[Recent possibilities for the treatment of osteoporosis in the aged]. / Neuere Möglichkeiten zur Behandlung der Altersosteoporose.

Treatment of idiopathic osteoporosis in the elderly presupposes exact radiological diagnosis, the exclusion of a primary illness as the cause of the pathological process and exact differential diagnosis from other metabolic osteopathies. We consider possible means of prevention of the immobilization of old people, and appropriate hormonal substitution in cases of previous illnesses which coincide with a disturbance of the gonadal function, as important prophylactic measures. In the case of manifest osteoporosis, if possible, an assignment of the disease to a manifestation with high or low bone turnover should be made, by means of biochemical adjuvants. In high bone turnover, the substitution of sex hormones or the administration of calcitonin is indicated, particularly if symptoms of pain are distinct. In osteoporosis with low bone turnover, fluoride in long-term therapy is the preferred medication. The latest studies show that a combination of fluoride and active vitamin D metabolites is preferable to monotherapy. All therapy for this disease, independent of the age of the patient, should be supported by isometric exercises, analgesics and appropriate dietary measures. Orthopaedic supporting measures should be applied only if conservative measures in acute vertebral fractures fail.

[The technic of the Bankart operation. A modified reinsertion technic]. / Die Technik der Bankart'schen Operation. Eine modifizierte Reinsertionstechnik.

A modified technique of reinsertion of the capsule to the bony rim of the glenoid was developed and performed in 57 patients with recurrent anterior dislocation of the shoulder joint. The technique is described in detail. The principal idea of this modified technique is to suture the lateral flap of the capsule into a small sulcus, which is chiselled into the transition zone between the cartilage of the joint and the bony rim of the glenoid. From the bottom of the sulcus four holes are drilled just below the corticalis of the glenoid rim with a dental drill. The capsule is fixed by two U-sutures transosseously. The advantages of this technique are: (1) stable capsular barrier along the rim of the glenoid reinserted by two strong U-sutures; (2) no step between the cartilage of the joint and the reinserted capsule (a Hill-Sachs lesion cannot hook in at the Bankart lesion); (3) the sutures are extra-articular; (4) the lateral flap of the capsule must not be shortened, and therefore full shoulder motion can be obtained; (5) the tendon of the subscapularis muscle is restored to its original position on the lesser tuberosity; (6) a short period of postoperative immobilization. In accordance with the standard rating scale of Rowe, 31 patients were graded as having excellent results, 8 good, none fair, and none poor.

Structural analysis of an offset-keel design glenoid component compared with a center-keel design.

Many different designs of glenoid prostheses have been developed in an attempt to reduce the loosening rates and improve the prognosis of total shoulder arthroplasty. This study investigated a design in which the keel is positioned anterior to the central plane of the component, an offset-keel design. The primary purpose of anterior location of the keel is to avoid contact between the keel and the cortical bone surface. However, anterior placement of the keel also situates it more directly under the line of action of the contact force in abduction; this has the possible advantage of reducing the bending stress on the cement mantle. Our purpose was to establish whether an offset-keel design reduces the cement stresses below those obtained with conventional central-keel designs. A computed tomography-based finite element model of the glenoid region is used and dynamic loading for 0 degrees to 180 degrees in both flexion and abduction is simulated with the use of data from van der Helm (J Biomech 1994;27:527-50). Finite element analyses are carried out for both the normal and the rheumatoid arthritic case. For the rheumatoid arthritic joint, a Larsen grade IV type destruction is reproduced and proximal subluxed loads are applied, associated with a deficient rotator cuff for 0 degrees to 180 degrees in flexion and abduction. Results predict that the cement mantle in the offset-keel design is much less stressed compared with that in the center-keel design for the maximum glenohumeral joint load in abduction for both the normal and the rheumatoid arthritis case. In flexion the offset-keel design still has lower cement stresses even though the load is acting on the opposite side of the glenoid cup from the keel; one explanation for this is that insertion of the offset keel involves removal of the lower stiffness cancellous bone, leaving the glenoid component flanges to be supported by the stronger bone remaining in the glenoid cavity. From a biomechanical point of view, the advantages of an offset-keel design would appear to be considerable.