[Chondromalacia patellae--arthrographic observations on the genesis and diagnosis of cartilaginous damage (author's transl)]. / Die Chondromalacia patellae--Arthrographische Beobachtungen zur Genese und Diagnose.

Thanks to recent advances in arthrography, diagnosis of cartilaginous lesions has increasingly become a task of the radiologist. An accurate assessment of the cartilage of the femoropatellar joint can be established via double-contrast technique and so-called "défilé" projections, whereas the axial projection of the patella without contrast medium shows only secondary arthrotic changes of bone and is unsuitable for demonstrating early cartilaginous damage. The classification of dysplastic patellae into different types according to Wiberg and Baumgartl yields a statistical correlation with the frequency of chondromalacia, but does not give any conclusive evidence in individual cases. A special influence on joint mechanics and the development of chondromalacia patellae is exercised by a cartilaginous ridge of the medial patellar facette.

[Shoulder arthrography in rheumatoid arthritis]. / Schulterarthrographie bei rheumatoider Arthritis.

Shoulder arthrography in a patient with rheumatoid arthritis is performed to differentiate between a rheumatoid flare and limitation of motion secondary to tear in the rotator cuff. Accurate diagnosis is important because of the therapeutic implications. The arthrographic findings characteristic of rheumatoid involvement of the shoulder joint are nodular filling defects of the joint, the subacromial and subdeltoideal bursa in case of rotator cuff tear, irregular capsular attachment, contracted joint space and visualized lymphatic drainage. A dilatation of the biceps tendon sheath has not been shown.

[The importance of radiologic studies for the differentiated treatment of scoliosis]. / Die Bedeutung radiologischer Untersuchungen für die differenzierte Behandlung von Skoliosen.

Structural scoliosis is defined by curvature, fixation, rotation and torsion. Each case is different and must be assessed on the basis of etiology, flexibility, patient age, skeletal age, progression and degree, level, and the number of the deformities in order to decide whether conservative or operative treatment should be administered. The most important factor in the choice of therapy is radiographic evaluation to allow accurate measurement. This involves standing X-rays of the whole spine (plan d'éléction), checking with corset and cast, tomography, spot-film radiography, CT and MRI in congenital and neuromuscular deformities and neurofibromatosis, oblique projection after operations, and radiography of the left hand and the iliac crest to determine the bone age. The classification and terminology of scoliosis are presented, as are the interpretation and measurement of the radiographs and the treatment indications.

Biomechanics of the patellofemoral joint and its clinical relevance.

An analysis of the patellofemoral joint based on experimental determinations of pressure distributions on the patellar cartilage and vectorial calculations is presented. The extension torque of all quadriceps muscles is similar. The force transmitted to the patella by the retinacula is small in all knee positions. Because the rigid patella has its own lever arms and tendon insertions at different heights, the forces on patellar and quadriceps tendons are unequal. The small patellar contact areas change according to flexion and are dependent on quadriceps force. Retropatellar pressure is thereby limited and becomes independent of flexion angle. By virtue of the direct force transmission of the quadriceps tendon to the femur, the increase in the retropatellar force is strongly limited beyond 70 degrees. The lateral-to-medial ratio of contact areas, pressing forces, cartilage areas, and bone mass is always 1.6:1, whereas the mean pressure is the same on both facets. The osseous form of the patella does not allow identification of dysplasia because cartilage compensates for apparent incongruence, especially about the medial ridge. This permits the rigid patella to adapt itself to very different abutments. Its individual form results from functional adaptation and does not explain chondromalacia. The ventralization of the tibial tuberosity does not alter retropatellar loading. The mediodistal transfer results in a high increase of pressure on both facets.

[Resection arthroplasty of the metatarsophalangeal joints after Clayton (10 years of clinical experience) (author's transl)]. / Die Resektionsarthroplastik der Metatarsophalangealgelenke nack Clayton. 10 Jahre klinische Erfahrung).

57 resection arthroplasties of the metatarsophalangeal joints using the method of Clayton were performed in arthritic and arthrotic deformities of the forefoot. 43 feet were controlled after an average of 5 years postoperatively. The good postoperative position of the toes changes into a progressive shortening, dorsal transposition and frequently valgus direction of the toes during the first year after operation. The deformity is much less than preoperatively. Passive mobility is good, but there is little active motion. The splay foot deformity is reduced in 50% of the cases. No arthritic recurrences were observed, callosities, clavi and mild pain were rarely found. Foot movements, walking ability was improved in all patients and 50% were wearing standard shoes. The results are influenced negatively by errors in resection technique, particularly lack of plantar rounding, exaggerated resection and unfavourable differencies in length of the metatarsal bones, and occasionally by secondary ossifications.

