[Intraoperative localization of metastases with a hand-held gamma probe]. / Intraoperative Metastasenlokalisation mit einer handgeführten Gammasonde.

A 50-y-old male patient with prostate cancer showed two suspicious lesions in bone scintigrams. They were assessed to be bone metastases by biopsy of the os ilium. After i.v. injection of 99mTc-HMDP a probe-guided localization permitted optimal surgical treatment. A bone metastasis in the os ilium was confirmed. The intraoperative detection with a hand-held gamma probe permitted accurate and complete excision of the tumour; the bone defect could thus be reduced to a minimum.

[Bosworth management of acromioclavicular joint dislocation]. / Die Versorgung der Schultereckgelenkluxation nach Bosworth.

It is reported on 26 cases of acromioclavicular joint dislocation, which were treated by the Bosworth-method of coraco-clavicular screw-fixation. 21 patients were followed up for an average period of 27 months. In spite of osteoarthritis in 44% and calcification in 83% all patients had free mobility. 67% were painfree, 33% had little pain. A fully professional and sporting rehabilitation was achieved in 91% respectively 86%.

[Corrections of and within the athletic shoe]. / Korrekturen am und im Sportschuh.

The footprint is unique to every human. Because of this, the ideal shoe should be constructed in such a way as to afford the foot enough space. Many sportsmen become problems in the lower extremities that can lead to stress fractures because the industrially made sportshoe is made for the average person. In order to reduce or even avoid these problems, corrections can be made on the shoe parts such as on the sole, the heel, the pad or the high-tops. According to the measurements we have made of the foot with the hydraulic principle according to Ernst and the use of a special innersole (F-Scan, produced bei Tenscan Inc.). These have shown that at lower speeds (9 km/h) the shock absorption from the foot is such as to relieve the tension of the orthostatic system. Where as at higher speeds (14 km/h) the absorbtion produces more tension leading to an overload on the foot. This can be measured through the innersole tension and form, so that even through manipulation compensation cannot be achieved.

[Postoperative treatment, rehabilitation and expert assessment of patients with endoprostheses of the hip joint]. / Postoperative Behandlung, Rehabilitation und gutachterliche Beurteilung von Endoprothesenträgern des Hüftgelenks.

The main demands on a total hip replacement are to reduce pain or achieve painlessness and to recover or improve mobility and walking ability. Today more younger patients were operated replacing a destroyed hip joint: the reintegration in professional and sportive activities is a major part of the rehabilitation process. The postoperative management especially in physical therapy can be standardized inspite of the use of various models. Usually full weight bearing is accepted after 3 months. A review of consecutive treatment methods and professional and sportive rehabilitation measures are presented. Hip replacement leads to restrictions in activity in general. The evaluation, in relation to the different indemnifying, is differentiated.

High-resolution, selective water-excitation MRI-based cartilage thickness and volume measurements in upper extremity joints.

The objective if this study was to obtain quantitative data about cartilage thickness and volume in joints of the upper extremity by applying a high resolution MR imaging technique, and to validate these data by A-module ultrasound and CT arthrography.
10 elbow and 7 shoulder joints (age 20 to 69 yrs) were investigated with a 3D gradient echo sequence with selective water excitation (TR 18 ms; TE 9 ms; FA 250, resolution 1 x 0,25 x 0,25 mm2, imaging time 19 min.). After trilinear interpolation to a 0,125 x 0,125 mm2 in-plane resolution, snake-based segmentation, and 3D reconstruction, cartilage volume and thickness were determined with a 3D Euclidean distance transformation algorithm. For validation the cartilage volume and thickness values were compared with CT arthrography and A-mode ultrasound.
The mean cartilage thickness of the elbow joint ranged between 0,99 and 1,35 mm and that of the shoulder between 1,18 and 1,79 mm. The mean systematic difference between the elbow cartilage volume obtained from MR imaging and CT arthrography was -0,11% (-6,0 mm3) and the mean random difference 5,7% (314 mm3). Only in the distal humerus, the mean cartilage thickness (average = 1,35 mm) was overestimated relative to CT arthrography (+20,7%, 0,23 mm). In comparison to A-mode ultrasound a slight underestimation was found in the distal humerus (-6,0%, -0,05 mm) and in the shoulder joint surfaces (humeral head: -22%; -0,26 mm; glenoid cavity: -13%; -0,25 mm). With few exception, there were no significant differences between MRI, CT arthrography and ultrasound in the other joint surfaces of the upper extremity joints (random deviations between 0,08 and 0,39 mm).
This specific MR imaging and postprocessing technique can be used for non-invasive determination of cartilage volume and thickness in joints with thin cartilage layers such as the shoulder with a high degree of accuracy.

