An alternative treatment method to restore limb-length discrepancy in osteoarthritis with high congenital hip dislocation.

AIM: The purpose of this study was to describe the rationale and to analyse the results of uncemented total hip arthroplasty (THA) in patients with osteoarthritis and congenital dislocation of the hip (CDH) prior to iliofemoral distraction. METHOD: Twenty hips were followed-up for 5.8 years (1-12 years). First the THA components were implanted after soft tissue release. In the interval, iliofemoral distraction with an external distraction apparatus was conducted. The second surgery consisted of an open reduction. An iliofemoral distraction of 0.8 mm/day was monitored. The treatment time was 86 days (50-210 days). In 61 days (32-94 days) the hip joints were distracted for 51 mm (41-75 mm). RESULT: The Harris Hip Score increased significantly by 47 points. The SF-36 health score showed a satisfying increase in all patients. CONCLUSION: In experienced hands this method is a relatively safe procedure for limb-length equalization in patients with severe CDH.

Numerical investigations of stress shielding in total hip prostheses.

Aseptic loosening of the prosthesis is still a problem in artificial joint implants. The loosening can be caused by, among other factors, resorption of the bone surrounding the prosthesis owing to stress shielding. In order to find out the influence of the prosthesis type on post-operative stress shielding, a static finite element analysis of a femur provided with the conventional uncemented stem BICONTACT and of one with the femoral neck prosthesis SPIRON was carried out. Strain energy densities and maximal principal strain distributions were calculated and compared with the physiological situation. Here, stress shielding was demonstrated in both periprosthetic femora. To determine the areas of the stress shielding, the bone in each FE model was subdivided into three regions of interest (ROI): proximal, diaphyseal, and distal. The numerical computations show stress shielding in the proximal ROI of both periprosthetic femora. Diaphyseally, the femoral neck prosthesis SPIRON, in contrast to the conventional uncemented long-stem prosthesis BICONTACT, causes no decrease in the strain distribution and thus no stress shielding. Distally, no change in the load distribution of either periprosthetic femur could be found, compared with the physiological situation.

[Radiologic evaluation of cup placement variation in conventional total hip arthroplasty]. / Radiologische Evaluation der Variationsbreite der Pfannenpositionierung bei konventioneller Hüftendoprothesenversorgung.

PURPOSE: Determination of the amount of variation in conventional acetabular cup positioning (radiological inclination and anteversion) in view of different factors that could influence the measured angles. MATERIALS AND METHODS: The intended acetabular cup position of 45 degrees inclination and 20 degrees anteversion was checked radiologically in 950 patients who received a cementless total hip replacement. The qualifications of the surgeon, operated side and implant model were recorded and analyzed with respect to a possible correlation with the results. Since a "safe angle" cannot be defined without consideration of other variables, a tolerable deviation of the target position was investigated. RESULTS: The mean inclination angle was 48.7 degrees (SD 7 degrees, minimum 28 degrees, maximum 75 degrees ). Anteversion was measured with a mean of 18.6 degrees (SD 9 degrees, minimum -9 degrees, maximum 50 degrees ). Assuming an acceptable deviation of +/- 5 degrees from the target position (45 degrees inclination and 20 degrees anteversion), only 22.7 % of the acetabular cups were in this range. In the case of an acceptable deviation of +/- 10 degrees, 34.5 % of the cups were still outside of the acceptable range. The qualifications of the surgeon, the implanted model, as well as the operated side did not have a significant influence on the results. CONCLUSION: The common implantation technique yielded significant variation with respect to anteversion and inclination. The application of computer-aided navigation in the placement of acetabular cups would help to improve accuracy and reproducibility considerably in total hip arthroplasty.

Chronic symptomatic proximal tibiofibular instability in a 3-year-old girl.

A 3-year-old girl was presented with recurrent pain at the right knee and a "snapping" when walking. A free range of motion of both knee joints, stable cruciate and collateral ligaments and a ventrally subluxating and snapping fibula when flexing the knee were found. Due to a longer course of recurrent subluxation and pain, an operation was performed and the tibiofibular ligaments and joint capsule were tightened by sutures. Other operative techniques proposed in the literature are discussed; most of them could lead to deformities or growth disturbances. The reports of tibiofibular instability in the literature are presented. The girl is the youngest patient with idiopathic proximal tibiofibular instability reported in the literature at least in the last 75 years.

[Results of hip arthroscopy in sports related groin pain]. / Ergebnisse der Hüftarthroskopie bei sportabhängigen Leistenschmerzen.