[Neurovascular compression syndroms of the shoulder girdle (author's transl)]. / Neurovaskuläre Kompressionssyndrome im Schultergürtelbereich.

Shoulder girdle compression syndroms appear intermittently and according to body carriage. Very seldom they are caused by neck ribs, mostly by a costoclavicular narrowness. Important for the symptoms is the nerval plexus compression, for diagnostic reasons the blood vessel compression. Essential are provocating tests, subclavia phonogramms and in doubtful cases, angiography. Oszillo- and sonography often fail, EMG and nerval conductive measurement are only of differential diagnostik importance. In all together 120 healthy persons compression was shown phonographically, phlebographically and manometrically in 58--88%. Only the symptomatic and distinct compression are abnormal. Physiotherapy should be applied, only operative decompression is a causal treatment. The transaxilar resection of the first rib with scalenotomy and eventually also resection of a neck rib is by fat better than any other method. This is a report of 112 operated patients.

[Dwyer's calcaneal osteotomy for varus deformity of the foot. (A follow-up study including gait analysis) (author's transl)]. / Die Calcaneus-Osteotomie nach Dwyer bei der Varusfehlstellung des Rückfusses. (Nachkontroll-Untersuchung mit Ganganalyse).

A follow-up study on 20 patients one to 9 years after lateral wedge resection of the calcaneus according to Dwyer is reported. In 18 feet with neurogenic varus deformity of the hind foot, the angle between the axis of the lower leg and the heel was altered from 11.4 degrees +/- 1.4 degrees SD varus to a normal value of 5.9 degrees +/- 0.9 degrees SD valgus. The position of the calcaneal tuberosity was changed from 6.7 degrees +/- 1.1 degree SD varus to 0.1 degree +/- SD varus in 7 congenital club feet. The osteotomy reduced accompanying deformities of pes cavus and pes adductus in the operated children.

[Therapy of gonarthrosis using chondroprotective substances. Prospective comparative study of glucosamine sulphate and glycosaminoglycan polysulphate]. / Die Therapie der Gonarthrose mit chondroprotektiven Substanzen. Prospektive Vergleichsstudie zwischen Glukosaminsulfat und Glykosaminoglykanpolysulfat.

68 patients with mild or moderate gonarthritis were treated with intra-articular injections of glucosamine sulphate or glycosaminoglycan polysulphate over a period of six weeks. The therapy was successful in two thirds of these patients. "Loading" pain was eliminated or improved in about 80%, "getting-going" pain in about 64%, and signs of synovialitis in about 66%. Gait function and mobility were improved. Glucosamine had a superior effect, in particular in mild arthritis, achieving an improvement of pain in 90%, while glycosaminoglycan polysulphate was successful in advanced cases. The tolerance of the two substances was 94%. The results and the underlying modes of action of the substances are discussed.

[Morphometric analysis of the proximal tibial cartilage tissue (author's transl)]. / Morphometrische Analyse des Tibiakopfknorpels als Beitrag zum Arthroseproblem.

We analysed the tibial cartilage of 5 juvenile and 10 adult non-degenerative knees for morphometric criteria. Determination of cellular and nuclear total volume per unit cartilage volume,, number of cells and nuclei per unit cartilage volumen and cellular and nuclear single volumen of chondrocytes in the superficial and basal cartilage layer was done in relation to their being covered by meniscus. We found cells and nuclei and their total volumen in the superficial layer constantly smaller, number of chondrocytes and nuclei constantly higher than in the basal layer. This was clearly seen in the meniscus-covered part of cartilage, less marked in the central non-covered part. In adults the central cells are superficially hypertrophic and gain few individual and total volume in the basal layer. These superficial central cells are on a high level of metabolism, synthesising much intercellular substance, but they prostrate in basal direction. The aging chondrocyte is maximal adapted to the strain and uncapable to react to further load.

[Experimental patello-femoral contactprint measurements. 2. Report: sagittal osteotomy of the patella according to Morscher (author's transl)]. / Experimentelle patello-femorale Kontaktflächenmessungen. 2. Mitteilung: Die sagittale Patellaosteotomie nach Morscher.

