cumulative survival of the Balgrist cup at 13 years was 97.3%, that of the Zweymüller-Alloclassic cup at 10 years was 99.2%. In comparison with the Alloclassic group, the Balgrist hip sockets showed increased radiolucent lines of zone 1 (p < 0.001), without any effects on the survival time or the clinical result however. Both cups resulted in good to excellent clinical results in the HHS (91 points). CONCLUSION: The long-term analysis of the Balgrist hip socket proved that the concept of the retightening conical expansion cup leads to good clinical results and fulfils the minimum survival rate of 95% at 10 years as demanded by Delaunay and Kapandji. The good results obtained with the aid of this concept are comparable to those of the Alloclassic screwing cup.

[Results after replacement of femoral neck prostheses - thrust plate prosthesis (TPP) versus ESKA cut prosthesis]. / Ergebnisse nach Wechsel von Schenkelhalsprothesen - Druckscheibenprothese versus ESKA-Cut-Prothese.

AIM: The aim of this study was to analyse and evaluate comparatively loosening mechanisms, failure frequency, surgical changing strategies and results after replacement of thrust plate prostheses (TPP) and ESKA Cut prostheses. METHOD: Between 1993 und 2007, 465 TPP and in the years 2000 and 2001 82 ESKA Cut prostheses were performed and evaluated prospectively. Until 2007 46 change interventions of the TPP and 35 of the CUT prosthesis became necessary. All patients who received a stem revision procedure in our hospital were included within this study. Besides the evaluation of clinical results according to the criteria of the Harris Hip Score on the average at 15.6 months (+/- 14.4) postoperatively, radiological loosening processes and surgical difficulties were registered. Furthermore, an analysis of perioperative data was performed according to some criteria of the German Federal Office of Quality Assurance (BQS), such as duration of the surgery, intraoperative blood loss and complications. Statistical investigations for comparative analysis as well as survival analysis of both groups were calculated using SPSS for Windows 13.0. RESULTS: The mean age of the 46 patients who had to undergo revision surgery after TPP was 60.1 years, that of 35 patients in whom revision surgery was necessary after receiving an ESKA Cut femoral neck stem was 56.6 years. The survival rate analysis according to Kaplan-Meier at 13 years was 89.4 % (TPP) and 53.6 % at 66 months (ESKA Cut). In all cases the partial osteointegration of the tripod surface of the loosened Cut prosthesis complicated the explantation. It led on the one hand to a significant difference of the surgery duration and on the other hand to an increased frequency of fractures of the trochanteric region. The conversion of the TPP on standard type stems was usually free of problems. The HHS increased significantly to the averages of 86.6 (TPP) or, respectively, 91.69 (ESKA Cut) after revision. CONCLUSION: In comparison with the usually problem-free changing procedure of the TPP to a standard type stem, the revision surgery of the Cut prosthesis becomes substantially more complex and leads frequently to complications. In view of unacceptable survival rates, the Cut prosthesis does not represent an alternative implant in young patients. Except for the implantation technique, which does not allow a less invasive surgical procedure, the TPP fulfils the requirements of femoral neck prosthesis due to acceptable survival rates and good convertibility.

[Eight-year results of the femoral neck prosthesis ESKA-CUT]. / 8-Jahres-Resultate der Schenkelhalsprothese ESKA-CUT.