INTRODUCTION: The study analyses the intraoperative findings and the clinical results of hip arthroscopy in sports related groin pain. METHODS: Between june 1998 and october 2002 we performed hip arthroscopy in 30 athletes (12 female, 18 male) with a history of sports related groin pain. Their average age was 36 (20 to 68) years. All patients had a clinical follow-up- examination at an average of 20 (12 to 48) months postoperative. The result was rated using the Larson-Score. RESULTS: We found a lesion of the acetabular labrum and performed a partial resection at 17 patients (57 %) (synovitis: n = 28 [93 %] loose bodies: n = 6 [20 %] torn ligamentum teres: n = 4 [13 %], others: n = 2 [6 %]). 11 patients (37 %) had a cartilage degeneration grade II in the Outerbridge classification (III degrees : n = 9 [30 %], I degrees : n = 4 [13 %], 0 degrees : n = 6 [20 %]). Preoperative 14 patients (47 %) complained severe groin pain (moderate: n = 14 [47 %], slight: n = 2 [6 %]) against only 3 patients (10 %) with severe groin pain at the follow-up examination (moderate: n = 11 [37 %], slight: n = 16 [53 %]). Following hip arthroscopy 28 patients (94 %) returned to full sports activity. The Larson-Score was increased significantly (p < 0.05) rating 43 (10 to 64) points preoperative to 59 (28 to 80) points at the follow-up. DISCUSSION: We found that persistent sports related groin pain was frequently caused by an intraarticular hip disorder. Following hip arthroscopy pain could be reduced in most patients as a return to full sports activity.

In vivo corrosion of four magnesium alloys and the associated bone response.

Degrading metal alloys are a new class of implant materials suitable for bone surgery. The aim of this study was to investigate the degradation mechanism at the bone-implant interface of different degrading magnesium alloys in bone and to determine their effect on the surrounding bone. Sample rods of four different magnesium alloys and a degradable polymer as a control were implanted intramedullary into the femora of guinea pigs. After 6 and 18 weeks, uncalcified sections were generated for histomorphologic analysis. The bone-implant interface was characterized in uncalcified sections by scanning electron microscopy (SEM), element mapping and X-ray diffraction. Results showed that metallic implants made of magnesium alloys degrade in vivo depending on the composition of the alloying elements. While the corrosion layer of all magnesium alloys accumulated with biological calcium phosphates, the corrosion layer was in direct contact with the surrounding bone. The results further showed high mineral apposition rates and an increased bone mass around the magnesium rods, while no bone was induced in the surrounding soft tissue. From the results of this study, there is a strong rationale that in this research model, high magnesium ion concentration could lead to bone cell activation.

Trapezius transfer in brachial plexus palsy. Correlation of the outcome with muscle power and operative technique.

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha's technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique. The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6 degrees (0 to 45) to 34 degrees (5 to 90) at the last review. The mean forward flexion increased from 12 degrees (0 to 85) to 30 degrees (5 to 90). Abduction (41 degrees) and especially forward flexion (43 degrees) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42 degrees of abduction and 56 degrees of forward flexion. Active abduction (28 degrees) and forward flexion (19 degrees) were much less in completely flail shoulders (n = 34). Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished. The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.

[Treatment of incomplete meniscal lesions in athletes]. / Die Therapie des inkompletten Meniskusrisses beim Sportler.

PURPOSE: Arthroscopic treatment of complete meniscal lesions is well established. Nevertheless there is discussion, how to treat incomplete meniscal tears, especially in younger and active patients. This study was designed to evaluate our standard-therapy without refixation of the meniscus. METHOD: Between 7/89 and 3/01 in 47 patients (48 knees, Ø age 29 years) an incomplete meniscal lesion following sports injury was found. The lesions were revitalized by "needling" or shaving. We performed no refixation. All patients had a postoperative flexion limit in an orthosis for 6 weeks. The follow-up examination was performed 6.5 (2 - 14) years postoperative. RESULTS: The avarage Lysholm-Score increased significantly from 55 points preoperative to 92 points at the follow-up examination. The Tegner-Score increased from 3.3 points preoperative to 6.2 points at the follow-up examination. The overall result was rated "exellent" and "good" by 83 % of the patients, "fair" by 15 % of the patients and "poor" by 2 % of the patients. Return to sports activity was possible at an avarage of 7 (3 - 12) months postoperative. CONCLUSIONS: In summary we found, that shaving and "needling" of an incomplete meniscal lesion in combination with partial synovectomi and standardized postoperative treatment leads to a high healing rate. A limited flexion for 6 weeks postoperativ in an orthosis at full weight bearing is recommended. In case of complete healing of the lesion the chondroprotective and joint stabilizing function of the meniscus, especially in young and active patients is obtained.

