[Long-term results of Imhäuser osteotomy for chronic slipped femoral head epiphysiolysis]. / Langzeitergebnisse der Imhäuser-Osteotomie bei Epiphyseolysis capitis femoris lenta.

BACKGROUND: The treatment of slipped capital femoral epiphysis (SCFE) has produced in its complexity a great deal of discussion. One well-established method of operative treatment is the corrective intertrochanteric osteotomy according to Imhäuser. This study presents the clinical and radiological long-term results and the biomechanical impacts of this invasive intervention. PATIENTS AND METHODS: A total of 28 patients with chronic SCFE with slip angles between 30° and 60° were treated by Imhäuser osteotomy at an average age of 13.7 years (SD± 2.2 years, range 9-19 years) and were reexamined after an average period of 24 years (SD± 6.7 years, range 12-32 years). RESULTS: The results of the biomechanical analyses indicated an increase of force affecting the articulating joint postoperative compared to preoperative, even though the pressure on the joint decreased. This can be interpreted as a result of the enlargement of the articulating joint surface. Of the patients 17 achieved an excellent Harris hip score, 8 a good and 3 a satisfying result in the clinical assessment. There were significant differences in the degree of arthrosis between the side with and the side without osteotomy. Out of 27 cases 10 showed a decrease in the degree of arthrosis of the side with osteotomy whereas 3 cases showed an increase. In 14 cases no difference was measured. CONCLUSIONS: Despite the valgisation the Imhäuser osteotomy relieves the hip joint thus probably counteracting degenerative alterations even though being unable to fully prevent this progress. The good biomechanical, clinical and radiological results support indications for Imhäuser osteotomy for slip angles between 30° and 60°.

17-year follow-up of the rough-blasted threaded Weill cup in uncemented total hip arthroplasty.

INTRODUCTION: For uncemented hip arthroplasty, various cup designs are available. The threaded Weill acetabular component (Weill cup; Zimmer, Winterthur, Switzerland) has been used for more than 20 years, with poor results of the smooth threaded design. Our study was intended to assess the 17-year outcome of the rough-blasted option of the threaded Weill cup. MATERIALS AND METHODS: Between 1987 and 1988, a series of 86 rough-blasted threaded Weill cups were implanted in combination with the CLS Spotorno stem (Zimmer Ltd, Germany) The patients' mean age at the time of surgery was 50 years (range 19-67 years). 67 out of 86 hips (78%) were available for a follow-up at a mean of 17 years (range 16-18 years). Radiographs were available from 55 out of 63 unrevised hips (87%) and analyzed for radiolucency and PE wear. RESULTS: Two out of 86 cups (3%) were revised due to aseptic loosening and another two cups (3%) were awaiting revision for the same reason. Ten patients (10 cups, 12%) were lost to follow-up, and nine patients with nine cups (11%) had deceased without radiographic signs of cup failure. Cup survival with "revision or awaiting revision" as endpoint was 86% (95% CI 75-92%). No deep infections occurred, and no polyethylene insert was exchanged. The Harris hip score was excellent in 37 out of 67 clinically examined hips (55%), good in 18 hips (26%), satisfactory in 5 hips (8%) and moderate or poor in 5 hips (8%) and 2 hips (3%), respectively. CONCLUSION: The rough-blasted threaded Weill cup provides a good long-term performance in cementless total hip arthroplasty. The results compare favourably to the smooth threaded cup design.

[Periprosthetic femoral bone reaction after total hip arthroplasty with preservation of the collum femoris : CT-assisted osteodensitometry 1 and 3 years postoperatively]. / Periprothetische femorale Knochenreaktion nach schenkelhalserhaltender Hüftendoprothetik : CT-gestützte Osteodensitometrie 1 und 3 Jahre postoperativ.