Total hip replacement in patients with severe bleeding disorders. A 30 years single center experience.

Arthropathy of the hip is moderate in frequency in haemophiliac patients, but is less common than ankle, knee or elbow arthropathy. We report about our experience with total hip replacement in patients with severe bleeding disorders over a period of 30 years. Between July 1972 and 2002, 15 hips in 13 patients were replaced. The main bleeding disorders were Haemophilia A in ten patients and severe v. Willebrand disease in three patients. The mean follow-up was 132 months (range 12-363). We can demonstrate good long-term results, with only one aseptic loosening after 14 years and one septic loosening after 14 months in an HIV-positive patient. The Harris Hip Score increased from 48 points (32-66) preoperatively to 89 (76-100) postoperatively. In conclusion, total hip replacement performed in a specialised haemophiliac centre is a safe procedure, and results in pain relief and improvement of the quality of life in patients with severe bleeding disorders.

[Ligament instability in total knee arthroplasty--causal analysis]. / Ligamentäre Instabilität bei Knie-TEP - Ursachenanalyse.

Ligament instability is a common reason for revision total knee arthroplasty (TKA). A meticulous analysis of the type of instability is very important in order to revise such a knee successfully. The objective of this study was to analyze the different reasons for ligament instability in revision TKA. A total of 135 knee revisions performed by one surgeon were analyzed pre- (clinical and x-ray) and intraoperatively for the cause of failure. X-ray analysis included the assessment of each component for position. Intraopertive analysis included stability testing in extension and 30 degrees , and 90 degrees of flexion, wear pattern, patella motion (shifting and tilting) and patella height. In 32.6 % of all cases, ligament instability was the primary reason for revision. In another 21.6%, ligament instability was identified as a secondary reason for revision. Analysis of the different instability forms showed combined instability in extension and flexion as the most common cause, followed by isolated instability in flexion (31.8%) and isolated instability in extension (9.1%). The high correlation between instability and malpositioning of the prostheses was obvious. Often, an isolated femoral malposition, in particular for rotation, was found, as well as an isolated malposition of the tibia component. In summary, ligament instability is a common reason for revision TKA. Many different forms of instability can be found either as isolated or combined instability types. Correct anatomical positioning of the components and balanced ligaments in the different extension and flexion positions are important for good clinical results, a stable joint, good function and longevity.

Fracture of ceramic heads in total hip replacement.

After introduction of ceramics in total hip replacement, there have been several studies on wear and fracture of the femoral head component. Though reports on fractures are few, we saw four fractures within 2 months. In all patients, a cementless hip prosthesis by four different surgeons was implanted between 3/2001 and 2/2004. In three patients, a ceramic-on-polyethylene pair and in one, a ceramic-on-ceramic pair was used. Only one patient suffered an adequate trauma. The mean survival of the ceramic head was 27 months (11-42). In two patients with polyethylene inlays, the inlay showed signs of wear out due to the fractured head. All four revision surgeries had a good outcome with satisfying results and no complications. Though we observe the postoperative development after implantation of ceramic components closely, we still believe that ceramics in total hip replacement in young and active patients are indicated with good long term results.

[Good results with a cemented titanium stem after 7-9 years]. / Zementierter Titan-Schaft erbringt gute Ergebnisse nach 7-9 Jahren.

AIM: Because of partially ver y controversial results in cemented hip stem replacements made of titanium alloy we investigated in our own patients the mid-term survival of the "Euroform"-stem. This stem is anatomically designed for cemented fixation, made of Ti (6)Al (4)V. METHOD: Within a period between 1990 and 2000 we implanted 2,141 Euroform-prostheses. The course of 103 patients which were operated between April 1990 and April 1992 was followed up. 9 patients died in the meantime and 8 could not be reached. Of the remaining 86 patients we could examine 73 patients with 79 prostheses (87 %). Investiagtion included a questionnaire and clinical and radiological examination to create the Harris-hip-score. The follow-up was 7-9 years, with an average of 94 months. RESULT: Of those 79 prostheses, revision surgery was performed for septic loosening in three cases and for aseptic loosening in two cases. Radiologically one stem was found to be loosen. This means that for aseptic loosening we had a revision rate for aseptical femoral loosening of 2.5 % after 94 months with a mean Harris-hip-score of 84 points. Good or excellent results were found in 82 %, fair results in 9 % and poor results in 9 %. CONCLUSION: The "Euroform" prosthesis is a cemented titanium alloy stem that has in contrary to some other published studies good mid- to long-term results.

