[Post-traumatic osteoarthritis of the elbow joint : Endoprosthetic options in young patients]. / Sekundäre Arthrose des Ellenbogengelenkes : Endoprothetische Möglichkeiten beim jungen Patienten.

BACKGROUND: In young patients, post-traumatic osteoarthritis of the elbow is a rare condition. Whereas clinical manifestations often differ from radiological findings, pain and stiffness are variably combined in symptomatic forms. In deciding whether to perform surgery, the patient's age, activity level, and symptoms, as well as the location and severity of the osteoarthritis have to be taken into account. Elbow joint instability has to be identified to stop the post-traumatic osteoarthritic progress. If joint preserving surgical methods fail, diverse options for partial or total joint replacement are available. THERAPY: The treatment goal in young patients, therefore, is to reduce pain with a sufficient range of elbow motion.

[Complication management in implant dislocation]. / Komplikationsmanagement bei Implantatdislokation.

There are many reasons for an implant malposition. Besides knowlege about prevention of implant dislocation, accurate planning of the osteosynthesis, extensive knowlege of the anatomy of the region in question, using all necessary diagnostic tools, choosing the correct approach and the best implant for fracture fixation are also important factors. Nevertheless, implant complications can still be found and if an intraoperative or postoperative implant dislocation occurs a suitable management is necessary. This article describes the different osteosynthesis implants and possible malpositions and dislocations. Tips and tricks are described in order to facilitate the correct indications for the further procedure.

[Arthroscopy of the elbow: diagnostic and therapeutic approaches]. / Ellenbogenarthroskopie: Diagnostische und therapeutische Möglichkeiten.

The elbow is one of the most complex joints of the human body. Bony, ligamentous and muscular constraints ensure elbow stability. During recent years elbow arthroscopy has become more and more popular resulting from technical and surgical innovations. The diagnostic and therapeutic elbow arthroscopy following traumatic elbow dislocation is the best example. Functional outcomes after elbow dislocation significantly depend on sufficient evaluation of elbow stability, possible accompanying soft tissue injuries and on the initiation of adequate therapy. Elbow arthroscopy after traumatic elbow dislocation allows visualization of ligament ruptures and cartilaginous lesions, the resection of loose bodies and flushing of the hemarthrosis. Moreover, elbow stability can be tested directly. Concerning therapy, elbow arthroscopy represents an additional diagnostic tool and an aid for possible surgical procedures. In this article the basic requirements and special techniques for elbow arthroscopy are described. Using the examples of an elbow dislocation and arthrofibrosis, arthroscopical standard views, arthroscopical stability test and arthroscopical arthrolysis are explained.

[Acromion reconstruction after arthroscopic subacromial decompression and iatrogenic acromial destruction]. / Akromionrekonstruktion nach arthroskopischer subakromialer Dekompression und iatrogener Akromiondestruktion.

OBJECTIVE: Reconstruction of the acromion, to achieve pain relief and better function of the deltoid muscle. INDICATIONS: After partial or complete removal of the acromion. CONTRAINDICATIONS: General surgical contraindications. Paresis of the axillary nerve. SURGICAL TECHNIQUE: Strategy of the operation with X-ray and CT scan. Patient in beach chair position. Disinfection of the shoulder and lateral pelvic region. Exploration of the defect area and searching for the lateral clavicula and spinascapulae end. Removal of a pelvic bone block. Fixation of the pelvic bone block to the spina scapulae with K-wires and finally osteosynthesis by a Reco plate (Synthes, Umkirch, Germany), wound closure. POSTOPERATIVE MANAGEMENT: For the first 6 weeks, a cast with the arm in 90° abduction. Passive motion without the cast should be performed once a day. Starting in week 7, weekly reduction of abduction (90°/60°/30°/0°). Active mobilization starting in week 10. Start to practice with weight bearing in week 13. RESULTS: Pain relief improved from VAS 7-9 to VAS 2-3. Improved ROM can be seen postoperatively and after 6 months for abduction/adduction 50-0-50°, anteversion/retroversion 80-0-10°, rotation out/in 40-0-10°.

Standardised cement augmentation of the PFNA using a perforated blade: A new technique and preliminary clinical results. A prospective multicentre trial.