BACKGROUND: Short-stemmed cementless femoral components in total hip arthroplasty have been designed to preserve the proximal femoral bone stock by load transfer to the femoral metaphysis. An in vivo method of computed tomography-assisted (CT) osteodensitometry after total hip arthroplasty is presented which differentiates between cortical and cancellous bone density (BD) changes around uncemented femoral components. PATIENTS AND METHODS: Cortical and cancellous periprosthetic femoral BD (mg Ca HA/ml) was determined prospectively in 31 patients at day 10, 1 year and 3 years after total hip arthroplasty with preservation of the collum femoris (C.F.P.-stem, Link, Hamburg, Germany) using computed tomography-assisted osteodensitometry. Clinical results (Harris hip score) and plain x-rays were assessed in all cases. RESULTS: Progressive proximal cortical BD loss was observed between the 1 year (Ø -8%) and 3 year (Ø -22%) postoperative measurements. Distal to the trochanter minor no significant cortical BD changes were observed. Proximal cancellous BD decreased progressively between the 1 year (Ø -33%) and 3 year (Ø -45%) analyses. The Harris hip score improved from 45 points pre-operatively to 93 points at the 3 year follow-up. All x-rays showed signs of stable ingrowth. CONCLUSION: Periprosthetic CT osteodensitometry has the technical ability to discriminate between cortical and cancellous bone structures with respect to strain-adapted remodeling. Progressive proximal cortical and cancellous BD loss indicates that metaphyseal fixation cannot be achieved with the analyzed C.F.P. stem design. The lack of cortical BD loss below the trochanter minor suggests diaphyseal fixation of the implanted stem.

[Current strategies of conservative and operative treatment of the most frequent muscular disorders]. / Aktuelle Strategien der konservativen und operativen Therapie der häufigsten Muskelerkrankungen.

Though up to now no causal treatment for the majority of neuromuscular disorders is available, their disease progress and above all the quality of life of these patients can be decisively improved by established medical procedures. The main symptom is variably rapid, progressive muscle weakness, which leads to muscular imbalance and differently manifested impairment of motor functions. This results in the essential orthopaedic problems in these patients, e.g. contractures and deformities of the lower and upper extremities, foot deformities and sitting instability due to progressive scoliosis. Since the affected muscles have no physiological adaptability, they cannot be trained like healthy muscles. The orthopaedic treatment includes conservative methods, e.g. physiotherapy, orthotic devices and aids as well as surgical spine stabilisation and correction of the contractures of the lower extremities. Very important in the care of patients with neuromuscular disorders are the early prophylaxis and treatment of respiratory insufficiency by regular respiratory therapy to learn breathing and coughing techniques and self-exercises as well as the timely initiation of assisted ventilation.

Lower limb surgery in Duchenne muscular dystrophy.

Two hundred and thirteen of 428 patients with Duchenne muscular dystrophy (DMD) of a prospective and open study were operated on bilaterally with hip and knee release, aponeurectomy of the iliotibial band and Achilles tendon lengthening. In 87 patients the operation was carried out during early restrictions of the lower limb joint mobility at an average age of 6.56 years (4.02-8.26, SD 1.42). The follow-up was on average 5.4 years (0.25-9.01, SD 2.7). This group was compared to a control group (natural history) consisting of 100 non-operated DMD patients. A significant (P < 0.001) release of the contractures could be obtained. Loss of walking ability occurred in the control group at an average of 9.29 years (5.85-13.63, SD 1.98) and in the operated group at an average of 10.55 years (8.17-14.39, SD 1.76). This shows that early lower limb surgery leads to a prolongation of independent ambulation of 1.25 years on average. In contrast to the patients of the control group all treated patients between ages 6 and 8 years could walk independently. The positive influence of early lower limb surgery could also be shown by the development of Hammersmith motor ability score, CIDD (Council of Investigation of Duchenne Dystrophy) grading and Vignos scale. Nevertheless, in consideration of the well-known course of DMD not only the prolongation of ambulation but also the achieved prolongation of assisted standing ability with no or mild contractures are aims of lower limb surgery. Since no improvement of muscle strength could be observed after lower limb surgery, further studies have to investigate if additionally administered steroids can prolong ambulation after early lower limb surgery.

Platelet function deficiency in Duchenne muscular dystrophy.

Platelet function and plasmatic coagulation of 51 patients with Duchenne muscular dystrophy (DMD) were studied in order to find an explanation for the known substantial blood loss in spinal surgery of these very patients. A normal plasmatic coagulation and a slight but not significant increase of bleeding time was found. However, a significant deficiency of platelet adhesion and ristocetin induced aggregation (P < 0.001) as well as a marked reduction of expression of glycoprotein i.v. (synonyms: GPIV, GPIIIb, CD36) to 50% were detected. We conclude from our study, that this finding of deficiency of platelet function in DMD patients is of no importance in everyday life and minor operations, e.g. lower limb surgery. In major spinal surgery, however, the platelet function deficiency occurs. A decompensation of platelet adhesion as well as aggregation capacity can be assumed due to the unavoidable intraoperative dilution effect by the inevitable volume replacement.

