[Loading and performance capacity after immobilization operations of the spine]. / Belastbarkeit und Leistungsfähigkeit nach Versteifungsoperationen der Wirbelsäule.

BACKGROUND: The results of spondylodesis depend on various medical and non-medical factors. Prerequisites for a good functional result are a well-founded assessment of the indications and a technically successful execution of the intervention. Furthermore, non-medical factors also play an important role. APPRAISAL: Attention must be paid to personal context factors and environmental conditions. In addition to psychological disorders and social background conditions, the economic considerations of the patient and expected pension payments influence the desire and willingness to return to gainful employment. ASESSMENT: Based on the physical findings, the criteria for assessment of the suitability for old-age pension insurance, the reduction in earning capacity for the obligatory social insurance and establishment of the severity of the resulting impairment/handicap according to the Social Compensation Act and the Act for the Severely Handicapped (Social Act IX) in Germany are systematically presented.

[Structure, contents and findings of an expert report prepared by a medical professional (I)]. / Das professionelle medizinische Gutachten: Struktur, Inhalt, Aussage (I).

The second section in this report on accident-related injuries is concerned with the development and result of the report. Criteria which are generally valid for the preparation of the expert report are developed. The priorities here are the previous history obtained from the medical files, the accident report, description of injuries and pain, determination of the result, evaluation of diagrams and procedures and the diagnoses emerging from the overall picture. Results are assessed in line with the scientific reference literature. The standardised method of result determination and the assessment improve the quality of the expert report. The second section is intended for experts and insurance company employees.

[Preparation and assignment of medical reports: basis for settlement of compensation claims]. / Medizinische Gutachten vorbereiten und vergeben: Grundlage der Regulierung von Personenschäden.

Medical reporting represents an essential element in the settlement of personal claims. Moreover, the report prepares the basis for determing the compensation which is appropriate to the injury. The practice of instructing the expert medical assessor to obtain the medical documents required has proved a failure and causes delays in completion of the report. The doctor who is the expert medical assessor is often unsuccessful in obtaining these vital documents. In doubtful cases the expert will deliver his report without access to the vital documents. Incomplete reports affect the settlement adversely and promote unnecessary legal disputes. Many errors can be avoided if the officials of the relevant insurance company prepare the report assignment carefully. Such preparation includes clarification of the accident circumstances, requests for copies of the primary diagnosis and requests for hospital and medical reports, including full details of surgery carried out. Printouts of the daily reports by the doctors involved are also required. Of course these doctors must be released from the obligation to treat medical records confidentially. Furthermore, if the original documents are used, results of the injury which may seem insignificant will not be overlooked. The report assignment and primary medical documents should be sent to the medical assessor at the same time. The report assignment contains a detailed questionnaire which takes into account the particular aspects of the individual claim.

[Deformities following spinal injury at the thoracolumbar junction]. / Fehlstellungen nach Wirbelsäulenverletzungen im thorakolumbalen Ubergang.

Due to anatomical characteristics, posttraumatic deformities following spinal injury occur in particular at the transition from the flexible lumbar spine to the rigid thoracic spine. Incorrectly classified vertebral body fractures can lead to the development of posttraumatic kyphosis due to incorrect treatment. It is likewise important to evaluate the integrity of adjacent discs and assess the sagittal index. Management of kyphosis is difficult and requires radiological evaluation following exact planning. Reconstruction of the sagittal anatomical contour is crucial to prevent stress in the compensatory curves. Performing a dorso-ventral or dorso-ventro-dorsal approach, pedicle subtraction osteotomy or an eggshell procedure is also helpful to achieve good correction without anterior reconstructive surgery. The clinical result is not dependent on correct repositioning alone; poor results can be expected in cases with pseudarthrosis, neurological deficits and severe kyphotic deformities. This article gives an overview of pathogenesis, diagnostic steps and therapeutic options for corrective spinal surgery.

[Expert appraisal of spinal injuries]. / Begutachtung von Wirbelsäulenverletzungen.

