[Computed tomography of the menisci]. / Die Computertomographie der Menisci.

Thirty patients were examined with CT of the menisci. All findings were confirmed by arthroscopy. One false positive diagnosis of a torn meniscus was made, caused by partial volume effect. In seven patients with irregular degenerative changes of the menisci, the abnormality could be clearly demonstrated. One meniscus ganglion was shown. Seven meniscus lesions, which were not shown by arthrography or arthroscopy, were clearly demonstrated by CT. The computer tomographic demonstration of menisci can replace knee arthrography as the examination of choice and should be performed before carrying out arthroscopy.

[Imaging of the Achilles tendon on the computed tomogram. Normal findings and pathological changes]. / Die Darstellung der Achillessehne im Computertomogramm. Normalbefunde und pathologische Veränderungen.

Ligaments and tendons, including the Achilles tendon, show the highest density among normal soft tissue structures in the body. Traumatic and degenerative changes of the Achilles tendon are often associated with marked thickening and reduction in density associated with increased opacity of the space in front of the Achilles tendon. These changes are easily demonstrated by CT, whereas conventional radiological techniques only show non-specific changes. Twenty-five patients were examined, including nine with pain, seven following rupture of the Achilles tendon and nine post-operative controls; it was found that CT can add information important for the diagnosis and treatment planning of abnormalities of the Achilles tendon.

Aesthetic and functional results of harvesting radial forearm flap, especially with regard to hand function.

There is controversy in the literature regarding donor site morbidity following radial forearm flap harvesting. The aim of this study was to verify possible functional and aesthetic impairments at the donor site. Thirty-five patients who underwent maxillofacial reconstruction using radial forearm flap were asked to give their subjective assessment of the aesthetic outcome at the donor site and of postoperative hand function. They were also examined for trophic status; cold intolerance and tactile sensitivity of split-thickness skin graft, palm and finger pads; grip strength and finger-to-thumb pinch strength; range of movement for the wrist and finger joints; as well as functional hand testing. Slight impairments regarding hand strength and mobility were observed. However, due to their small extent they were of no clinical relevance, as shown by 85.7% of our patients displaying optimal functional hand testing values (80-100%), and 88.6% giving a positive subjective assessment (80-100%) of postoperative vs preoperative hand function. The results show that donor site morbidity following radial forearm flap harvesting is low.

The significance of multiple trauma in children.

Accident-related injuries, mainly traffic-connected, are the most serious threat to health and most-frequent cause of death in the pediatric age group. Usually these are multi-system injuries. While the total number of accidents has decreased over the last 20 years, traffic accidents have become more serious. Conventional prognostic scores are not applicable in children with multiple injuries because of their essential pathophysiologic differences with adults. The Pediatric Trauma Score closes this gap. It is simple to use and provides high reliability.

Multiple trauma in children patterns of injury--treatment strategy--outcome.

TOPIC OF THE STUDY: In 1994 more than 50,000 children under 15 years were involved in a road accident in Germany. About one third of them received major injuries and 431 children died. These data obviously show the importance of multiple trauma in children in a developed country. METHODS: Between 1985 and 1990, 64 multi-traumatized children were evaluated after receiving treatment at the Aachen University Hospital. It was possible to evaluate 66% of the patients at the follow-up examination after 1 and 5 years. The results have been measured with the ALOS (Aachen long-term outcome score) and the GOS (Glasgow outcome score) in relation to the degree of trauma. OWN RESULTS: 12.5% died mainly from the effects of a cerebral injury. 25% developed different complications. Again the effects of craniocerebral trauma determined the long-term outcome. All other injuries can be managed by aggressive treatment without major consequences. CONCLUSIONS: In multi-traumatized children, craniocerebral trauma is the key injury regarding both lethality and long-term outcome. Therefore, prevention is of primary importance. Aggressive treatment of thoracic and abdominal trauma can usually help to cure completely these injuries. Especially osteosynthetic procedures, exerting little strain and performed as appropriate for children, have made injuries of the limbs less critical.

[Reinforcement of freshly glued or sutured rupture of the anterior cruciate ligament using the semitendinous tendon. Indications and early results]. / Verstärkung der frisch geklebten oder genähten Ruptur des vorderen Kreuzbandes durch die Semitendinosussehne. Indikation und Frühergebnisse.