A psychometric evaluation of the acute tremulous state.

The acute alcohol withdrawal state (tremulous state), with mainly vegetative symptoms and without evident loss of conciousness or confusion, was evaluated as to functional psychopathological disturbances aiming to present a complete and objective record of the clinical findings and to establish a control of the course and drug treatment. We tried to meet the inherent inability to cooperate by using proven and also new test devices (flicker fusion, simple reaction time on light and tone, reaction on multiple serial stimuli, visual motor coordination, tachistoscopic perception and memory test, test of concentration and sustained performance with simple arithmetical calculation by analogy with the Pauli test) to circumvent the difficulties arising when patients have to answer long questionnaires. The tests enabled a measurement of the disturbances as objective as possible and proved to have a discriminating sensitivity for different functions. The correlations between the results were found to be similar for alcoholics and controls. tthe degree of the established functional cerebral and cerebellar defects which was revealed was more severe than expected in this mild stage of withdrawal.

Critical evaluation of known bone material properties to realize anisotropic FE-simulation of the proximal femur.

PURPOSE: In a meta-analysis of the literature we evaluated the present knowledge of the material properties of cortical and cancellous bone to answer the question whether the available data are sufficient to realize anisotropic finite element (FE)-models of the proximal femur. MATERIAL AND METHOD: All studies that met the following criteria were analyzed: Young's modulus, tensile, compressive and torsional strengths, Poisson's ratio, the shear modulus and the viscoelastic properties had to be determined experimentally. The experiments had to be carried out in a moist environment and at room temperature with freshly removed and untreated human cadaverous femurs. All material properties had to be determined in defined load directions (axial, transverse) and should have been correlated to apparent density (g/cm(3)), reflecting the individually variable and age-dependent changes of bone material properties. RESULTS: Differences in Young's modulus of cortical [cancellous] bone at a rate of between 33% (58%) (at low apparent density) and 62% (80%) (at high apparent density), are higher in the axial than in the transverse load direction. Similar results have been seen for the compressive strength of femoral bone. For the tensile and torsional strengths, Poisson's ratio and the shear modulus, only ultimate values have been found without a correlation to apparent density. For the viscoelastic behaviour of bone only data of cortical bone and in axial load direction have been described up to now. CONCLUSIONS: Anisotropic FE-models of the femur could be realized for most part with the summarized material properties of bone if characterized by apparent density and load directions. Because several mechanical properties have not been correlated to these main criteria, further experimental investigations will be necessary in future.

[Core decompression in Ahlbäck's disease. Follow-up and therapy control using MR tomography]. / Markraumbohrung (Core-Dekompression) bei Morbus Ahlbäck. MR-tomographische Verlaufs- und Therapiekontrolle.

Clinically suspected spontaneous osteonecrosis of the knee (Ahlbäck's disease) was confirmed by MR imaging and subsequent histology in 4 male patients with sudden onset of severe knee pain. The first typical radiological sign for osteonecrosis--flattening of the affected femoral condyle--was seen in no case. All patients were treated surgically by extraarticular drilling for core decompression and were delivered from the complained severe knee pain immediately after surgery. The healing process of early osteonecrosis could be confirmed by the normalisation of bone marrow signal in MR imaging (3 to 15 months follow-up). Core decompression seems to be an effective treatment in early osteonecrosis of femoral condyles. MR imaging is the most sensitive method for early diagnosis of osteonecrosis and for preoperative planning as well as a helpful tool for a non-invasive postoperative follow-up.

[The percutaneous removal of osteoid osteomas via CT-guided drilling]. / Perkutane Entfernung von Osteoidosteomen durch CT-kontrollierte Bohrung.

Osteoid osteomas were removed by CT-guided core drill excision of the nidus in 4 patients. All osteoid osteomas were located in the lower extremity and included cortical lesions in the femur (n = 2), and the tibia (n = 1) and one spongious lesion in the navicular bone of the foot. Nidus diameter ranged from 2 to 3 mm. The patients were discharged after the procedure same day or next day depending on the kind of anaesthesia performed. Follow-up periods ranged from 6 to 56 months and revealed no signs of recidivation. CT-guided core-drill excision of the nidus seems to be a very promising alternative to surgical procedures because of its high cost-effectiveness and minimal invasiveness.