Appraisals and expert opinions of clearly identified injuries of the spine, ranging from fractures and dislocations to intervertebral disc ruptures and haemorrhage into soft tissue are generally unproblematic. The residual functional deficit is commensurate with the extent of damage. However, differences between the patient's symptoms and objective findings can be unrelated to the injury, and are often explained by the actual compensation process or other psychological/psychosocial factors. The current article discusses a basis for providing expert medical opinions, as well as a number of practical tips on the German medical insurance system. Particular attention is paid to expert opinions on causality. The article also includes information on the evaluation of structural injuries to the spine on the basis of assessment criteria that have proven to be reliable and authoritative in recent decades.

["Isolated injury" of the alar ligaments: MRI diagnosis and surgical therapy]. / "Isolierte Verletzung" der Ligamenta alaria : Kernspintomographische Diagnostik und operative Therapie.

UNLABELLED: Spinal distortions caused by traffic collisions play a large role in medical expert opinions. Prolonged or chronic conditions present particular difficulties. The radiologist E. Volle developed and published a system for the classification of isolated injuries of the alar ligaments. As a result, surgery on the craniocervical junction was carried out in a large number of patients and the results published on multiple occasions. This article describes the anatomy of the alar ligaments, complicated injuries, the concept of the isolated lesion of the alar ligaments and their surgical management. German and international publications are evaluated. RESULT: It was impossible to substantiate isolated injuries to alar ligaments. According to current knowledge, the published results are based on a misinterpretation of MRI findings. These results are to be considered as artefacts. There is no anatomical correlation for the classification of isolated injuries to alar ligaments. Surgical stabilisation due to an allegedly isolated injury to the alar ligaments is therefore not indicated. This statement does not apply to injuries sustained in high-speed trauma in combination with complex injuries of the atlanto-occipital and atlanto-dental-joint (joint capsules, atlanto-occipital membrane) with clear signs of instability.

[Pain and its treatment reflected in time]. / Der Schmerz und seine Therapie im Spiegel der Zeit.

This article describes the history of pain therapy and anesthesiology with respect to the field of surgery. The history of this part of medicine is dependent upon the development of the appropriate medication groups, which were of great importance in the field of pain therapy and anesthesiology. Specifically the development of nitrous oxide, ether, morphine and the first local anesthesiologic substances will be described and discussed. The above mentioned developments combined with the knowledge of physiology of pain and new results from psychological studies led to the modern pain therapy in recent perioperative treatment concepts. Modern pain therapy is a multimodal therapy concept with a variety of specialties working as a team to optimize an individualized therapy plan which respects the needs of every single patient under different circumstances (acute, perioperative and chronic pain).

[Wiplash injury and "railway spine"]. / Schleudertrauma und ,,railway spine" (I). Die Verantwortung von Arzten und Psychologen: Versicherungsmedizinische Bedeutung somatofomer Störungen und ihre Abgrenzung zur posttraumatischen Belastungsstörung.

Although post-traumatic stress disorder was only recently admitted into the international classification systems, psychological reactions to traumatic incidents have been frequently described for more than 100 years. The article deals with the mental reactions to a trauma in different historical situations. Included are the "railway spine" injuries of the 19th century, victims of accidents where third party liability could be claimed, accident insurance, the psychological consequences of National Socialism and whiplash injury. The analysis suggests that different reactions don't describe an identical disorder. It seems that reactions to injuries are mainly influenced by the historical and social background and the fact of beeing insured.

[From "wet caries" to controllable complication. History of post-traumatic and postoperative osteitis]. / Vom "feuchten Beinfrass" zur beherrschbaren Komplikation. Die Geschichte der posttraumatischen und postoperativen Osteitis.