AIM: With the help of a clinical and radiological follow-up evaluation 8 years after implantation of the femoral neck prosthesis CUT (ESKA Implants, Lübeck Germany), the question of whether this metaphyseal anchoring implant is recommendable in young patients will be answered. METHOD: Between 2000 and 2001 82 CUT-prosthesis procedures were performed in 79 patients (38 female, 41 male patients; average age 51.3 years) and evaluated prospectively. The clinical investigation was carried out according to the criteria of the Harris Hip and Merle d'Aubigné scores. Radiological periprosthetic bone changes were registered and a measurement of the CCD angle and femoral offset was performed. The survival rate was calculated according to both the Kaplan-Meier and the life-table analyses. RESULTS: During the 12-month follow-up examination the HHS (48.4 preop.) as well as the Merle d'Aubigné score (10 preop.) increased significantly to an average value of 85.1 and 15.8, respectively (p < 0.000). Cumulative survival with replacement of the prosthesis as an end point at 8 years was 49.6 %. Due to 25 aseptic loosenings, three periprosthetic infections and three cases of persisting thigh pains, 31 replacements of the femoral neck prosthesis became necessary up to June 2008. The implantation of the CUT prosthesis led to a significant valgisation (p < 0.001) of 17.4 degrees degrees with a consecutive reduction of the femoral offset of 5 mm. Radiologically periprosthetic progressive radiolucencies, hypertrophic cortical bone changes as well as atrophy of the calcar femoris were often evaluated and interpretated as a sign of a stress shielding and migration process. CONCLUSION: The analysis of the eight-year follow-up of 82 CUT prostheses shows that the implant does not fulfil our expectations of a femoral neck prosthesis, in spite of the possibility of a less invasive and bone-saving implantation technique. In view of unacceptable survival rates, valgisation changes of the joint geometry and critical changing procedures, from our point of view the femoral neck prosthesis CUT does not represent a recommendable alternative implant in young, active patients.

[Clinical and radiological results of the thrust plate prosthesis in patients with aseptic necrosis of the femoral head]. / Klinische und Radiologische Ergebnisse nach Implantation der Druckscheibenendoprothese (DSP) bei Patienten mit Femurkopfnekrose.

AIM: In this study, we investigated the results after implantation of the thrust plate prosthesis (TPP) in patients with femoral head necrosis. We intended to answer the question if the femoral neck prosthesis, inaugurated by Huggler and Jacob in Switzerland, which needs a good bone stock for a successful implantation, is a recommendable alternative to other cementless intramedullary fixed prostheses. METHOD: In a prospective study, 62 patients who had received 70 TPP because of femoral head necrosis as a result of various aetiologies between 1993 and 2004 were examined clinically and radiologically. The follow-up examinations were carried out 3 and 6 months postoperatively and subsequently once a year. The mean follow-up interval was 6.0 +/- 1.9 years (1.0-10.2 years). Clinical examination was carried out using the Harris hip score; the radiological examination was performed according to predefined criteria in an exact a.-p.-view. Four sectors can be distinguished: A corresponds to the femoral neck stump, B to the bony stock cranial (= 1) and caudal (= 2) to the mandrel of the prosthesis, C is the region above and under the bolt and D is the cortical area around the lateral plate. Furthermore, we performed a Kaplan-Meier survival rate analysis. RESULTS: We found excellent clinical results. The preoperative Harris score increased from 48.3 to 91.6 +/- 6.6 at 24 months after the operation. Radiolucencies of various relevancies were detected depending on the localisation. We often saw bony atrophy under the thrust plate (sector A: A 1 21.4%, A 2 9.9%) and small radiolucencies along the bolt (sector C 30 % in general). As a pathological finding we interpreted progressive radiolucencies of sector B, which was considered to be a sign of loosening, when they showed a thickness of > or = 2 mm. Therefore, we had to change one TPP. In two additional cases we saw an extended atrophy under the lateral plate, which was also interpreted to be a sign of loosening. The Kaplan-Meier survivorship analysis for 5 and 10 years was 95.1% (95% - 0.95 +/- 0.05). Our study suggests that, in spite of a slightly higher aseptic loosening rate in comparison with cementless stem prosthesis, the thrust plate prosthesis proved worthwhile. On account of our previous experience we consider the TPP to be a good alternative implant, especially for young patients. CONCLUSION: Due to excellent clinical results and nearly identical findings in the survivorship analysis in comparison to cementless stem prostheses, the TPP is also a good alternative implant for total hip arthroplasty in patients with femoral head necrosis. For a successful implantation of the TPP a good bone quality of the proximal femur is necessary. Therefore we cannot recommend the use of a thrust plate prosthesis in patients with femoral head necrosis and simultaneous osteopeny.

[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.