Ipsilateral peroneus brevis tendon grafting in a complicated case of traumatic rupture of tibialis anterior tendon.

Ruptures of tibialis anterior tendon can be caused by open, closed, direct, or indirect trauma, as well as spontaneously. Sixty-three cases of tibialis anterior tendon ruptures have been reported in the international literature. The treatment of choice is the surgical end-to-end or side-to-side anastomosis after previous Z-lengthening. The case of a 28-year-old world-class female triathlete who sustained an open laceration of the tibialis anterior tendon from the bicycle chain guard is reported. The primarily applied tendon suture became infected and a wound revision with wide resection of the tendon stumps was necessary. This lead to an extensive defect of the tendon combined with a deep-seated keloidal scar reaction of the skin. The surgical closure was performed using free ipsilateral peroneus brevis tendon grafting. Four months after the operation the patient was completely rehabilitated. Eight months later she became the second European triathlon champion.

Spinal stabilization in Duchenne muscular dystrophy: principles of treatment and record of 31 operative treated cases.

The aim of this study was to report results of prophylactic spinal stabilization in patients with Duchenne muscular dystrophy. There is still debate regarding the ideal instrumentation. A prospective study of a consecutive series of 31 patients stabilized with the ISOLA system from D2 to S1 will be presented. The mean follow-up was 22 months (range, 1-60 months). The evaluation of the Cobb angle and pelvic obliquity revealed the following: 1) Cobb angle: preoperation, 48.6 degrees (range, 22-82 degrees); postoperation, 12.5 degrees (range, 0-30 degrees); follow-up, 12.5 degrees (range, 0-42 degrees); and 2) pelvic obliquity: preoperation, 18.2 degrees (range, 3-40 degrees); postoperation, 3.8 degrees (range, 0-13 degrees); follow-up, 5.1 degrees (range, 0-14 degrees). Spinal stabilization with the ISOLA system was found to be a suitable treatment for scoliosis owing to Duchenne muscular dystrophy. It should be carried out after loss of ambulation as soon as a progressive curve of more than 20 degrees is documented. The complication rate was found to be high.

Scoliosis in Duchenne muscular dystrophy: aspects of orthotic treatment.

The x-linked Duchenne muscular dystrophy (DMD) is the most frequent generalized muscle disorder arising from a lack of the sarcolemmic protein "dystrophin". Patients with DMD develop in the majority a progressive scoliosis when they cease walking and/or standing at the age of 10 years and become confined to a wheelchair. Increasing muscle weakness leads to a progression of the curvature, the pelvic tilt and problems in sitting. Together with the simultaneous progressive weakness of the respiratory muscles a restrictive pulmonary insufficiency will occur. Surgical stabilization of the spine (> 20 degrees Cobb, forced vital capacity > 35%) by an adequate multisegmental instrumentation enabling early mobilization is now the treatment of choice. However, orthotic treatment may offer an acceptable compromise in exceptional cases, if the patient rejects surgical intervention or is in the late (inoperable) stages of the disease. Such a treatment is superior to a primary sitting support provision with insufficient possibilities of correction. The authors' experiences with 48 scoliosis orthoses made for 28 patients with DMD are reported. A "double plaster" cast has emerged as the best method to optimize adaption, especially in severe curvatures and the time taken for manufacturing the orthosis. A great deal of experience, patience and the consideration of the patients' individual demands are inevitable for a successful orthotic treatment.

Atraumatic recurrent posterior shoulder subluxation: review of the literature and recommendations for treatment.

Isolated atraumatic recurrent posterior subluxation of the shoulder (ARPS) constitutes 1% of all shoulder subluxations; it is therefore difficult for any single clinic to gain a large experience in treating this condition. Based on a review of the literature 83 cases of ARPS out of 237 reported cases with all types of posterior subluxation of the shoulder (185 patients) were analyzed. Most cases of ARPS occur between 11 and 20 years of age; they are frequently associated with changes such as dysplasia of the glenoid labrum or an alteration in the spinoglenoid angle. More than half of all ARPS occur bilaterally. The diagnosis is based on history, physical examination including tests of instability, or on techniques of dynamic examination (ultrasonography, arthroscopy). A plan of management related to the underlying etiology has been developed. At the first occurrence, cases of subluxation should be treated conservatively by kinesitherapy and physical therapy. Operative treatment is indicated when conservative management for at least 6 months has been unsuccessful and subluxation continues to occur during everyday activities, but it should never be instituted in patients with emotional disorders. The underlying pathologic lesion should determine the technique for shoulder reconstruction in atraumatic posterior shoulder subluxation. In cases in the atraumatic voluntary subgroup, surgery is indicated if conservative treatment fails and the voluntary component has been eliminated. In this subgroup, isolated soft tissue procedures have not been shown to produce good long-term results, and supplementary bony procedures are considered necessary. Conservative treatment exclusively is recommended in voluntary cases.