Biterminal tenotomy for the treatment of congenital muscular torticollis. Long-term results.

Fifty-five patients who, in a twenty-eight-year period, had been managed with a biterminal open release because of congenital muscular torticollis, were re-examined at an average of fifteen years and a minimum of five years after the operation. Forty-eight patients reported no functional or cosmetic impairment. Palpable soft-tissue strands remained in twenty-nine patients, but bending toward the untreated side was limited more than 10 degrees in only one patient. The rate of recurrence was 2 per cent. Facial asymmetry improved or resolved in more than one-half of the patients. We recommend that biterminal release be performed at the age of three to five years in all patients who do not respond to non-operative treatment.

A dynamic shoulder model: reliability testing and muscle force study.

This study introduces a dynamic shoulder model, where forces were applied to individual muscles in ten cadaveric specimens. The model provided reproducible glenohumeral joint motion and thereby allowed the investigation of active, glenohumeral joint mechanics. Forces were created by servo-actuated hydrodynamic cylinders and applied to the deltoid muscle and to the rotator cuff through wire cables. Computerized regulation initiated precise, time controlled cycles of glenohumeral joint motion. The position of the glenohumeral joint in all spatial orientations was measured and recorded using an ultrasonic sensor device. Reproducibility of glenohumeral joint motion was demonstrated on the basis of five cycles of glenohumeral joint elevation. Repeatability variance of position measurements for five cycles of elevation averaged 0.80 degrees for abduction, 0.75 degrees for anteflexion and 1.36 degrees for internal rotation. Arm weight and force distribution at the shoulder musculature were estimated according to the literature. In comparison to estimated physiologic conditions, a one third increase of arm weight led to a significant (p < 0.05) decrease of elevation of 20%, a one third decrease of arm weight to an average increase of elevation of 18% (p < 0.05). Exclusion of the supraspinatus muscle caused a significant (p < 0.05) 6% decrease of elevation of the glenohumeral joint. Without force applied to the subscapularis and infraspinatus/teres minor muscles, elevation decreased 16% (p < 0.05). A decrease of glenohumeral joint elevation of 25% resulted when force was applied to the deltoid muscle alone (p < 0.05).

Reconstruction of the anterior cruciate ligament. A new positioning and fixation technique.

A new technique for ACL reconstruction is presented. The middle third of the patellar tendon is anchored to the inner surface of the lateral femoral condyle under direct visual control. The transplant is fixed tibially beneath a bone block removed from the ventral tibial head. Thirty-three patients were evaluated preoperatively and 27 months (range, 24 to 30 months) postoperatively. The mean preoperative function score (Lysholm scoring scale) was 72 +/- 14 points; the mean postoperative score was 84 +/- 13 points. The Lachman test was positive for all patients preoperatively, but the test results in the postoperative follow-up examination were negative--1+ in 31 knees and 2+ in 2 knees. All 33 knees elicited a definite "hard" end point. The postoperative KT-1000 measurement for anterior tibial displacement showed no significant difference between the operated versus the unoperated knee. Before their knee injury all patients had been engaged in sports. At the follow-up examination, 13 patients had made a full return to their former sports activities, 13 were restricted in their sports activities, and 7 patients no longer participated in sports.

Dynamic double tendon replacement of the posterior cruciate ligament.

Reconstruction of the posterior cruciate ligament combined with medial capsular repair was performed in eight men and four women whose average age was 29 years. In an effort to simulate the tensile behavior of the two major divisions of the posterior cruciate ligament, i.e., the anterolateral and posteromedial portions, we used the gracilis and semitendinosus tendons as substitutes. Since we consider this a dynamic operation, we feel its full benefits are measured better by functional parameters than by purely objective parameters. Accordingly, followup between 1 and 4 years (averaging 32 months) revealed all patients were subjectively pleased with their operative results. Postoperative objective evaluation still demonstrated a positive posterior drawer sign (although decreased) in all cases and a diminished medial joint space opening in most cases. Thigh girth differences were found at followup in most cases, probably as a result of disproportionate activity of the contralateral extremity. We feel that our dynamic reconstruction is an excellent alternative when one is considering surgery for a torn posterior cruciate ligament.

[Scintigraphic control and x-ray findings following the cement-free implantation of the PM shaft in connection with hip joint allo-arthroplasty]. / Szintigraphische Verläufe und röntgenologische Befunde nach zementfreier Implantation des PM-Schaftes im Rahmen der Hüftgelenksalloarthroplastik.