Inopportune rupture forms deteriorate the prognosis after reconstructive operations on the anterior cruciate ligament. In order to improve the treatment results, we apply fibrin glue on intraligamentous ruptures and reinforce the reconstruction result with a distally fixed semitendinosus tendon graft. In old ruptures with beginning degenerative changes on the rupture stumps we refix the rest of the cruciate ligament as a posterolateral ligament part through transosseous sutures and also use the semitendinosus tendon as a reinforcement graft. 19 of the 26 cruciate ligaments treated in this way were stable at the reexamination which took place 9 months after the operation on a average. 7 remaining instabilities are due to degenerative changes of both the tendon graft and the reconstructed rests of the cruciate ligaments: this could be proved by CT-studies. Using a tendon graft in combination with alloplastic materials ought to improve the postoperative results in future.

[Fresh rupture of the inner ligament of the knee joint. An analysis of a sports traumatologic patient sample from 1981 to 1987]. / Zur Problematik der frischen Innenbandruptur am Kniegelenk. Eine Analyse des sporttraumatologischen Krankengutes von 1981 bis 1987.

Acute injuries of the medial collateral ligament occur either isolated or in combination with lesions of the cruciated ligament and medial meniscus. 126 patients were investigated retrospectively and special attention was drawn to the distribution and kind of ruptures. All distal lesions of the ligament and the most of intraligamental ruptures were combined with injuries of the anterior cruciated ligament and posterior portion of the medial meniscus. On the contrary the more favourable proximal lesions were found "isolated" as well. But in these cases an elongation of the ligamentum popliteum obliquum and a dischargement of the posterior parts of the medial meniscus were common. True isolated lesions of the medial collateral ligament were found if only the deep ligamental layers were involved. Special attention is drawn to the large variety of surgical possibilities.

[Alloplastic treatment of knee ligaments. Experience using artificial support in fresh injuries of the inner ligament]. / Alloplastische Versorgung der Kniegelenksbänder. Erfahrungen mit der Kunststoffschienung bei frischen Innenbandverletzungen.

From November 1983 to July 1985 a plastic reinforcement of the collateral medial ligament was performed in 14 patients. In all cases there was an additional reconstruction of the anterior cruciate ligament and a partial resection respectively refixation of the medial meniscus. In order to confirm the collateral ligament alloplastically in 6 cases a non-resorbable plastic connection (Gore-Tex patch), in 8 cases a resorbable plastic connection (PDS) was used. All the patients could be clinically reinvestigated on an average of 13 months after the operation. The results are presented.

[Avulsion fractures of the knee and upper ankle joint. Classification and therapy]. / Abscherfrakturen am Knie- und oberen Sprunggelenk. Klassifikation und Therapie.

Injuries of the joint surface interfere with joint mechanics. Avulsed fragments should be reattached to prevent development of arthrosis. Of 150 fractures of the knee joint 72% were osteochondral and 28% chondral avulsion. About half of the chondral lesions could be refixed successfully. If replantation is impossible, this cartilage defect has to be smoothed and, when indicated, connected to spongy bone by subchondral drilling.

[Therapy for recent and old injuries of the fibular capsular ligament in the ankle joint]. / Die Therapie frischer und veralteter fibularer Kapselbandverletzungen am oberen Sprunggelenk.

Fresh injuries of the fibular capsule-ligament-complex in the age in which physical competition takes place must be treated surgically. To achieve optimal postoperative results, the different forms of ruptures of the fibular ligaments must be treated in a differentiated way. A reconstruction of the Lig. talofibulare anterius generally succeeds without trouble, whereas a reconstruction of the Lig. calcaneofibulare often requires a plastic replacement by a periostal flap. At old ruptures, however, the tendon plastic is the safest way of reconstructing the stability of the ankle. The distally stalked tendon graft has several advantages, especially when the graft is attached in accordance with the anatomy of the fibular ligaments.

[Injuries of the posterior end of the medial meniscus and the posterior oblique ligament. Classification and therapy]. / Verletzungen des Innenmeniscus-Hinterhorns und des hinteren Schrägbandes. Klassifikation und Therapie.