The recommended treatment method for chondropathy from Morscher 1978 using a sagittal patellaosteotomy was tested experimentally with contact area measurements with the erasing method on 11 corpse knees of the types II, II/III and III. Measurements were made in the bending region up to 90 degrees, and in isolated positions up to 140 degrees. The measurements showed a clear decrease in the contact area of the medial side of the lateral facet, and occassional displacement of contact whereby loses on the paramedial segment were compensated for by early loading on the border segment. Thus unphysiological loading of the medial facet occurred, from which chondromalasys could develop. Only three patellas had an increased contact area during inflexions up to 90 degrees, and then only because the central cartilage area, which usually undergoes the greatest loses, was already incongruent. Since during a complete knee bending the retropatella cartilage has almost 100% contact and that due to the medial cartilage ridge a considerably smaller incongruence is present as can be expected from the bone crosssection of the patella, we cannot expect any contact increase through an osteotomy.

[Contact surfaces, compressive forces and pressure distribution in osteosynthesis. Model studies using pressure-sensitive foil]. / Kontaktflächen, Anpresskräfte und Druckverteilung bei Osteosynthesen. Modelluntersuchungen mit Druckmessfolien.

Previous pressure gauges have been unable to measure exactly the stress over the cross-section of fractures or osteotomies. This first became possible with the pressure sensitive foil. Known operative procedures were examined with this foil using a self-compressing plate and a synthetic tube model. Contact area, compressive force, pressure and pressure distribution were measured simultaneously and analogously. A straight plate produces extremely little force and pressure on the gap. Both are limited to about a quarter of the cross-section just below the plate. The consequence is no sufficient stability. Also, using a prebent plate results in inhomogeneous pressure distribution with high values, but a distinct decrease of the stress on the opposite side of the plate, especially by compression applied at the end of the plate. But compression from near the fracture side gives the highest values and a most homogeneous force distribution. In this case the force recorded 1700 N, the mean pressure 5,2 MPa and the contact 90% of the cross-section. The length thrust of the plate ends approximately at a torque of screw tightening at 1,0 Nm. Using torques up to 2,5 Nm, force and pressure increase isometrically. Higher torques have no influence. Converging screws result in smaller contact, force and pressure, because they produce a vector force away from the gap and a smaller length thrust.

[Correction of Bechterew kyphosis]. / Die Korrektur der Bechterew-Kyphose.

The derangement of posture in advanced flexion deformity due to ankylosing spondylitis, as well as operative correction procedures are analysed. The "Dorsal Lordosating Spondylodesis", DLS, according to Zielke is introduced. This method of polysegmental correction and transpedicular fixation via USIS implants allows the recreation of a balanced upright posture by restoration of smooth lumbar lordosis. We present results of 173 patients corrected by DLS. Since the total amount of correction is split into 5-7 osteotomy sites, complication rates are substantially lower than in the monosegmental methods. Besides the gain of body height and immediate pain relief, the restoration of a horizontal axis of vision could be achieved. The latter, for all patients the most important feature, was maintained as up to 5 years follow-up's show.

Polysegmental lumbar osteotomies and transpedicled fixation for correction of long-curved kyphotic deformities in ankylosing spondylitis. Report on 177 cases.

Despite conservative therapy in ankylosing spondylitis, kyphotic deformities are common. Mono-segmental lumbar osteotomy had a high complication rate. Therefore, a poly-segmental lordosis osteotomy of the lumbar spine was introduced in four to six segments using trans-pedicled screws and threaded rods in eight to ten segments (isolated correction is possible for each segment). Instead of dangerous short kinking, a poly-segmental lordosis osteotomy results in harmonious lordosis with a correction per segment of about 10 degrees, and complications are decreased. Of 177 patients undergoing the operation, there was a 2.3% mortality rate with cardiopulmonary problems, 2.3% with irreversible complications, and 18.1% with reversible complications, mostly small root lesions, of which 7% were reoperated. The 173 surviving patients had a correction of 43%, and improvement in body height of 9 cm, and improvement of flexion by 57%. Fifty-three patients have been followed for more tha 18 months. the visual axis in all cases was horizontal. No pseudoarthrosis occurred. After correction, the frequent spondylodiscitis healed. Ninety-two percent were pain free compared with 15% before the operation. Loss of correction of body height was 20%, of flexion 4%, and of the lordosis 7%, which was 18% in 37 patients after three years.