147 bone scans with 99mTc-MDP following 60 cementless hip arthroplasties were analysed at 3 to 160 weeks after operation. Results are compared to clinical evaluation according to Merle d'Aubigné. X-ray changes in a number of patients are included. In uncomplicated cases, bone scan activity decreased quickly within 26 weeks postoperatively. Decrease of scintigraphic activity was markedly delayed in patients with low Merle d'Aubigné values or persisting pain. In 4 cases, bone scan activity increased again. In these cases, reoperation revealed rotational instability of the shaft endoprostheses. Unusual x-ray phenomena such as development of a bony cup at the tip of the prosthesis or seams were found mainly in patients with less satisfying results. We consider nuclear imaging an important additional examination to evaluate bony integration of PM shaft endoprostheses after hip replacement, especially as interpretation of x-ray features alone is still doubtful.

Reconstruction of the lateral ligaments of the ankle using a regional periosteal flap.

We have treated 94 patients with chronic instability of the lateral side of the ankle by reconstruction of the ligaments with local periosteal tissue. We reviewed 90 cases after a mean follow-up of 2.8 years (2 to 9) using a questionnaire, clinical examination and radiography. The results on a 100-point ankle score indicated that 81% had a good or excellent result. The periosteal flap-replacement technique allows anatomical reconstruction and does not sacrifice other ligaments or tendons in the foot.

Trapezius transfer after brachial plexus palsy. Indications, difficulties and complications.

Most brachial plexus palsies are due to trauma, often resulting from motorcycle accidents. When nerve repair and physiotherapy are unsuccessful, muscle transfer may be considered. Paralysis of the deltoid and supraspinatus muscles can be addressed by transfer of the trapezius. Between March 1994 and June 1997 we treated 38 patients with brachial plexus palsy by trapezius transfer and reviewed 31 of these (7 women, 24 men) after a mean follow-up of 23.8 months (12 to 39), reporting the clinical and radiological results and subjective assessment. The mean age of the patients was 29 years (18 to 46). The operations had been performed according to the method of Saha described in 1967, involving transfer of the acromion with the insertion of the trapezius to the proximal humerus, and immobilisation in an abduction support for six weeks. Rehabilitation started on the first postoperative day with active exercises for the elbow, hand and fingers, and electrical stimulation of the transferred trapezius. All 31 patients had improved function with a decrease in multidirectional instability of the shoulder. The average increase in active abduction was from 7.3 degrees (0 to 45) to 39 degrees (25 to 80) at the latest review. The mean forward flexion increased from 20 degrees (0 to 85) to 44 degrees (20 to 90). Twenty-nine of the 31 were satisfied with the improvement in stability and function. Trapezius transfer for brachial plexus palsy involving the shoulder improves function and stability with clear subjective benefits.

Medial meniscus replacement by a tendon autograft. Experiments in sheep.

In 20 skeletally mature female merino sheep, divided into four groups, we performed total medial meniscectomy, removal of the middle third of the patellar tendon, and tenotomy of the calcaneal tendon of the right hind leg. Group I (control) had no additional procedures. In the other three groups the medial meniscus was replaced by the middle third of the patellar tendon from the ipsilateral knee. The animals were killed at three (group II), six (group III), or 12 months (group IV) and the tendon-meniscus examined macroscopically, by light and scanning electron microscopy, and biomechanically. Remodelling of the tissue had taken place by 12 months but the failure stress and tensile modulus for the tendon-meniscus were lower than for the normal meniscus. Our evidence suggests that, in sheep, replacement of a meniscus by a tendon autograft may decrease the severity of the degenerative changes that occur after meniscectomy.

Relative motion of a mobile bearing inlay after total knee arthroplasty--dynamic in vitro study.

OBJECTIVE: The purpose of this study was to measure the in vitro range of motion of a mobile bearing inlay knee prosthesis under dynamic isokinetic loading conditions. Additionally, the effect on the range of motion of rotational malalignment of the tibia baseplate was determined. DESIGN: Specimens with implanted knee prostheses were mounted onto a custom built knee simulator. 3-D inlay movement was measured by an ultrasonic tracking system. BACKGROUND: More recent knee prostheses include mobile bearing inlays type designs. These systems are intended to allow higher conformity of the tibiofemoral joint and thereby decrease contact stress without decreasing the knee's range of motion. METHODS: Dynamic testing in the knee simulator mimicked both the speed and resulting moment of a knee isokinetic extension test. The tibia baseplate was first implanted with no rotational malalignment, followed by sequential internal and external rotation of upto 15 degrees. RESULTS: Correctly aligned, the inlay center moved 3.5 mm (SD, 1.5 mm) posterior during extension. With the tibia baseplate externally rotated more than 10 degrees the movement pattern changed. CONCLUSION: At up to 10 degrees of rotational malalignment the primary motion pattern of the mobile bearing is maintained. However, beyond 10 degrees unintended motion may occur. RELEVANCE: These test results correlate to radiographic measurements of in vivo movements of mobile bearing inlays showing "paradoxical" movement of the mobile inlay compared to physiologic meniscal movement.

