[Tendon transfer in pediatric foot deformities]. / Sehnentransfers bei kindlichen Fussdeformitäten.

Tendon transfer surgery plays a central role in the treatment of pediatric foot deformities. Tendon transfers are essential for balancing in neurogenic deformities but also important for the treatment of congenital or idiopathic deformities. Furthermore tendon transfer represents an important management tool for revision surgery of failed treatment in foot deformities. Complications and pit-falls which can potentially lead to failure may occur during the indications and planning of the transfer as well as during the surgery. The identification and analysis of possible pitfalls and complications as well as their management is the central issue of this article. Knowledge about possible problems and their management are essential for successful treatment of pediatric foot deformities.

[Preserving foot surgery for diabetics]. / Erhaltende Fusschirurgie beim Diabetiker.

The reconstruction of a diabetic foot is still a challenge for the orthopedic surgeon. Untreated fractures, dislocations and foot and ankle deformities with consequent ulcerations may increase the risk of limb amputation. For patients who refuse a major amputation a surgical reconstruction can be started using bone grafts, angle stable locking plates and ankle arthrodesis nails. The goal of reconstruction in all patients is to avoid amputation.

Angiomorphometry in malignant tumors and inflammatory disease.

Angiographic differentiation of malignant and inflammatory lesions is occasionally impossible, since certain criteria for malignancy also apply to benign lesions. The authors analyzed samples of microangiographic specimens of kidneys with inflammation, tumor, and normal control organs to define mathematically the frequency of such angiographic parameters as caliber fluctuation, vascular avulsion, change of direction and diameter, and change in predominant vascular structure. The described method is transferred to clinical angiograms, and results of both groups are compared. In this preliminary analysis, caliber fluctuation appears to be the single most important criterion for differentiation of malignant and benign angiographic alterations.

Experimental study of the effectiveness of capillary embolization using contrast-enhanced Ethibloc.

In experimental and clinical use, Ethibloc in combination with 40% glucose preinjection has proven to be of major advantage in tumor embolization. However, its low radiographic contrast is a limiting factor in monitoring its vascular distribution and venous propagation. Various contrast media were tested in order to enhance this contrast in laboratory and animal experiments. Normal rat kidneys (N = 96) and renal tumors, induced by Dimethylnitrosamine (N = 66) were tested as in previous studies. Ethibloc-N was produced by substituting Lipiodol for poppy seed oil which is an ingredient of the original Ethibloc. This proved to be the only embolization medium that combined the excellent properties of the original Ethibloc with increased contrast. All other embolization media tested resulted in new complications such as under-or overembolization and pulmonary embolism.

Ultrastructural findings after intraarticular application of hyaluronan in a canine model of arthropathy.

We investigated the effect of intraarticularly applied hyaluronic acid (hyaluronan) on the cartilaginous structure of experimentally induced chondromalacia patellae in dogs. For the induction of chondromalacia, we used the Pond-Nuki technique, which involved severance and resection of the anterior cruciate ligament, as a canine model of arthropathy in 27 foxhounds (three groups of nine animals each). In a pilot study, we evaluated the effect of resection of the anterior cruciate ligament with no therapy. Patellar specimens were retrieved at 3, 6, and 12 weeks postoperatively. Subsequently, we compared a treatment group that received intraarticular injections of hyaluronan with a placebo group that received saline solution. The groups were compared at 3, 6, and 12 weeks postoperatively. Three animals from the treatment and placebo groups received five injections of hyaluronan during one of the 4-week intervals (weeks 3-6, 6-9, or 12-15). Specimens were retrieved 5 weeks after the last injection. In both groups, the uninvolved contralateral knee served as a control. The specimens were taken from the medial and lateral patellar poles. Histological analysis included light microscopy and transmission electron microscopy. The structural and ultrastructural changes were assessed qualitatively and were quantified with use of a modified Mankin score. Our results indicate that chondromalacia patellae may be induced with the Pond-Nuki technique. We found a significant reduction (p < 0.01) of cartilaginous lesions in the hyaluronan group compared with the placebo group. Our results suggest that intraarticularly applied hyaluronan is effective in delaying the degenerative process of cartilage degradation. Therefore, we conclude that the use of hyaluronan may be indicated during the early stages of chondromalacia.