[Therapy of bone and joint changes in renal osteodystrophy in adulthood]. / Therapie von Knochen- und Gelenkveränderungen bei renaler Osteodystrophie im Erwachsenenalter.

The renal osteoarthropathy in patients with chronic renal disease undergoing hemodialysis is characterized by increased bone turnover. This is the consequence of secondary hyperparathyroidism and leads to fibro-osteoclasia and osteomalacia. Mineralization of the atypical bone fibers is diminished and the collagen texture is altered. The biomechanical properties of such bone are reduced, which means that the incidence of fractures is increased and fracture healing seems to be disturbed. Therapy given for renal failure leads to segmental necrosis of the epiphyses. In the growing skeleton longitudinal growth is diminished and deviations in the axes of long bones are often observed. Corrective osteotomies, treatment of fractures and artificial joint replacements are therefore necessary in patients with renal failure. Observations recorded in 13 patients (aged 16-67 years) with chronic renal insufficiency who underwent 21 surgical interventions and were followed up for 6 years have led to formulation of the following general recommendations. Corrective osteotomies should only be performed when they are absolutely essential; the rate of nonunions is very high. The same is true for fixation of fractures with plates and nails. When joint replacements are inserted because of segmental necrosis and fractures the course is almost the same as in patients without renal osteoarthropathy when bone cement is used for fixation.

Repair of nonunions by electrically pulsed current stimulation.

Five congenital and 52 acquired nonunions of bone were stimulated using an invasive device. The unit delivered a constant but pulsed right-angled current of positive polarity measuring 20 to 25 muAmps (voltage of 750 mV) and a frequency of 20 Hz. The power pack encapsulated in epoxy resin was implanted at the time of operative fragment stabilization. THe cathode was inserted at the site of the nonunion gap. After two to 12 months, all but two of the acquired nonunions and one of the congenital pseudarthroses healed. In the unsuccessful cases, the bone ends were often totally necrotic. Four cases required reimplantation because of broken wires or expiration of the battery, and two cases failed owing to purulent infection. Electrostimulation is an adjuvant treatment to fragment stabilization in hyporeactive and hypovascular or congenital pseudarthroses. Electrical stimuli may be assumed to simulate conditions which are essential for bone healing.

[Replacement of the cruciate ligament with heterologous connective tissue structures]. / Kreuzbandersatz mit heterologen Bindegewebsstrukturen.

Twenty-four implantations of heterologous connective tissue structures replacing ligaments and tendons are evaluated in order to present the early results in the heterologous replacement of cruciate ligament structures. Twenty implantations are analysed after 18 to 36 months. The biologic structure which is very strong in comparison with the autologous tissue is not modified to a great extent during a period of 21 months, i.e. the ligament prosthesis remains unchanged so that the appellation "bio-prosthesis" seems justified. At present the preliminary clinical results are satisfying. Consequently, heterologous connective tissue structures can be used in repeated surgical interventions for the stabilization of chronic ligament instabilities.

[Natural course in lumbar disk prolapse]. / Spontanverlauf beim lumbalen Bandscheibenvorfall.

This study reports on 74 patients with lumbar nucleus prolapse (NP) and nerve root symptoms. In all patients the clinical diagnosis was confirmed using a CT-Scan. After 1.7 y a clinical follow-up was performed. Four patients have required surgery in the meantime. Ninety percent of the patients treated conservatively experienced marked pain relief and generally appreciated the results of conservative treatment. Nevertheless, 67% had some complaints. The neurological findings showed essential improvement even in cases of severe paresis. Follow-up CT scans performed in 35 of these patients and in a control group of 23 patients showed partial regression of the prolapse at an average of 48.3% and 50.4%, respectively. The NP disappeared in 3 with no regression in 2 cases. If regression occurred, it apparently took place during the first 6 months. Regression of NP and clinical improvement showed no positive correlation. The investigation demonstrated fair results with conservative therapy even in cases with minor regression.