High tibial osteotomy versus unicompartmental joint replacement in unicompartmental knee joint osteoarthritis: 7-10-year follow-up prospective randomised study.

The clinical outcome of patients treated either by high tibial osteotomy or unicompartmental arthroplasty for medial unicompartmental osteoarthritis of the knee was compared in a prospective randomised study. In total, 32 patients received a high tibial osteotomy (HTO) and 28 patients a unicompartmental arthroplasty (UKA). More intra- and postoperative complications were observed after HTO. Patients were assessed at an average of 2.5 (1.6-5), 4.5 (3.6-7), and 7.5 years (6.6-10) after the operation. Using the Knee Society Score, 71% (15) of patients after osteotomy and 65% (13) after replacement had a knee score of excellent or good 7-10 years postoperatively. The Kaplan-Meier survival analysis 7-10 years postoperatively showed a survivorship of 77% for UKA and 60% for HTO. Although the unicompartmental prosthesis used in this series has not shown promising results, we conclude that with the advanced design of unicompartmental prosthesis today, UKA offers better long-term success.

[Operability of primary inoperable pelvic tumors by preoperative regional hyperthermia in combination with systemic chemotherapy exemplified by Ewing's sarcoma]. / Operabilität primär inoperabler Beckentumoren durch präoperative regionale Hyperthermie in Kombination mit systemischer Chemotherapie am Beispiel eines Ewing-Sarkoms.

Failure of local tumor control is of critical importance in the clinical management of large pelvic tumors. For bulky sarcomas of the pelvis a new treatment strategy could be of importance in the future using preoperative regional hyperthermia combined with systemic chemotherapy. In our case history of a patient with unresectable Ewing sarcoma of the pelvis no tumor response could be observed during multi-drug chemotherapy alone. However, after treatment with regional hyperthermia combined with systemic chemotherapy, the tumor mass became resectable and was separated from the adjacent tissue by a fibrotic pseudocapsule. Histological evaluation of the tumor tissue showed a complete change of the pattern.

Trapezius transfer in deltoid paralysis.

In most cases the genesis of brachial plexus palsy is traumatic, often because of bike accidents. If physiotherapy and neurosurgical procedures such as nerve repair do not have the desired outcome, muscle transfer operations are possible. The results of our favored transfer of the trapezius muscle to compensate paralysis of the deltoid muscle will be presented. Preoperatively radiological, clinical and electromyographic examinations are necessary. Our results are based upon the clinical and radiological check ups and the subjective assessment of the patients. Thirty-one patients (7 female, 24 male) underwent a trapezius transfer between March 1994 and December 1996. The average age was 29 years (range 18-46 years). We performed the operations using a modification of Saha's technique. With the patient in lateral decubitus position and protection of the opposite plexus, a sagital skin incision is the first step, followed by the preparation of trapezius and deltoid muscle as well as the bony parts of the shoulder (acromion, clavicle, scapular spine). The deltoid origin is cut from the lateral third of the clavicle, the acromion and the lateral half of the scapular spine. The next step is transection of the root of the acromion and the lateral clavicle. After elevation of the remaining trapezius insertions from the clavicle and scapular spine, the proximal humerus is exposured by splitting the partly detached deltoid muscle longitudinally. Then the acromion fragment and humerus are prepared for the bone-to-bone contact. In 90 ° of abduction the acromion fragment with its trapezius insertion is transferred and fixed to the humerus with two 4.5-mm screws. Finally the deltoid is sutured on the top of the trapezius and the skin is closed over two suction drains. Postoperatively we immobilize the operated arm in an abduction support for 6 weeks. The physiotherapy program starts on the first postoperative day with active training of elbow, hand and fingers and electrostimulation of the transferred trapezius muscle. Six weeks after the procedure we take an X-ray and start with progressive adduction of the arm. The preoperative subluxation of the humeral head was abolished in all cases. We achieved an average increase of active abduction from 7.3 ° (range 0-45 °) preoperatively to 39.2 ° (range 25 °-80 °) 1 year after the operation; the increase of forward flexion was from 20 ° (range 0 °-85 °) to 43 ° (range 20 °-90 °). All patients were satisfied with the improvement of stability and function of the operated shoulder. Finally we can conclude that the trapezius transfer for flail shoulder gives a satisfactory outcome regarding shoulder function and stability as well as the subjective situation of the patients.