[Hypernephroma in a pelvic kidney. Diagnostic problems during angiography (author's transl)]. / Hypernephroides Karzinom in einer Beckenniere. Diagnostische Probleme bei der Angiographie.

A hypernephroma in a pelvic kidney of a 54-year-old patient is described, which could not be demonstrated angiographically. This is explained by marked compression of the kidney because of the limited available space and the pressure of the surrounding organs. There was also histological proof of advanced intimal fibrosis in the artery and extensive obstruction of the vein by tumour, leading to diminished circulation of blood. The extreme rarity of hypernephromas in pelvic kidneys is stressed; this is barely mentioned in the literature.

[A technic of magnetic resonance tomographic pelvimetry in obstetrics]. / Technik der kernspintomographischen Beckenmessung in der Geburtshilfe.

Magnetic resonance imaging (MRL) allows for the first time direct determination of maternal pelvic dimensions without ionising radiation. Phantom measurements and the correlation with traditional pelvimetric measurements in 10 patients after Caesarean section have shown mean differences of +/- 2 mm, with a maximum of 5 mm. The evaluation of pelvic configuration is obtained analogous to the conventional roentgenogram. In addition to conventional or digital x-ray pelvimetry, the soft tissues of the maternal pelvis and the presenting part of the foetus is delineated with high contrast. Positioning in the body coil can be accomplished even late in pregnancy or in impending labour, acceptance by the pregnant women being high. Whereas in a given indication after delivery conventional x-ray pelvimetry continues to be performed, antenatally MRI pelvimetry has now been established in our Departments as the method of choice--based on meanwhile 107 examinations. Present drawbacks are the relatively high cost and the limited availability of MR units.

[Indications and value of treatment by catheter occlusion (author's transl)]. / Indikation und Wert der Katheterverschlussbehandlung.

The value of the catheter occlusion therapy is analyzed in 92 cases retrospectively, and the indication, and complication risk of these procedures are considered. In the following vessel areas occlusion with different methods have been performed with decreasing frequency; kidneys, pelvis, legs, gastrointestinal tract, external carotid and internal carotid artery. Serious complications have been observed in therapeutic investigations at the head, especially in occlusions of the external carotid artery. In this group embolisation therapy should be performed with strict indication only.

[Early postoperative control of internal thoracic artery-coronary artery anastomoses using intra-arterial DSA]. / Frühe postoperative Kontrolle von Arteria-thoracica-interna-Anastomosen mit Koronararterien durch intraarterielle DSA.

Early postoperative angiographic control is important for prognosis and medical therapy for patients undergoing coronary bypass surgery. Grafts from the internal mammary artery had been shown to be superior to venous bypasses for anastomoses to the left anterior descending coronary artery. Thus, the need for angiographic demonstration of graft patency and function is increasing. We report on the angiographic analyses of 73 patients after left internal mammary artery (LIMA) bypass surgery by filling of the graft via retrograde injection of contrast medium into the left brachial artery. In all cases the bypass, anastomosis and downstream vessel were clearly visualised. No complications or side effects were observed.

Function after correction of a clawed great toe by a modified Robert Jones transfer.

We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically. The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001). The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux.

Rupture of an intracranial aneurysm--unusual complication of an electric shock.

Here we report about a 35-year-old electrical engineer who was found dead in his study. Postmortem examination revealed that death resulted because of subarachnoid and intraventricular hemorrhage caused by the rupture of an intracranial aneurysm. Right hand and left cheek revealed electrical marks with metallizations on skin, an electric shock was diagnosed to have preceded death. The close temporal correlation suggests that a sudden rise in blood pressure was caused by the electric current and was thus responsible for the rupture of the aneurysm.

Budd-Chiari-Stuart-Bras syndrome: clinical, sonographic, radiological reexaminations in occlusive diseases of hepatic veins.