In former times treatment of osteomyelitis was based on very few surgical principles such as incision of the infected region, debridement with sequestrectomy, and continuous drainage to prevent superficial closing of the wound. There were no rules for asepsis, anesthesia, and microbiology in the treatment of bone infection. Therapy improved dramatically when J. Lister introduced and performed antisepsis. With the beginning of the twentieth century it became much more standardized and differentiated. In the 4th decade of the twentieth century, the development of antibiotics changed the regime of osteomyelitis therapy again. Especially systemic intravenous antibiotic therapy was very successful in the treatment of the hematogeneous osteomyelitis. Treatment failed in post-traumatic and postoperative osteitis. Local antibiotic therapy on a delivery system was the breakthrough for these cases. The application of PMMA cement as an antibiotic delivery system led to this new possibility for treating bone infections and is still in use nowadays.

[Complications of vertebroplasty]. / Komplikationen in der Vertebroplastie.

Percutaneous vertebroplasty was first introduced in 1984 by Galibert et al. for the treatment of hemangiomas in the spine. The current indications for vertebroplasty also include compression fractures due to osteoporosis as well as osteolytic metastases and spinal myeloma lesions. With the numbers of percutaneous vertebroplasty performed by orthopedic and trauma surgeons, neurosurgeons, and radiologists steadily increasing, complications have also risen. Over the last 3 years an increasing number of cases with varying complications, their genesis, and their management have been reported in the literature. Complications include asymptomatic cement leakage, cardiovascular effects, embolism with lethal outcome as well as severe neurological deficits. This article presents a review of the complications reported in the literature, strategies for preventing possible complications as well as current concepts in therapy management. Several of our cases with cement leakages are presented.

[Rachitic knock knees in children]. / Das rachitische X-Bein im Kindesalter. Pathogenese und Therapie aus historischer Sicht.

Knee malpositions, for example valgus or varus deformations or flexion contractures, were often cited in the historical literature. In earlier times, clinical pictures such as rickets were often the reason for this kind of deformity. A causal therapy did not exist until the twentieth century. In most cases of rickets, genu valgum was reported as the typical knee deformation. The differential diagnosis for genu valgum caused by rickets was genu valgum traumaticum, paralyticum, and inflammatorium. The most important reports on the pathogenesis of valgus deformation can be found in publications by Hueter and von Mikulicz. The causal therapy of rickets was introduced at the beginning of the twentieth century.Vitamin therapy and UV phototherapy were developed during this period. Using these therapies, rickets decreased dramatically. Kurt Huldschinsky, a pediatrician from Berlin,was one of the main inventors of UV phototherapy in Germany. At the end of the nineteenth century, the operative correction of knee deformities increased while conservative treatment continued to be applied. Plaster casts,orthoses, and osteoclast therapy were the main noninvasive therapeutic possibilities. Positive aspects of the conservative techniques were mostly the good results and easy, timesaving technique compared with the operative treatment. The operative therapy increased with the knowledge of antisepsis and asepsis as well as advances in anesthetic procedures. Operative treatment modalities, for example tibial and femoral osteotomies, were more precise, but connected with multiple complications and greater time expenditure. Sufficient vitamin prophylaxis rendered knee deformations caused by rickets a rarity.

[The German Orthopedics Society 1918-1932. Developments and trends]. / Die Deutsche Orthopädische Gesellschaft von 1918-1932. Entwicklungen und Strömungen.

The German Orthopedic Society was founded in 1901. The period between 1918 and 1932 was characterized by the aftermath of World War I. Up to the middle of the 2nd decade, orthopedic surgeons mainly treated soldiers and civilians affected by the war. Almost every congress dealt with amputations and artificial limbs. At the same time, orthopedic surgery became a specialty at the German universities, legitimizing it as a subject of its own. Besides the large number of victims of the First World War who had to be treated by orthopedic surgeons, there was a second group of patients, the so-called cripples. These handicapped people had not previously been treated in general. A new law established in 1920 guaranteed the government's support for treatment and education of these patients. This law was called "Krüppel-Fürsorge-Gesetz," which entailed welfare but also resocialization of the handicapped, including their return to work. The German nation recognized the economic benefit of this law and accepted the financial burden. During this period, German orthopedic surgeons developed many important surgical techniques, diagnostic tests, and technical findings for the production of orthoses and artificial limbs. Some examples of techniques are described in the article: UVirradiation for the treatment of rickets according to K. Huldschinsky, Borggreve's rotationplasty of the leg (Umkehrplastik), hallux valgus arthroplasty according to Brandes, and Bragard's sign.

