Three-dimensional acetabular orientation during periacetabular osteotomy: a video analysis of acetabular rim position using an external fixator as navigation tool during reorientation procedure.

INTRODUCTION: Bernese periacetabular osteotomy is an effective procedure for treating acetabular dysplasia. However, limited visual control of the acetabular position during surgery may result in under- or overcorrection with residual dysplasia or femoroacetabular impingement. Thus, we wanted to find a simple method to control the effect of correction in the sagittal and coronal plane. METHOD: The acetabular coordinates are shown by two perpendicular tubes of an external fixator mounted onto a third tube that is fixed to the acetabular fragment with two Schanz screws. This method enables the isolated acetabular reorientation in the coronal, sagittal, and transverse plane. In a sawbone pelvis model, the acetabular rim is marked with a copper wire and a silicon adherent. To show the radiographic effect on acetabular parameters and the rim position, we visualized correction in the coronal and sagittal plane under fluoroscopic control. RESULTS: Lateral rotation of the acetabular fragment had the highest impact on radiographic lateral coverage of the femoral head. But also ventral coverage increased during isolated lateral rotation. Anterior rotation showed almost no effect on lateral coverage and just a little effect on ventral coverage but caused severe total acetabular retroversion. CONCLUSION: Three-dimensional control of the acetabular orientation during periacetabular osteotomy is important to avoid over- and under-correction. Isolated lateral rotation of the acetabular fragment should be the predominant direction of correction during periacetabular osteotomy. Ambitious anterior correction may be the main source for severe acetabular retroversion following periacetabular osteotomy.

Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios.

INTRODUCTION: In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. METHODS: Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°. RESULTS: No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. CONCLUSION: The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Operative therapy for rheumatoid arthritis of the hand]. / Operative Therapie bei rheumatoider Arthritis der Hand.

The need for operative treatment of severe rheumatic deformities of the hand and wrist is decreasing due to the increased use of disease-modifying drugs; however, some patients do not tolerate or do not sufficiently respond to these drugs, which often results in the hands being affected and in advanced stages to severe deformity and loss of function. In these cases operative surgery can help to slow the progression of rheumatic destruction and restore the function of the patient's hand. This article describes the principles of surgery for rheumatoid arthritis of the hand. A meticulous synovectomy or tenosynovectomy is the first stage of treatment. With progression of rheumatic destruction various salvage procedures are necessary to preserve the best possible functional state.

[Operative treatment of the rheumatic shoulder]. / Operative Therapie der rheumatischen Schulter.

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

[Wrist arthroscopy : challenging procedure of modern hand surgery]. / Handgelenksarthroskopie : Herausforderndes Verfahren der modernen Handchirurgie.

Arthroscopy of the wrist has developed in the shadow of arthroscopy of the large joints. Nowadays, wrist arthroscopy has a relevant importance in the diagnostics and therapy in hand surgery and is indispensable for serious surgery of the wrist. Special equipment and extensive knowledge of the surgeon are necessary for carrying out the procedure.

[Operative joint-preserving therapy of gonarthrosis]. / Operative gelenkerhaltende Therapie der Gonarthrose.

The guiding principle of operative joint-preserving therapy of gonarthrosis is the search for a safe, minimally invasive, efficient and ultimately reasonably priced therapeutic procedure to preserve or restore joint integrity. A comprehensive analysis and treatment of pathologies adjacent to and distant (axis deviations) from the joint are prerequisites for success of treatment. A comparison of results from the current literature with respect to the operative treatment of arthritis is limited due to the divergence of indications, terminologies used, techniques of the therapeutic procedure, inhomogeneity of patient collectives and the different follow-up and control schemes (scores). Conclusive, prospective, randomized double blind studies with large case numbers are associated with a high degree of organizational effort in planning, patient recruitment and execution and remain a rarity. Long-term prognosis depends on the stage of arthritis at the time of the arthroscopic intervention. Operative measures, such as correction osteotomy can be effective in the early stages. A short duration of symptoms, mechanical blocking and low-grade cartilage damage are factors which have a favorable prognosis. Cell-based cartilage repair techniques can reduce secondary degenerative alterations only in cases of local cartilage damage representing a prearthritic condition. Advantages of autologous chondrocyte transplantation compared to microfracturing have been found depending on the size of the defect and the follow-up time period. Furthermore, preservation and replacement of primary knee stabilizers, such as the anterior cruciate ligament and meniscus, have an important function for secondary prevention. A one-for-all therapy for joint-preserving operative treatment of gonarthrosis is lacking.