Ten patients with clinically and histologically verified Budd-Chiari-Stuart-Bras Syndrome (i.e. occlusive disease of small or large efferent hepatic veins) were re-examined, the examination also including combined ultrasonography and computed tomography. These non-invasive methods help to establish a quick diagnosis by locating and defining the most severe changes, by helping to select the most appropriate invasive diagnostic procedure, and by defining their topographical target. They thus facilitate immediate, optimal therapy. The disease process often starts in the right dorsal lobe of the liver and may cause extreme hyperplasia of the left or middle lobes, causing gross changes in the shape of the liver and considerably displacing the gallbladder in some cases. Thrombosis of the portal vein and pulmonary embolism seem to be most frequent complications or accompanying diseases. We therefore suggest immediate long-term anticoagulation, provided portal hypertension is not too severe; patients with severe portal hypertension should undergo a shunt operation. Our patients were followed up for periods ranging from 3 to 8 years. The very variable prognosis includes complete cure and good compensation over a long period and appears to be much better than has been reported by some authors.

Spontaneous cholecystocolonic fistula: a model situation for bile acid diarrhea and fatty acid diarrhea as a consequence of a disturbed enterohepatic circulation of bile acids.

Fistulas between the biliary and gastrointestinal tract complicate 12% of cases with cholecystitis. Communications of the biliary tract occur with decreasing frequency into the duodenum, colon and stomach. Clinical symptoms of cholecysto-colonic fistulas are chills and temperature elevation indicating ascending cholangitis. As bile acids bypass the small intestine, diminished fat absorption results. The unusual amount of bile acids in the colon delays water absorption, causing bile acid diarrhea. A pneumocholangiogram is seen in only 50% of the cases. Barium enema will visualize the fistula most often.

Prerenal hypertension caused by a postoperative A-V fistula.

The A-V fistula in the renal pedicle with functioning renal parenchyma leads to a prerenal hypertension by the blood-steal effect from the renal artery through the fistula into the vein, according the pressure gradient over the fistula. The etiology of these A-V fistulas is pointed out. A case corrected by surgical removal of the fistula is reported.

The clinical trial of TOMOTRON--a new electronic device--and eight months' clinical experience.

We have been using digital tomography (TOMOTRON) clinically for eight months. Its advantages include savings in both time and dose, good image quality through increased contrast, and improved magnification and image postprocessing compared with conventional tomography. However, lower image resolution and small image sections are the disadvantages of digital tomography. Weighing these advantages and disadvantages by our experience, the diagnostic accuracy of digital tomography is higher than conventional tomography, particularly in skeletal studies.

[Treatment of acute iliac artery occlusion by catheter lysis, catheter dilatation and implantation of a new kind of metallic vascular endoprosthesis]. / Die Behandlung eines akuten Beckenarterienverschlusses durch Katheterlyse, Katheterdilatation und Implantation einer neuartigen metallischen Gefässendoprothese.

Methods of interventional radiology have achieved a significant importance for the treatment of acute iliac artery occlusion if either local or general clinical controindications preexclude routine surgical means of vessel repair. The newly developed balloon-expandable metal mesh vascular endoprosthesis is shown to accomplish percutaneously a definitive reconstruction of heavily diseased iliac artery vessel segments which very well compares with the hemodynamic and morphologic aspect of surgical treatment such as thrombectomy combined with TEA or bypass surgery. Both, short and long-term results one year after the implantation of two balloon-expandable metallic vascular stents reflect a much higher efficacy in functional treatment of iliac artery related claudication than a routine percutaneous transluminal angioplasty alone. In addition, it is shown that local lysis based on a standard protocol of selective intrathrombus instillation of urokinase helps to clear totally clogged iliac arteries.

A new concept in the treatment of anterior knee pain: patellar hypertension syndrome.

This prospective clinical study evaluated 69 patients (136 knees) presenting with anterior knee pain after failure to respond to conservative treatment. All patients agreed to undergo minimally invasive intraosseous pressure measurements of the patella under local anesthesia. Forty patients (50 knees) demonstrated a positive pain provocation test (the typical pain sensation could be reproduced by raising intrapatellar pressure) and were treated with a new method of intraosseous drilling and decompression. Ninety percent of the patients treated experienced pain relief >3 years postoperatively. Repeated intraosseous pressure measurements in 33 knees 1 year postoperatively confirmed objective intraosseous pressure reduction in 88%. Patients with anterior knee pain and a positive pain provocation test were labeled as hypertension syndrome of the patella. These results indicate simple extra-articular patellar decompression may offer a valuable new form of treatment in select patients with anterior knee pain, ie, hypertension syndrome of the patella.