[Orthopedics and patients under national socialism dictatorship]. / Orthopäden und Patienten unter der nationalsozialistischen Diktatur.

The 12-year dictatorship of National Socialism represents a decisive event in the history of orthopedics in Germany. Treatment and care was limited to those patients whose prognosis promised their reintegration into the work force. Those orthopedic patients with mental and psychological handicaps no longer came under the care of orthopedists and were potential candidates for annihilation. Despite concerted efforts to the contrary, as can be gleaned from the lists of topics at the annual meetings, the prevailing political circumstances encumbered scientific activities. The almost total isolation from international contacts had a negative effect. Orthopedists were hindered in their work by the law on sterilization, which provided for sterilization in cases of severe physical deformity. Some orthopedists even considered the presence of hip dysplasia to be an indication. The roles played by Georg Hohmann, Hellmut Eckhardt, Lothar Kreuz, and other leading orthopedists are described in detail. It can be regarded as certain that Hohmann and Eckhardt were able to prevent dire consequences for their orthopedic patients and the profession by cautious tactics. The ethnical problems of involvement with National Socialism are thoroughly discussed.

[Transition from malum coxae senile to the arthrosis deformans concept. A summary of the best known theories and classifications]. / Der Weg vom Malum coxae senile zum Begriff der Arthrosis deformans. Eine Zusammenfassung der bekanntesten Theorien und Klassifikationen.

The disease of degenerative arthritis has been known for thousands of years. Paleopathology has provided findings of ancient degenerative alterations. Furthermore, physicians in classical antiquity described several forms of joint diseases. A challenging problem was the therapy, which was limited at that time. For centuries all joint diseases were subsumed under the term"rheumatism." In 1683 Thomas Sydenham, who suffered himself from gout, first differentiated this joint disease from the larger group of rheumatic joint diseases. Another early classification was undertaken by John Haygarth in 1779. He differentiated gout from malum coxae senilis and the chronic rheumatic diseases. The different theories and the resulting classifications were influenced by different disciplines such as surgery, internal medicine, pathology, anatomy, neurology, microbiology, and radiology. This investigation includes the time period from the early nineteenth century until 1925 when the word "arthrosis" was first used in a medical publication. This investigation is based on research at the library of the German Museum for Orthopedic History and Science as well on the systematic search for articles in different German journals such as Zeitschrift für Orthopddie and Fortschritte auf dem Gebiet der Röntgenstrahlen. It includes almost all important books and publications about degenerative arthritis for this time period. In the past there were many different descriptions for degenerative arthritis. The establishment of X-rays and new methods in histology and microbiology and the aspect of biomechanical theories led to a better understanding of the different diseases. The authors tried to construct new classifications without the knowledge of the causal and formal pathogenesis. This is the reason for the large number of different classifications, which had to be revised after a short period of time. This publication gives an overview about the most important articles and books which led to the classification currently in use.

[The German Orthopedic History and Research Museum. A museum for research and public health]. / Das Deutsche Orthopädische Geschichts- und Forschungsmuseum. Ein Museum für Forschung und Offentlichkeit.

The German historical museum of orthopaedic surgery was founded 1959 in Würzburg. The main task of this institution is the furtherance of science in medical-history. Since the beginning, 41 years ago, the number of books and exhibits increased continuously. The library of the museum is the biggest public collection in Germany and contains more then 6000 books and publications in orthopaedics. Furthermore the museum includes a big amount of exoprostheses of the upper and lower limb, alloarthroplasties of hip- and knee-joints, traumatologic implants and instruments of orthopaedic surgery. A big number of bone-preparations with pathologic alterations and variations will also be presented. The exhibition and the library is open to the public and is available to those people in the history of orthopaedic surgery. Local requirements in Würzburg were one of the reasons to transfer the place of the museum to Frankfurt/Main. The museum was reopened at 6th of June 1998 at the university of Frankfurt/Main, department of orthopaedic surgery.