[Musculoskeletal symptoms in patients with post-polio syndrome]. / Orthopädische Beschwerden und Funktionseinschränkungen beim Post-Polio-Syndrom.

BACKGROUND: The prevalence of the post-polio syndrome (PPS) is in estimated 50 % of persons with established poliomyelitis with a subsequently stable phase of at least 15 years. The basic mechanism is a loss of motoneuron cells in the spinal cord resulting in muscle weakness and fatigue. In addition pain, cold intolerance and a loss of stamina are frequently reported. There are few studies focusing on the orthopaedic symptoms in the PPS. This study should support the health-care professionals to the address the needs of PPS patients. METHODS: A questionnaire was developed to collect data on patients who have been diagnosed by a neurologist as fulfilling the criteria of a PPS. It consists of two parts. In the first part, general patient data are collected. In the second part, details of health, pain, and activities of daily living are collected at two points in time: the time of the stable phase immediately after the acute phase of the disease and the phase after the PPS diagnosis. The questionnaires were sent to patients with a diagnosis of PPS. A total of 124 questionnaires were analysed (male: 45, female: 79). Parts of the data were used to calculate a score. It was hypothesised that the score would demonstrate a higher load of orthopaedic symptoms in the PPS phase. RESULTS: The results show that the phase after poliomyelitis (stable phase vs. PPS phase) was associated with significantly different sum score relating to the orthopaedic impairments. The score in the stable phase is on average 18.6 units lower than that in the post-PPS diagnosis phase (p < 0.001). The hypothesis that in the PPS phase the load of orthopaedic symptoms is increased is confirmed by our data. The "loss of functioning in the upper extremity" is also significantly associated with the score (p = 0.004). CONCLUSIONS: At the time the survey was taken, patients reveal a high level of musculoskeletal impairments and disabilities after PPS than during the stable phase with regard to general health as well as pain status and performance of daily activities. Age has no significant impact. Many of the patients are severely limited, especially with regard to activities such as walking, climbing stairs, and performing simple household tasks. Since there is no causal therapy for the underlying degeneration of the anterior horn cell pools, treatment is focused on the compensation of the functional limitations.

[Botulinum toxin a treatment in spastic forms of cerebral palsy: a retrospective clinical study]. / Anwendung von Botulinumtoxin A in der Behandlung der spastischen infantilen Zerebralparese: Retrospektive klinische Beobachtungsstudie.

BACKGROUND: Botulinum toxin therapy now has a firm place in the treatment of spastic forms of cerebral palsy in children. This paper considers the subjective and practical results and the degrees of satisfaction from the point of view of the patients and their families. It also documents the data of infiltrations carried out under anaesthesia. PATIENTS AND METHODS: 57 patients with an average age of 11 (± 6.7; 2-30) and with infantile spastic cerebral palsy underwent altogether 118 botulinum toxin A infiltrations. The patients were divided into two groups: those with spastic hemiparesis or diparesis, and those with tetraparesis, and then compared with each other. The results of the treatment were evaluated from the point of view of the patients and their families with the help of a specially developed questionnaire. RESULTS: The study shows that, broadly-speaking, patients less affected with spastic hemiparesis or diparesis felt they profited more from the treatment than patients more severely affected with tetraparesis. The statistics also show that the first group's expectations were significantly more often fulfilled and that they more frequently perceived greater success after each infiltration than the group with tetraparesis. Most patients and their families from both groups were satisfied with the treatment. CONCLUSION: Patients and their families feel that the use of botulinum toxin in the management of spastic cerebral palsy in children is an effective and accepted form of treatment. The aims of the therapy should be defined accurately and realistically before starting treatment, especially for those severely affected with tetraparesis, and discussed in detail with both the patient and his/her family.