Meniscectomy undoubtedly leads to arthrotic degeneration in the knee joint. This can be proven by X-ray technique. It is especially the resection of the medial meniscus which increases the anteromedial instability of the knee joint. It is important therefore to preserve a meniscus whenever this is possible. The resection or partial resection of a medial meniscus showing a lesion in loco classico is still indicated. If, however, a meniscus is only marginally detached from its fixation to the lig. collaterale mediale posterior a carefully carried out reinsertion of the medial meniscus has proven to be appropriate. It is on one hand the vascular supply of the base of the meniscus which indicates a reinsertion, on the other hand an anteromedial instability of the knee joint can be compensated by a reinsertion.

[Patella dislocation with special reference to cartilage damage]. / Die Patellaluxation unter besonderer Berücksichtigung des Knorpelschadens.

Dislocations of the patella are discussed in the light of their pathogenesis, their possible injury pattern and their consequences. An exemplary case is presented. Especially the injury to the retropatellar cartilage with following chondromalacia--sometimes initiating the development of patellofemoral osteoarthritis--renders the dislocation of the patella a severe injury of the knee region. In case of spontaneous reduction and uncertain history the diagnosis may be difficult. The dislocation of the patella can be suspected if a hemarthrosis is found without an instability of the knee ligaments. The possibilities of an operative repair are described with special regard to the cartilage injury. Importance was layed upon the shape variabilities of the patellofemoral joint predisposing to recurrent dislocation.

[Results of the fixation of pertrochanteric fractures by condyle nails using Ender's and Simon-Weidner methods]. / Ergebnisse der Fixierung pertrochanterer Frakturen mit Kondylennägeln nach Ender und Simon-Weidner

2 year-results are reported after intramedullary fixation of pertrochenteric fractures with the so-called "feather nails" of Ender and Simon-Weidner. The procedure is discussed with special references to possible complications. This method performed with the necessary experience represents a real progress in the treatment of pertrochenteric fractures.

[Results of meniscus sutures in the framework of reconstruction in combined injuries of the knee joint: clinical aspects, arthrosonography, arthrography and computerized tomography]. / Ergebnisse von Meniscusnähten im Rahmen der Rekonstruktion von Kombinationsverletzungen des Kniegelenkes. Klinik, Arthrosonographie, Arthrographie und Computertomographie.

In spite of encouraging experimental results of suturing menisci in the not-vascularised area, even today in most of these cases subtotal resection will be done. The results of meniscal reconstruction in 15 patients with a longitudinal tear of the degeneration area as consequence of a combined injury of the knee joint are discussed. Only one patient suffered a postoperative rerupture. The others did not show any signs of continuing tears of the menisci during a study period of 18.7 months. Whereas in arthrography only in a few cases superficial notches, sign for a physiological recessus, were found, CT-scan as well as arthrosonography showed in large degree of correspondence change of density in the region of suture, which can be interpreted as a process of scar transformation. Thus it is recommendable to use suture of meniscus next to stabilizing measurements of injured knee-joint, even in the zone of degeneration.

[Biomechanics of the knee joint after meniscus resection. Stress analysis of the cadaver knee]. / Biomechanik des Kniegelenks nach Meniscusresektion. Belastungsanalysen am Leichenknie.

Load bearing analysis has been performed in cadaver knees after different types of inner meniscus resection in extension and in 30 degrees and 60 degrees flexion. Contact areas, mean and maximum pressure differences and load flow changes were measured in the medial and lateral compartment of the knee. The investigation led to following findings: After posterior meniscal tear the resection of the tear with marginal smoothing is followed by a minimum of parameter deviation. All the other types of resection like simple tear resection, partial meniscus resection, amputation of the posterior horn or subtotal resection are accompanied by highly increased deviations of the measured biomechanical parameters. Those are not only observed in the medial part of the knee but also in the lateral compartment. At the medial site a decrease of the load bearing area and the pressure can be registered. In contrast to that there is an increase of these parameters at the lateral site. Consecutive osteoarthritis after medial meniscectomy is therefore interpreted not as a result of increased pressure but of a floating load bearing.

[Determinants of the global quality of life after polytrauma]. / Determinanten der globalen Lebensqualität nach Polytrauma.