[Spondylodiscitis in kyphotic deformity of ankylosing spondylitis and its healing affected by dorsal correction osteotomies. Report of 33 patients]. / Die Spondylodiszitis bei kyphotischer Deformität der Spondylitis ankylosans und ihre Ausheilung durch dorsale Korrekturosteotomien. Bericht über 33 patienten.

Out of 144 patients with kyphotic deformities in Ankylosing spondylitis 33 (23%) had 45 disco-vertebral lesions of the spondylodiscitic type. They were characterized by osteolyses, scleroses and absence of syndesmophytes. 5 had additional arch fractures. All were localized in or below the apical vertebra in the lumber or the lower thoracic spine. Compared with the total collective strong pain, high sedimentation rates and extravertebral manifestations were more frequent, osteoporosis rare, and the degree of kyphosis and the types of ossification same. The radiology showed the lesions as inflammatory etiology. Functionally, however, they are pseudarthroses. All spines were lordosed by dorsal osteotomies and therewith statically corrected and for one year externally immobilized. The spondylodeses fusioned in this time. Complications did not occur on account of the spondylodiscites. The therapy of kyphosis had an influence on the spondylodiscites. They all healed except for one. After a follow up of two years 98% were completely fused, also those with non-identical levels of correction and lesion. The loss of correction in the segments of lesion was negligibly more than in the total collective. 91% of the patients were pain-free compared to 12% preoperatively. The spondylodiscites were no hindrance for dorsal lordosing osteotomies and can be treated successfully by means of this static correction and the immobilisation.

Management of bleeding disorders in traumatic-haemorrhagic shock states with deep frozen fresh plasma.

Coagulation disorders in traumatic-haemorrhagic shock need not represent a simple coagulation problem. They may also occur as a complex of local and disseminated intravascular consumption, dilution, extravascular loss and depressed synthesis of coagulation factors. In the severely bleeding patient with a haemorrhagic diathesis heparin is contrainedicated because it does not normalize coagulability immediately. Therefore, it fails to stop haemorrhage and the shock becomes untreatable. Fresh frozen plasma, however, has proved to be suitable as a simultaneous substitution therapy for the coagulation disorder and the hypovolaemic shock. 25 patients suffering from severe traumatic-hemorrhagic shock associated with coagulation disorders and haemorrhagic diathesis were successfully treated with fresh frozen plasma, after conventional shock therapy had failed over a period of 2 hours. The success was documented clinically and by numerous laboratory tests. Thrombocytopenia has only a secondary responsibility for the haemorrhagic state.

[Carcinoids of the small intestine. Retrospective study of the radiological diagnosis of 15 patients (author's transl)]. / Karzinoide des Dünndarms. Retrospektive Studie der radiologischen Befunde von 15 Patienten

The radiological workup of 15 patients with a carcinoid has been evaluated. As 7 of the 15 patients presented for emergency operation, only the remaining 8 had barium studies (7 barium meals and 1 barium enema). Two of the barium meals were even retrospectively, entirely negative. In two others, initially the diagnosis was missed despite radiological signs, which had been overlooked on follow-up films. Fluoroscopic examination of the small bowel would probably have ensured the detection of the lesion. At the time of diagnosis nine tenth of the tumours were already infiltrating and more than half of them metastasizing. The presence of the carcinoid syndrome implies the production of the causative hormones in the liver or the pulmonary circulation. In order to find the primary intestinal carcinoid in a cureable stage- that is, before it has metastasized-, all patients with diarrhoea and repeated bouts of abdominal pain should have a careful follow-up examination of the small bowel. This examination must include fluoroscopies.

[Freshly frozen preserved plasma for the treatment of intravascular coagulation in polytraumatized patients]. / Frischgefroren konserviertes Plasma zur Behandlung der intravasalen Gerinnung beim Polytraumatisierten

Coagulation disorders in hemorrhagic shock need not represent an isolated intravascular coagulation. They may also occur as a complex of local disseminated intravascular consumption, extravascular consumption, dilution, and reduced synthesis of coagulation factors. In the severely bleeding patient with hemorrhagic diathesis heparin is contraindicated because it does not normalize coagulability. Therefore, it fails to stop hemorrhage and shock remains untreatable. Fresh frozen plasma, however, has proved to be suitable as simultaneous substitution therapy of coagulopathy and of hypovolemic shock. 11 patients suffering from traumatic-hemorrhagic shock associated with intravascular coagulation and hemorrhagic diathesis were successfully treated with fresh frozen plasma, after conventional shock therapy had failed over a period of hours.