Pertrochanteric fractures are a rising major health-care problem in the elderly and their operative stabilisation techniques are still under discussion. Furthermore, complications like cut-out are reported to be high and implant failure often is associated with poor bone quality. The PFNA(®) with perforated blade offers a possibility for standardised cement augmentation using a polymethylmethacrylate (PMMA) cement which is injected through the perforated blade to enlarge the load-bearing surface and to diminish the stresses on the trabecular bone. The current prospective multicentre study was undertaken to evaluate the technical performance and the early clinical results of this new device. In nine European clinics, 59 patients (45 female, mean age 84.5 years) suffering from an osteoporotic pertrochanteric fracture (Arbeitsgemeinschaft für Osteosynthesefragen, AO-31) were treated with the augmented PFNA(®). Primary objectives were assessment of operative and postoperative complications, whereas activities of daily living, pain, mobility and radiologic parameters, such as cement distribution around the blade and the cortical thickness index, were secondary objectives. The mean follow-up time was 4 months where we observed callus healing in all cases. The surgical complication rate was 3.4% with no complication related to the cement augmentation. More than one-half of the patients reached their prefracture mobility level within the study period. A mean volume of 4.2ml of cement was injected. We did not find any cut-out, cut through, unexpected blade migration, implant loosening or implant breakage within the study period. Our findings lead us to conclude that the standardised cement augmentation using the perforated blade for pertrochanteric fracture fixation enhances the implant anchorage within the head-neck fragment and leads to good functional results.

[Complications after pertrochanteric fractures]. / Komplikationen bei pertrochantären Frakturen.

Fractures at the coxal end of the femur have an incidence of almost 100.000 p.a. in Germany. Pertrochanteric femur fractures make up almost half of this collective. The highest incidence of 1.32% is seen in patients over the age of 85. Osteosynthesis is the treatment of choice. The options include extramedullary nail/screw systems or intramedullary nail systems. Study findings to date do not show a clear advantage of one procedure over another. The published complication rates remain high. The main complication is secondary reduction loss with cutout of the hip screw. Other complications include femoral neck shortening and lateralization of the hip screw with local irritation at the iliotibial tract. Functional outcomes after osteosynthesis are still less than satisfactory. Surgery only frees one third of patients from pain. In addition, a majority of patients also suffer loss of independence and social contacts. An alternative approach to treatment is total joint replacement. This is indicated in extreme cases of osteoporosis in combination with osteoarthritis. However, initial high stability must be weighed against an increased risk of dislocation and a higher rate of 1-year mortality.

Does the surface structure of implants have an impact on the formation of a capsular contracture?

BACKGROUND: The formation of a fibrous capsule around a silicone breast implant is part of a physiologic foreign body reaction after breast augmentation. In contrast, the formation of a capsular contracture is a local complication of unknown cause. This study aimed to discover whether the surface structure of the implant (textured vs smooth) has any impact on the formation of a capsular contracture. METHODS: This prospective study included 48 female patients with unilateral capsular fibrosis grades 1 to 4 in Baker's clinical scaling system. Of these patients, 14 received implants with a textured surface (Mentor), and 34 received implants with a smooth surface (Mentor). The implants all were placed in a submuscular position by the same experienced plastic surgeon. The clinical data were assessed using standardized patient questionnaires. For histologic diagnosis, operatively excised capsular tissue was examined. Preoperatively, venous blood samples for determining serum hyaluronan concentrations were taken from the patients. The control group consisted of 20 patients without capsular fibrosis. RESULTS: The separate analysis of clinical data for the patients with textured and those with smooth-surfaced breast implants showed a slightly reduced degree of symptoms for the patients with textured silicone breast implants, as compared with those who had smooth-surfaced implants. The histologic assessment of the fibrosis showed a symmetric distribution for Wilflingseder scores 1 to 3 (29% each), whereas 13% of the capsular tissues could be assigned to Wilflingseder score 4. In contrast, the histologic assessment of the patients with smooth-surfaced implants predominantly showed a Wilflingseder score of 3 (65%). The serologic investigations via enzyme-linked immunoassay (ELISA) showed serum hyaluronan concentrations of 10 to 57 ng/ml (25.0 +/- 11.7 ng/ml). Therefore, no statistically significant differences in terms of serum hyaluronan levels could be determined between the two groups of patients. In comparison with the control group, the patients with implants showed elevated serum hyaluronan levels (p < 0.05). CONCLUSIONS: The histologic examination and serum hyaluronan concentration analysis showed no statistically significant difference between smooth-surfaced and textured implants (Mentor) with respect to the development of capsular contracture. On the other hand, the severity of capsular contracture showed a positive linear correlation with the degree of local inflammatory reactions, which were independent of the implant surface.