[Radiological findings, evaluation and treatment of patellofemoral pain after total knee arthroplasty]. / Radiologische Diagnostik, Beurteilung und Behandlung des patellofemoralen Schmerzes nach primärer Knieendoprothetik.

Total knee arthroplasty (TKA) is one of the most successful operative procedures over the last decades in orthopedic surgery; however, some patients suffer from pain, limited range of motion, instability, infections or other complications postoperatively. Patellofemoral pain (PFP) in particular is a common problem after TKA and often necessitates revision surgery. Mainly increasing and localized contact pressure and patella maltracking are held responsible for PFP but the reasons vary. Diagnostics and therapy of PFP is not easy to manage and should be treated following a clinical pathway. The authors suggest that patients with PFP should be categorized after basic diagnostic measures according to the suspected diagnosis: (1) tendinosis, (2) mechanical reasons, (3) intra-articular non-mechanical reasons and (4) neurogenic/psychiatric reasons. Efficient application of special diagnostic measures and further therapy is facilitated by this classification.

[Postoperative treatment strategies after rheumatic orthopedic operations of the shoulder. A suggestion]. / Nachbehandlungsstrategien nach rheumaorthopädischen Operationen an der Schulter. Ein Vorschlag.

Although surgical treatment of rheumatoid patients is quite common for disorders of the shoulder, less is known about the efficacy of the postoperative regimens. Clear therapeutic standards are still missing; however, without systematic and intensive postoperative physical therapy, a good postoperative outcome cannot be achieved. This article shows our postoperative treatment regimens and describes our preferred techniques in physical therapy.

[Orthopedic operations and postoperative treatment of rheumatic elbows]. / Orthopädische Operationen und Nachbehandlungsregimes am rheumatischen Ellenbogen.

This article gives an overview of the indications for operative treatment and the respective post-treatment of rheumatic elbows. The goal should be to preserve the function of the elbow joint and freedom from symptoms to prevent joint destruction which unfortunately can still be seen nowadays.

[Arthroplasty for rheumatic elbow joints]. / Endoprothetik des Rheumatischen Ellenbogengelenks.

Without proper treatment rheumatoid arthritis can lead to pain, instability and destruction of the elbow joint. As with artificial knee replacement various designs are available and in general non-constrained and semi-constrained designs are preferred. Fully constrained designs should be avoided due to high loosening rates. Results have shown a significant pain reduction, however, a restricted range of motion has to be expected. Restrictions in load-bearing and mobility are among the major problems after elbow arthroplasty in patients with rheumatoid arthritis which have to be discussed with the patient before surgery. Future studies will have to evaluate the effectiveness of new modular designs.

[Examination of the painful wrist]. / Diagnostik des schmerzhaften Handgelenks.

The anatomy of the wrist is complex. Mechanical, neurological or systemic causes are responsible for a painful wrist. In many cases a specific diagnosis can already be made by taking a precise medical history. Physical examination includes inspection, palpation of landmarks and a dynamic examination in regard to joint regions. Plane X-Ray examinations are the basic tools in diagnostic imaging. Additional radiographic adjustments, ultrasound-, MRI- and CT-examinations may lead to more detailed information in special cases. A diagnostic arthroscopy is accomplished, if a pathological cause for wrist-pain with non-invasive methods cannot be found.

[Examination of the painful wrist]. / Diagnostik des schmerzhaften Handgelenks.

The anatomy of the wrist is complex. Mechanical, neurological or systemic causes are responsible for a painful wrist. In many cases a specific diagnosis can already be made by taking a precise medical history. Physical examination includes inspection, palpation of landmarks and a dynamic examination in regard to joint regions. Plane X-Ray examinations are the basic tools in diagnostic imaging. Additional radiographic adjustments, ultrasound-, MRI- and CT-examinations may lead to more detailed information in special cases. A diagnostic arthroscopy is accomplished, if a pathological cause for wrist-pain with non-invasive methods cannot be found.

Adenocarcinoma of the rectum in childhood following chemotherapy and radiotherapy for a rhabdomyosarcoma--a case report.