[In-vivo wear of the slide combinations ceramics-polyethylene as opposed to metal-polyethylene]. / In-vivo-Verschleiss der Gleitpaarungen Keramik-Polyethylen gegen Metall-Polyethylen.

The present study deals with long-term dimensional changes in cemented Müller-type total hip endoprostheses. Creep and wear contribute to different extents to the dimensional changes in polyethylene. The total amount of polyethylene wear is represented by the displacement of the femoral head into the socket. Within the first postoperative years, the head shifts up to a relatively high rate of about 0.5 mm per year. This rate diminishes after 5 years to an average of about 0.1 mm (ceramics) and 0.2 mm (metal) per year. Values exceeding 0.2 mm per year for the shift of the femoral head are considered to be unfavourable with regard to a probable loosening of the prosthesis. In this study we determined the orientation of the centre of the prosthetic head in relation to the wire marker of the polyethylene cup, comprising in all 369 total hip prostheses. After an average of 77 months, 96% of the prostheses with ceramic heads (n = 109) had a wear rate of less than 0.2 mm per year. Using metal heads (Protasul-2 and Protasul-10) this rate could only be measured in 71% (n = 109) of the prostheses (61.5 months). The combination ceramics-polyethylene produces half of the total amount of wear produced by metal-polyethylene. Younger patients should preferably be treated with a ceramic ballhead.

[Changes in the juvenile pelvis in congenital systemic diseases of the skeleton (author's transl)]. / Veränderungen des kindlichen Beckens bei angeborenen Systemerkrankungen des Skeletts.

Constitutional disorders of the skeleton show a characteristic appearance in the radiogram of the juvenile pelvis. These radiologic changes are presented in tables and are discussed demonstrating individual cases. Because of the limited reactive possibility of the skeleton not every disorder shows a typical feature of differential diagnosis and radiologic pattern. To differentiate from the congenital dysplasia of the hip and Legg-Calvé-Perthes disease the distribution of the skeletal disorders and their course therefore have to be known. Accordingly the therapeutic consequences have to be drawn. In this purpose the radiologic diagnostics of the juvenile pelvis are of significant value.

[Replacement of proximal end of the femur (author's transl)]. / Der Ersatz des proximalen Femurendes.

The article reports on replacement of the proximal end of the femur, including the acetabulum, by means of special endoprostheses in a total of 49 hips. Besides treatment of pertrochanteral and subtrochanteral fractures of the femur in individual cases, and an increasing field of application within the framework of prosthetic exchange operations, resection and replacement of the coxal femur are mainly employed in tumour processes. Primary malignant tumours require pre-treatment and after-treatment by chemotherapy (with the exception of chondrosarcoma) in order to meet the demand of oncological radicality. Tendency to luxation, which is the most frequent component, can be reduced by employing a sophisticated surgical technique, good physiotherapy, appropriate training of the patients, and application of a Hohmann's bandage. The radiological course indicates that all the complications involved in endoprostheses, especially loosening, may be expected, even though they may occur with a certain delay of time. Besides general osseous atrophy of the prosthesis-bearing diaphysis, it is mainly the lateral "traction" side which is affected. Sintering of the prosthesis can temporarily delay breakdown of the anchoring. Prosthesis fractures are possible. Hence, the special endoprosthesis proximal to the hip joint is a recommended alternative to surgery of a crippling nature. In view of the fact that it is hardly possible to retract one's steps at a later date, indications towards special endoprosthesis must continue to be highly differentiated and closely adapted to each individual case.

A case of bone fluorosis of undetermined origin.

After predominant theories on the causes of fluorosis are described and remarks made about the metabolism of fluoride, an observation of bone fluorosis in a 64-year-old patient is reported. Because, despite painstaking research, none of the known causes of bone fluorosis could be found in our patient, a new pathomechanism is being offered for discussion, i.e., increased renal or intestinal absorption or an increase of fluoride deposited in the bone; i.e., an inborn or acquired error of fluoride metabolism. We recently observed a similar case with none of the well-known origins.

[Studies of explanted shot-peened osteosynthesis plates]. / Untersuchungen explantierter kugelgestrahlter Osteosyntheseplatten.