This study investigated multiple trauma patients, who were injured between 1991 and 1995 and treated in our department. The aim of this study was to identify the determinants of quality of life after multiple trauma. From a total of 186 patients 173 (93%) were examined. The patients were asked to rate their quality of life according to the Nottingham Health Profile (NHP) and to a visual analogue scale (VAS). The VAS and the NHP isolated the age of the patients, the duration of artificial respiration, and the duration of rehabilitation as the predictors for a reduced overall quality of life. These results show that quality of life after multiple trauma not only depends on the severity of injury but also on demographic and psychosocial factors.

[Ligamentization as an explanation for the stability of periosteal flap repair in the replacement of the fibular ligament system]. / Die Ligamentisation als Erklärung für die Stabilität der Periostlappenplastik beim Ersatz des fibularen Bandapparates.

The gold standard in the operative treatment of chronic insufficiency of the lateral ligaments of the ankle joint is replacement with a tendon (tenodesis). The disadvantage of this method is limitation of movement. The results of the replacement of ligaments with a periosteal flap are similar to the results after tenodesis, but the rate of complications is significant lower. We investigated the histological changes in periosteal flaps in patients. We saw an alignment of the collagenous fibers in the periosteal flap 8-12 weeks after the operation. The results are statistically significant. The conclusion is that the periosteal flap in the replacement of ligaments changes into a ligament-like structure.

[Free, vascularized, folded fibula transplantation]. / Die freie, vaskularisierte, gefaltete Fibulatransplantation.

A free vascularized folded fibula as possibility for reconstruction of segmental bony defects up to 9 cm is described. Preserving its vascularisation, the fibula is osteotomized and folded into two equal or two vascularized bone transplants of different length with only one arterial and venous pedicle. Folding of the fibula leads to a biomechanically superior stabilisation. This technique was used in a posttraumatic osteomyelitic defect of the tibia after a Pilon tibiale fracture.

[Meniscus preserving interventions of the knee joint]. / Meniskuserhaltende Eingriffe am Kniegelenk.

A meniscal lesion is the most frequent injury of the knee joint. Several experimental and clinical studies of the past 15 years pointed to the importance of the meniscus for the biomechanics of the knee joint. In particularly the posterior horn of the medial meniscus plays an important role regarding the stability of the joint. On the one hand, a total resection of the meniscus raises the risk of arthrosis, whereas on the other hand it increases the relative insufficiency of the medial capsule and collateral ligament. Because of these findings, nowadays the aim is to preserve most parts of the meniscus in case of injury. Apart from meniscopexia, longitudinal tears of the vascularised meniscus layer near the base, as well as of the so-called degeneration area, are sutured. Arthrographies performed postoperatively revealed smooth contours of the meniscus without any penetration of contrast fluid, which would have been a sign for a persistent lesion.

[Diagnosis and therapeutic management following traumatic anterior shoulder dislocation according to extrinsic prognostic factors]. / Diagnostik und Therapieplanung nach traumatischer ventraler Schulterluxation anhand extrinsischer Prognosefaktoren.

We examined the importance of preoperative CT- and NMR-imaging concerning the detection of a bankart-lesion by a retrospective evaluation of 36 patients with primary traumatic or posttraumatic recurrent shoulder dislocations. Because of unfavourable extrinsic prognostic factors, we advised shoulder arthroscopy and surgical stabilization in all cases. Intraoperatively 35 of 36 patients (97%) presented a bankart-lesion. Preoperatively a bankart-lesion was detected in 32 cases (91%) by CT (n = 29) or NMR (n = 7). We could predict the probability of a bankart-lesion with a high reliability by clinical evaluation alone due to several risk-factors. All patients had at least 2 unfavourable prognostic factors. Under these circumstances we could assume a bankart-lesion with a probability of 97%. Therefore in our opinion preoperative CT or NMR is not advised as standard diagnostic procedure in patients with high-risk of recurrence according to extrinsic prognostic factors. We recommend preoperative CT or NMR when the estimation of prognostic factors concerning the risk of redislocation is doubtful and in case of difficult clinical and ultrasound examination regarding shoulder laxity or rotator cuff lesions.