[Differential indications for lumbosacral fusion and reposition operation in spondylolisthesis]. / Differentialindikation zur lumbosakralen Fusions- und Repositionsoperation beim Wirbelgleiten.

The indication for operative treatment in spondylolisthesis results from pain, progressive sliding and, in up to 60% of the patients with progressive dislocation, from radicular malfunction. The posterolateral fusion in situ is a safe procedure, but the deformation remains and in spondyloptosis plastic deformation of the fusion mass can lead to further dislocation. With the external fixator as an instrument for reduction and the internal fixator for stabilization the reduction of even serious spondyloptosis and the recovery of a normal spine alignement and posture is possible, with an acceptable neurological risk. Therefore a concept of treatment is suggested, which as a rule is aiming at the anatomical reduction of the dislocated vertrebra beside stabilization and nerveroot decompression. Depending on the extent of the slip, reduction and stabilization is to be performed in one, two or three stages. An anterior or posterior fusion is sufficient in grade I dislocation. In grade II-V a combined posterior and anterior surgical proceedure is recommended.

[The isolated loss of extension of the great toe following osteotomy of the fibula (author's transl)]. / Die isolierte Grosszehenheberschwäche nach Fibulaosteotomie.

A peroneal nerve palsy can be observed following operative procedures or traumatic lesions of the lower leg. Primary damage of the nerve must be differentiated from the tibialis-anterior syndrome and the pseudo-paralysis. Following corrective osteotomies of the tibia with dissection of the fibula in the upper or medial third isolated lesions of the extensor hallucis longus muscle can be seen. Electromyographic and anatomical studies reveal that they may be caused by an isolated damage of the motor nerve fibres connecting the deep branch of the peroneal nerve with the extensor hallucis longus muscle lying very close to the fibula. Suggestions how to avoid this damage are made in the paper.

[Quadriceps femoris muscle during immobilisation and remobilisation (author's transl)]. / Musculus quadriceps femoris bei Immobilisation und Remobilisation

40 patients of which one leg had been immobilized in a pop cast for 3 and 12 weeks have been investigated with view to the quadriceps muscle. Mechanical and electromyographic investigations revealed the muscular changes under immobilisation and their recovery after removal of the cast. After 12 weeks of immobilisation and 24 weeks of remobilisation the muscle mass is still diminished.

[Muscles of the leg during immobilisation. An electromyographic study (author's transl)]. / Einfluss der Gipsimmobilisation auf die Aktivität der Beinmuskulatur. Eine elektromyographische Untersuchung.

By means of electromyographic evaluation we investigated the function of the rectus femoris, the vastus medialis, the tibialis anterior and the triceps muscle. The effects of immobilisation in above or below knee PoP were investigated with view to the muscular activity in walking and the effect of the immobilization in isometric exercises. The results are discussed. The vastus medialis can only be activated very poorly in a PoP and is not inervated at all during gait. The functional activity of the triceps is reduced markedly in either above or below knee PoP. In knee movement this muscle starts to be activated only over 90 degrees of flexion. The results suggest that an above knee PoP is sufficient to immobilise defects of the quadriceps and its tendon. Defects of the triceps and its tendon seem not necessarily to request an above knee PoP for immobilization. This case has however the advantage to decrease the danger of unexpected knee movements followed by a reflectoric muscle contraction. Its force could be greater than the stability of the repaired tendon.

[Skateboard injuries (author's transl)]. / Verletzungen beim Skateboard-Fahren.

Following the introduction of skateboards into Germany in 1976 an increasing number of accidents and injuries have been noted, affecting mainly children 10 to 14 years of age. The causes were lack of experience and the careless use of the boards on public streets. More than 30% of injuries were fractures mainly affecting the upper limb. Because of the frequent involvement of the epiphyseal plates the post-accidental growth may be seriously disturbed. Severe and sometimes fatal head or abdominal injuries have been reported, mainly after collision with cars.

[Expert assessment within the scope of the severe disability regulation and social compensation law]. / Begutachtung im Rahmen des Schwerbehindertengesetzes und des sozialen Entschädigungsrechtes.