Shot peening is a cold-working process to increase the fatigue life of osteosynthesis plates. Using ceramic particles for this process we observed no change in the corrosive properties of the plates. Up to now we implanted 37 shot peened osteosynthesis plates for fixation of intertrochanteric osteotomies. 13 plates were explanted after an average time of 14,2 months. We investigated the plates as well as the tissue surrounding the implants. Metallurgic specimens showed not so many pittings at the shot peened plates in the region of the screw hole as were seen at the polished plates after the same period of implantation. By histological investigation corrosive products or fretting particles were detected mostly in the region of the screws. Only a few metal particles were found in the region between the screw holes. Analysing the elements which were black or red-brown coloured in histological specimens by scanning electron microscopy we identified these particles as metal components. But there was a great difference in the relation of the particles found in the tissue compared to the components forming the plates alloy. This is due to the difference of distribution of the metal components at the surface of the implant in comparison with the central part of the plate. These austenitic stainless steels are protected by an enrichment of Cr in the surface layer. This could be shown in the shot peened plates as well as in the polished plates. The results of our investigations show a corrosive behaviour which is at least equal at both plates types in laboratory investigations as well as after implantations in men.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of alumina-polyethylene and metal-polyethylene in clinical trials.

The dimensional changes of hip sockets of Müller-type total endoprostheses is the subject of this article. Regular anteroposterior roentgenographs of the pelvis were taken to determine the orientation of the center of the prosthetic head in relation to the wire marker of the polyethylene cup. Three different materials used for the femoral balls and matched with polyethylene as socket material were investigated, and the results of the displacement of the ball into the socket were compared. Both creep and wear contribute to the dimensional changes of the hip sockets; the proportional amount of each mechanism is not known. Data from laboratory examinations suggest a relatively high rate of creep in the first six months after implantation. With longer periods, the dimensional changes are predominately caused by wear. In the beginning of joint function, measurements show a high rate of the yearly dimensional changes. The head shifts up to 0.5 mm per year and diminishes after five years to rates of 0.1-0.2 mm, respectively. All dimensional changes that exceed a shift of the head of 0.2 mm per year are considered to be unfavorable and to contribute to loosening of the implants. Using metallic balls (Protasul-2), 64% had a wear rate of less than 0.2 mm; of those using Prostasul-10, 77% had lower rates than 0.2 mm. In patients where ceramic balls were implanted, the displacement rate was below 0.2 mm per year in 95%. Therefore, ceramic seems to be the most favorable material.

[Diagnosis of focal spinal diseases - a critical review]. / Zur Diagnostik herdförmiger Wirbelsäulenerkrankungen--eine kritische Betrachtung.

The article offers a critical review of the diagnosis of focal diseases of the vertebral column, based on 200 histological vertebral column examinations. The findings obtained by means of the roentgenological, histological and bacteriological examinations can be subdivided into 6 groups: 1. Non-specific and specific cases of spondylitis (59 patients); 2. Systemic malignant diseases and primarily malignant tumours (23 patients); 3. Metastases (71 patients); 4. Benign tumours (11 patients); 5. Miscellaneous cases (28 patients) and 6. Unclarified cases (8 patients). The authors comment on the following points with specific reference to the results obtained by them: a) Possibilities and limitations of roentgenological diagnosis: roentgenologically, the inflammatory diseases are most easy to identify, but is not always possible to differentiate safely between non-specific, specific and plasmacellular spondylitis. There are clear limitations to the diagnosis of the type of focal diseases of the spinal column; this applies particularly to the benign and malignant types of tumours. b) Necessity of arriving at an accurate diagnosis: it is imperative to aim at an accurate diagnosis before any meaningful therapy can be initiated. The mandatory need for this is explained via examples covered by the present study. c) Closed or open biopsy: it is shown by means of a review of the literature that open biopsy yields more representative material for the histological examination than closed needle biopsy. It goes without saying that this is a true prerequisite for an accurate histological diagnosis. In this connection, the authors go into the details of the difficulties governing any histological examination. d) informative value of further additional examinations: Scintigraphy, tomography and computer tomography may be valuable aids in the discovery and better visualisation of a vertebral focus, but they are not helpful in arriving at a diagnosis regarding the type of focus involved. Laboratory examinations are not very helpful, either. e) Accuracy of the authors' own diagnostic measures: in spite of open biopsy, 177 cases only out of 200 (88%) could be diagnosed on a purely histological basis. In 12 further cases, diagnosis was established after correlation of the histological finding with the x-ray film. 8 cases (4%) could not be clarified. In 7 patients (3.5%) it must be assumed that the focus was not located despite open biopsy.