We report a case of rectal adenocarcinoma in a 9-year-old boy, which took the form of a second malignant neoplasm following treatment for an early childhood malignancy. The abdominal complaints were for a long time interpreted as an infectious disease. At the time of diagnosis of the rectal carcinoma, the tumor had already progressed to the stage of metastatic disease. Therapy consisted of deep anterior rectal resection and regional arterial chemotherapy for liver metastases. The child died 18 months after the diagnosis of rectal carcinoma. As survival for childhood tumors improves, rare second malignant neoplasms will become increasingly common in children and adolescents. This phenomenon emphasizes the need for continued clinical surveillance of patients who have been treated with chemotherapy or irradiation for childhood tumors. The increased risk of second malignant neoplasms and an early onset of adult-type tumors has to be considered.

[Ultrasound evaluation of the acromioclavicular joint. A comparison with magnetic resonance imaging]. / Wertigkeit der Ultraschalldiagnostik des Acromioclaviculargelenks. Ein Vergleich mit kernspintomografischen Messungen.

INTRODUCTION: Ultrasound is useful in detecting acromioclavicular pathologies in cases of trauma, inflammations and degenerative changes in sports medicine. Many studies compare joint space and capsular dimensions of symptomatic and asymptomatic patients. However, no study has examined the reproducibility and reliability of these measurements. The aim of this study was to evaluate the reliability of ultrasonographic measurements in assessing the acromioclavicular joint. MATERIALS AND METHODS: 27 acromioclavicular joints of 15 healthy subjects were examined by T1 weighted magnetic resonance imaging (MRI) to determine the normal limits of joint space (a) and joint capsule (b). These measurements were compared to standardised ultrasonographic (11 Mhz) measurements, which were repeated three times. RESULTS: The mean difference between MRI and ultrasound measurements was 1.5 +/- 1.3 mm and 1.3 +/- 1.2 mm for distance a and b, respectively. Reproducibility of ultrasonographic measurements was high with a mean standard deviation of 0.3 +/- 0.2 mm and 0.4 +/- 0.3 mm for distance a and b, respectively. CONCLUSION: Due to low costs, safety and wide availability ultrasonography is suited for the evaluation of the acromiocalvicular joint. However, when interpreting the results measurement errors, limitations in resolution of the system used, and the anatomy of the acromioclavicular joint and its anatomic variants have to be taken into consideration.

[Efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect]. / Effektivität der Physiotherapie in Eigenregie bei Rotatorenmanschettendefekten.

AIM: Although the outcome of surgical treatment of rotator cuff tears is well documented in the literature, less is known about the efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect. METHODS: A series of 30 patients (38 shoulders) with rotator cuff tears seen by ultrasonography were included in this prospective study. Rotator cuff tears were divided into partial defects (group A), full thickness tears of the supraspinatus tendon (group B), and massive rotator cuff defects (group C). Treatment consisted of a home program of stretching and strengthening exercises that were performed by the patients daily for a period of 12 weeks and controlled by a physician every 2 weeks. Range of motion, a modified constant score, and impingement signs at initial examination and after 12 weeks were compared. RESULTS: All groups experienced improvement in range of motion. The Constant scores improved significantly (p < 0.05) in all groups (A: 13.0 [+/- 7.9 SD], B: 13.2 [+/- 11.4 SD], and C: 17.5 [+/- 6.6 SD]). Impingement signs showed a downward trend in all groups. DISCUSSION: The results of this study show that patients with rotator cuff defects do benefit from simple home exercises independent from the size of the defect.

Gliding properties of the long head of the biceps brachii.

To elucidate the role of mechanical forces that resist motion of the long head of the biceps brachii, the gliding resistance of the tendon during abduction and adduction was measured. Nine human cadaveric glenohumeral joints were obtained (mean age 68 years, range 47-84). A testing device was developed to simulate glenohumeral abduction and adduction motion. Gliding resistance was calculated as the force differential on the proximal and distal ends of the biceps brachii at five glenohumeral angles (15 degrees, 30 degrees, 45 degrees, 60 degrees and 75 degrees ). The average gliding resistance in abduction at 15 degrees, 30 degrees, 45 degrees, 60 degrees and 75 degrees for a 4.9 N load was 0.41, 0.40, 0.36, 0.32 and 0.28 N, respectively. At these same angles, but during adduction motion, the force on the proximal tendon end was either identical or less than the distal tendon end (p>0.46) indicating a lack of resistance and even a phenomena of "negative" resistance in which some other force overcame the friction. The difference in gliding resistance between abduction and adduction was significant (p<0.05). The results indicate that forces opposing biceps tendon gliding are more complicated than simply due to friction. Tendon deformation inside the bicipital groove produces a direction-dependent effect due to a mechanism of elastic recoil. Understanding forces that are absorbed by the tendon during active motion may provide insight into pathological changes that develop inside and around the tendon.