First results with the trochanter fixation nail (TFN): a report on 120 cases.

A complication rate between 4-18% for the conventional osteosynthesis of the proximal femur fracture continues to be unacceptable even if increasing age and co-morbidity of patients are taken into account. Therefore, new intramedullary techniques are under development, and we here report our results with the novel trochanteric fixation nail (TFN). During the study period (March 2003-February 2004) all patients with a trochanteric fracture Type A1-A3 (AO/ASIF classification) were eligible for the study, and 120 patients (mean age 81 years, range 47-100; male/female 1:4) subsequently enrolled. Most frequent was the (according to the AO classification) A.2.1. type of fracture (n=39) and the A.2.2. fracture (n= 39). Operation time from cut to stitch was 45 mins (minimal 21/maximal 194). Thirty-seven (31%) postoperative X-rays were classified as very good, 60 (50%) as good, 18 (15%) as satisfying and five (4%) as bad post-reposition results according to the Garden Alignment Index. The clinical results were documented by the time of hospital stay, postoperative mobilization and time of rehabilitation compared to the old social status. Time to hospital discharge was 17 days (9 /25). Overall complication rate was 7.5% (9 patients) with 5.8% [7] local wound infection; 1.6% [2] cutting out of the helical blade through the cortex of the femoral head. We had three (2.5%) hospital deaths in our patient group. We conclude that TFN is a safe and reliable technique. Compared with techniques like PFN and Gamma-nail, clinical results are excellent with less complications.

[Hip replacement after failed internal fixation in patients with proximal femur fracture--a simple procedure?]. / Der Wechsel von Osteosynthese zur Prothese bei hüftnahen Femurfrakturen - ein einfaches Verfahren?

Between January 1995 and December 2000 we operated on 1 437 patients with fractures of the proximal femur. In 789 cases an osteosynthesis was performed and in 648 cases a prosthesis was implanted. In the group of patients with primary osteosynthesis we stabilized 89 fractures with screws, in 319 patients a dynamic hip screw (DHS) and in 381 patients a Proximal-Femurnail (PFN) were implanted. Because of major complications we had to reoperate on 42 patients (5.3 %) with primary osteosynthesis. For analysis of this high complication rate we studied the fracture type, the type of complication, the operation time, the primary and secondary implant type and the time of postoperative mobilisation in this group of 42 patients. We saw 27 type A and 15 type B fractures, according to the AO classification. In the patient group with complications 4 times a primary screw stabilisation was done, 22 dynamic hipscrews (DHS) and 16 proximal femurnails (PFN) were implanted. After changing the primary osteosynthesis into 15 hemiprostheses and 26 total prostheses of the hip, we found in over 30 % major complications. A change of the procedure after primary osteosynthesis has to be regarded as a more difficult operation than the primary implantation of a prosthesis.

Elevated plasma endothelin concentrations in cyclosporine-treated patients after bone marrow transplantation.

Administration of cyclosporine is often associated with the development of renal dysfunction and hypertension. Since recent data from animal experiments provide evidence that endothelin, a potent vasoconstrictive peptide, might play a role in mediating cyclosporine-related renal and cardiovascular side-effects, the present study was designed to investigate whether plasma endothelin concentrations are elevated in cyclosporine-treated patients. Plasma endothelin concentrations, determined by radioimmunoassay after Sep Pak C18 extraction, were significantly elevated in cyclosporine-treated patients after bone marrow transplantation (8.3 +/- 1.4 ng/l, n = 28) compared to patients not treated with cyclosporine after bone marrow transplantation (3.9 +/- 0.2* ng/l, n - 11), patients with haematological disorders (3.9 +/- 0.3** ng/l, n = 11) not treated with bone marrow transplantation and to normal control subjects (3.1 +/- 0.2*** ng/l, n = 33) (*P < 0.05, **P < 0.01, ***P < 0.001). Furthermore, plasma endothelin levels exhibited a significant correlation with cyclosporine concentrations (r = 0.57, P < 0.01). The present data, demonstrating elevated plasma endothelin concentrations in cyclosporine-treated patients, suggest that the cyclosporine-associated renal and cardiovascular side-effects might in part be mediated by cyclosporine-induced stimulation of endothelin release.