In the wake of the First and Second World Wars, an extensive system of social compensation and assistance for the war disabled evolved in Germany and later on also for civilians. Depending on the origin of the disability, the benefits are composed either of revenues and pensions and/or tax reductions and nonfinancial assistance. In any case, the extent of these benefits depends on the grade of disability (GdB/MdE) determined by medical examination and on expert opinions in accordance with detailed legal regulations.

[Juvenile bone cysts - recommendations for treatment and new results]. / Die juvenile Knochenzyste - Behandlungsvorschläge und neue Ergebnisse.

The simple bone cyst (sbc) is generally regarded as a tumourous bone lesion, to be classified with the bone tumours. It is a non-malignant disease which, however, affects adolescents in the immediate area of the epiphysis, so that disturbances of growth and deformities cannot always be avoided. The commonest localisation is stated to be at the proximal humerus, followed by the femur. The authors shell out small sbc, filling the defect with autologous spongiosa, but treat recurrences and extensive cyst formation by means of limb-preserving resection. Procedure followed, e.g. at the humerus; resection of the tumour en bloc, formation of a groove in the head of the humerus, into which an autologous tibia graft is driven, after this has been fitted into the distal humerus after Lexer, where the transplant is fixed by 2 AO screws, or by boring the graft into the marrow canal of the distal humerus, without using extraneous material for osteosynthesis. Postoperative stabilisation is effected in a thoracic abduction plaster for an average of about 12 weeks. A review of the results of treatment in 26 patients with sbc of the humerus showed a recurrence rate of 55% after curettage and filling with spongiosa, against 7% following resection. Complete removal of the cyst by resection can thus be taken to be the most reliable prophylaxis against recurrence in the upper arm. In certain cases, we also perform a subtotal resection of the proximal femur. Of these patients, 22 were followed up:(ABSTRACT TRUNCATED AT 250 WORDS)

[Recommendations for standardized radiologic follow-up of thrust plate endoprosthesis]. / Empfehlungen für die standardisierte radiologische Nachuntersuchung der Druckscheibenendoprothese.

The thrust-plate endoprosthesis (TPE) is a cementless, total endoprosthetic replacement of the coxal femur with metaphysical anchorage. A combination of the TPE with an endoprosthetic cup component, which is also cementless, is recommended based on the concept of the TPE. The TPE requires a special radiological technique. In radiological follow-up examinations, the positioning area of the TPE, particularly on the resected femoral neck, is especially important. A gap-free, level positioning of the implant on the resected and flat-ground femoral neck is ideal. In order to be able to exactly judge the positioning area, the bony area and the TPE that lies on it should have no overlap in the anterio-posterior optical path of the X-ray and must be hit exactly orthogonally by the central X-ray beam. As radiological examinations of human femoral preparations show, this succeeds best with an inner rotation positioning of the femur from 10 to 20 degrees. According to our experience, especially in freshly operated patients, the positioning of the legs with the femur in a slightly abducted position (about 10-20 degrees) is better tolerated. Only when the positioning of the TPE cannot be exactly judged with the above-mentioned examination method should the examiner use an X-ray image intensifier. Experience has shown that this is only necessary in exceptional cases. In the present examination, the special problems of radiological examination of the TPE are discussed. Recommendations for standardized radiological examinations, as well as findings following TPE implantation, are given.

[Reconstruction technics for ruptured rotator cuff]. / Rekonstruktive Techniken der Rotatorenmanschetten-ruptur.

The principal signs for the diagnosis of a ruptured rotator sheath are a painful arch and painful, restricted movement of the shoulder joint. The diagnosis is confirmed by arthrography. Surgical reconstruction is indicated only if prior conservative treatment has been unsuccessful. A variety of approaches to the rotator sheath are advocated. Of these, the posterior-superior incision described by Debeyre et al. is particularly worthy of consideration. This approach is especially suitable for more extensive ruptures. It is described here with modifications, including the various fixation methods used for rupture of the rotator sheaths in the authors' own patients. The results obtained by the authors are classified and compared with opinions expressed in the literature. It is emphasized that the procedure described is particularly suitable for reconstruction of ruptured rotator sheaths.