Biomechanical comparison of effects of supraspinatus tendon detachments, tendon defects, and muscle retractions.

BACKGROUND: Rotator cuff ruptures are frequently associated with loss of strength of the shoulder. However, the characteristics of the rotator cuff tear that are responsible for the loss of force generation and transmission have not yet been identified. The purpose of this study was to compare the effects of supraspinatus tendon detachments, tendon defects, and muscle retractions on in vitro force transmission by the rotator cuff to the humerus. METHODS: The rotator cuff tendons from ten cadaver shoulders were loaded proportionally to the respective cross-sectional areas of their muscles. A fiberglass rod was cemented into the medullary canal of the humerus and connected to a three-component load cell for the measurement of the forces transmitted by the rotator cuff to the humerus. This study was performed with the humerus in a hanging arm position and with various sizes of supraspinatus tendon detachments, tendon defects, and muscle retractions. RESULTS: Detachment or creation of a defect involving one-third or two-thirds of the supraspinatus tendon resulted in a minor reduction in the force transmitted by the rotator cuff (< or =5%), while detachment or creation of a defect involving the whole tendon resulted in a moderate reduction (11% and 17%, respectively). Simulated muscle retraction involving one-third, two-thirds, and the whole tendon resulted in losses of torque measuring 19%, 36%, and 58%, respectively. Side-to-side repair of the one-third and two-thirds defects nearly restored the force transmission capability, whereas a deficit remained after side-to-side repair following complete resection. CONCLUSIONS: Our results support the rotator cable concept and correspond to the clinical observation that patients with a small rupture of the rotator cuff may present without a loss of shoulder strength. Muscle retraction is potentially an important factor responsible for loss of shoulder strength following large rotator cuff ruptures. CLINICAL RELEVANCE: Supraspinatus muscle retraction diminishes glenohumeral abduction torque significantly more than either a defect in the tendon or a simple detachment of the tendon from the tuberosity. In cases of irreparable defects, side-to-side repair may be worthwhile to restore muscle tension and the integrity of the rotator cable.

[Influence of sequence type on the extent of the susceptibility artifact in MRI--a shoulder specimen study after suture anchor repair]. / Abhängigkeit der Artefaktgrösse vom Sequenztyp in der MRT--Präparatstudie zur Beurteilung der postoperativen Schulter nach Labrumfixation.

PURPOSE: To compare the extent of susceptibility artifacts after metallic suture anchor implantation by analyzing 14 different MRI sequences. MATERIALS AND METHODS: A metallic suture anchor was implanted in the central area of three glenoid porcine specimens. The specimens were imaged with a 1.5 T scanner using a protocol of 14 standard sequences including gradient echo, spin echo and turbo spin echo sequences with and without fat-saturation. Artifact size was measured for each specimen and sequence. The resulting mean artifact areas were determined for each type of sequence and the mean values of the three specimens compared. RESULTS: Gradient echo-sequences produced significantly larger artifact areas than the spin echo and turbo spin echo sequences, whereby the artifacts of the 3D-gradient echo sequences were smaller than the artifacts of the 2D-gradient echo sequences. A turbo spin echo sequence with a high readout band width and a short effective echo time showed the best results. For the conventional spin echo sequence, a reduction in the echo time did not significantly decrease the artifact size. Spectral fat-saturation did not affect the area of the susceptibility artifact compared to the non-saturated sequence. CONCLUSION: Gradient echo sequences should not be used after metallic suture anchor repair. Turbo spin echo sequences showed a decrease in the artifact size compared to conventional spin echo sequences and should be performed with a short effective echo time and a high band width. Spectral fat- saturation did not increase the artifact size significantly.