[Clinical value of ultrasonography and computerized tomography prior to abdominal interventions]. / Klinischer Stellenwert von Sonographie und Computertomographie vor abdominellen Eingriffen.

We studied the value of ultrasound and computed tomography in the preoperative diagnosis of abdominal diseases in 100 patients. Reference methods were the reports of surgery and pathology. A computed tomography or ultrasound diagnosis could be correct or false and was considered uncertain, if the main diagnosis was missed but computed tomography or ultrasound suspected pathology, which then could be clarified by other procedures. Overall, computed tomography was superior with 75 correct, 13 false and 12 uncertain diagnoses compared to ultrasound with 58 correct, 31 false and 11 uncertain diagnoses. Ultrasound often failed because obesity or gas impaired visibility. If only cases without technical problems of ultrasound were taken into account, diseases of liver, gallbladder, pancreas, kidney, the adrenal region and other abdominal masses were equally well diagnosed by ultrasound and computed tomography. As expected, the diagnostic value of both modalities was markedly reduced in diseases of the bile duct and the gastrointestinal tract. Because the study design required both, ultrasound and computed tomography, cases already clarified by ultrasound were not included. This fact might have further reduced the sensitivity of ultrasound in comparison to computed tomography. Furthermore, ultrasound was mostly one of the first diagnostic procedures performed right after the patient's admission with little information on anamnestic and clinical data. The information given prior to computed tomography was in general more detailed.

[Rectus transfer in spastic diplegia]. / Die Verpflanzung der Sehne des Musculus rectus femoris bei Patienten mit spastischer Diparese.

OBJECTIVES: Change of function of the rectus femoris through medial transfer of its distal tendon. This procedure transforms a hip flexor and knee extensor into a hip and knee flexor. Thus the muscle acts as a hip flexor during the terminal stance phase and swing phase and as a knee flexor during the swing phase. This permits the foot to clear the ground and to improve the spastic gait. INDICATIONS: Functional sequelae of a simultaneous spasticity of knee flexors and extensors causing a stiff gait. Isolated spasticity of rectus muscle with continuous muscle activity during stance and swing phase, recurvatum of the knee during the stance phase, limited flexion (<15(o)) of the knee during the swing phase and lack of clearance of the foot. CONTRAINDICATIONS: Pattern of global flexor spasticity. Loss of power of hip flexors. Paresis of quadriceps. SURGICAL TECHNIQUE: Isolation and detachment of the distal tendon of the rectus femoris. The tendon can be transferred either medially or laterally. For a medial transfer the tendon is sutured to the gracilis tendon which is detached as proximal as possible. This permits to displace the direction of pull behind the center of rotation of the knee. For a lateral transfer the tendon is sutured to the iliotibial tract. RESULTS: In 94,8% of patients (n=137; 274 limbs) followed for a mean of 21 months (7 to 39 months) the results were good to satisfactory using the score of Gage. The Duncan-Ely test was negative in these patients. The gait was markedly improved. Important complications did not occur.

[The sick physician. A patient like every other?]. / Der kranke Arzt. Ein Patient wie jeder andere?

The sick physician is a patient like any other. However, thanks to his particular training and experience, he generally knows more about the difficulties involved in diagnosing and treating an illness, and about its complications and course. He has a right not only to receive intelligently founded information, but also to compassion on the part of the colleague treating him, in particular when this is a specialist. Out of concern for his aura of medical perfection, he is often more social than other patients. On account of his insider knowledge, especially when confronted with organizational deficiencies, he tends to be a more difficult patient, who is also more likely to develop complications. On the other hand, he may have had a patient with the same illness, who may serve him as a model. When he has recovered from his illness, he is more critical towards himself and his medical skills. His empathy with the pain and fears of others increases, and his behavior towards his surroundings, in particular his family and patients, may change markedly. The setting up of special advisory centers for sick physicians, as is the case in London, is to be recommended.