[Long-term results of thrust plate prostheses: comparison of patients younger than and older than 50 years]. / Langfristige Analyse der Druckscheibenendoprothese: Vergleich von Patienten unter und über 50 Jahren.

BACKGROUND: Hip replacement in patients younger than 50 years old is no longer an exception in view of the increasing necessity for care. The aim of the present study was to analyze whether the results after implantation of thrust plate prosthesis (TPP) with metaphyseal anchorage are equal for patients below 50 years compared to older patients. PATIENTS AND METHODS: The investigation comprised 465 TPP implantations. In 149 TPP the patient age was below 50 years (group A) und in 316 TPP cases above 50 years (group B). Clinical and radiological evaluation of the results for both groups was carried out as well as a differentiated survival analysis with defined endpoints. RESULTS: Survival analysis of group A (96%/13.2 years) showed a significantly improved survival rate compared to group B (86%/12.5 years). Additionally, the risk of prosthesis and/or radiological signs loosening of was significantly lower in group A than in group B (p <0.05). CONCLUSION: Comparison of long-term results of prostheses with intramedullary fixation shows that the anchorage principle of TPP with bone-saving implantation to the proximal femur is justified especially for patients below 50 years of age.

[Comparative study after hamstring ACL plasty with RigidFix (pin fixation) and EndoButton (anchor fixation)]. / Vergleichende Studie nach vorderer Hamstring-Kreuzbandplastik mit RigidFix (Pinfixation) und EndoButton (Ankerfixation).

AIM: Within a prospective case group study, two hamstring fixation techniques, a pin fixation with RigidFix (RF) and an anchor fixation with EndoButton (EB), were compared. METHOD: 67 patients were followed clinically and by MRI preoperatively (t0), at six months (t6) and at twelve months (t12). In one group (N = 21), EB was used for representing a juxta-articular graft fixation. The second group (N = 46) with RF was used to represent the ab-articular fixation. KT-1000 stability measurement, IKDC, Lysholm and Tegner scores were used to determine the clinical outcomes. Reflux and tunnel widening (TW) were investigated by MRI. RESULTS: The KT-1000 values were slightly more stable at t6 (EB: 2.1 +/- 4.1 mm, RF: 1.0 +/- 2.5 mm) in the RF group (p = 0.044) but equalised later at t12 (EB: 0.5 +/- 3.1 mm, RF 1.0 +/- 2.4 mm). The median Tegner score at t6 (EB: 4.3 +/- 1.2, RF 4.1 +/- 1.7) and t12 (EB: 5.9 +/- 1.8, RF 5.4 +/- 2.0) were comparable (p = 0.692). The mean Lysholm score at t6 (EB: 90 +/- 11, RF: 91 +/- 8.9) and t12 (EB: 95 +/- 7.5, RF: 95 +/- 7.4) was comparable in each group (p = 0.589). The same was valid in the median of the IKDC score at t6 (EB: II, RF III) and t12 (EB: II, RF III). The category "femoral reflux" showed slight minimal fringe in the EB group at t6 but aligned to "no reflux" together with the RF group at t12 (NS, p = 0.550). A tunnel widening was not detectable in either of the groups.

[Eight-year results of the femoral neck prosthesis ESKA-CUT]. / 8-Jahres-Resultate der Schenkelhalsprothese ESKA-CUT.

AIM: With the help of a clinical and radiological follow-up evaluation 8 years after implantation of the femoral neck prosthesis CUT (ESKA Implants, Lübeck Germany), the question of whether this metaphyseal anchoring implant is recommendable in young patients will be answered. METHOD: Between 2000 and 2001 82 CUT-prosthesis procedures were performed in 79 patients (38 female, 41 male patients; average age 51.3 years) and evaluated prospectively. The clinical investigation was carried out according to the criteria of the Harris Hip and Merle d'Aubigné scores. Radiological periprosthetic bone changes were registered and a measurement of the CCD angle and femoral offset was performed. The survival rate was calculated according to both the Kaplan-Meier and the life-table analyses. RESULTS: During the 12-month follow-up examination the HHS (48.4 preop.) as well as the Merle d'Aubigné score (10 preop.) increased significantly to an average value of 85.1 and 15.8, respectively (p < 0.000). Cumulative survival with replacement of the prosthesis as an end point at 8 years was 49.6 %. Due to 25 aseptic loosenings, three periprosthetic infections and three cases of persisting thigh pains, 31 replacements of the femoral neck prosthesis became necessary up to June 2008. The implantation of the CUT prosthesis led to a significant valgisation (p < 0.001) of 17.4 degrees degrees with a consecutive reduction of the femoral offset of 5 mm. Radiologically periprosthetic progressive radiolucencies, hypertrophic cortical bone changes as well as atrophy of the calcar femoris were often evaluated and interpretated as a sign of a stress shielding and migration process. CONCLUSION: The analysis of the eight-year follow-up of 82 CUT prostheses shows that the implant does not fulfil our expectations of a femoral neck prosthesis, in spite of the possibility of a less invasive and bone-saving implantation technique. In view of unacceptable survival rates, valgisation changes of the joint geometry and critical changing procedures, from our point of view the femoral neck prosthesis CUT does not represent a recommendable alternative implant in young, active patients.

[Results after replacement of femoral neck prostheses - thrust plate prosthesis (TPP) versus ESKA cut prosthesis]. / Ergebnisse nach Wechsel von Schenkelhalsprothesen - Druckscheibenprothese versus ESKA-Cut-Prothese.

AIM: The aim of this study was to analyse and evaluate comparatively loosening mechanisms, failure frequency, surgical changing strategies and results after replacement of thrust plate prostheses (TPP) and ESKA Cut prostheses. METHOD: Between 1993 und 2007, 465 TPP and in the years 2000 and 2001 82 ESKA Cut prostheses were performed and evaluated prospectively. Until 2007 46 change interventions of the TPP and 35 of the CUT prosthesis became necessary. All patients who received a stem revision procedure in our hospital were included within this study. Besides the evaluation of clinical results according to the criteria of the Harris Hip Score on the average at 15.6 months (+/- 14.4) postoperatively, radiological loosening processes and surgical difficulties were registered. Furthermore, an analysis of perioperative data was performed according to some criteria of the German Federal Office of Quality Assurance (BQS), such as duration of the surgery, intraoperative blood loss and complications. Statistical investigations for comparative analysis as well as survival analysis of both groups were calculated using SPSS for Windows 13.0. RESULTS: The mean age of the 46 patients who had to undergo revision surgery after TPP was 60.1 years, that of 35 patients in whom revision surgery was necessary after receiving an ESKA Cut femoral neck stem was 56.6 years. The survival rate analysis according to Kaplan-Meier at 13 years was 89.4 % (TPP) and 53.6 % at 66 months (ESKA Cut). In all cases the partial osteointegration of the tripod surface of the loosened Cut prosthesis complicated the explantation. It led on the one hand to a significant difference of the surgery duration and on the other hand to an increased frequency of fractures of the trochanteric region. The conversion of the TPP on standard type stems was usually free of problems. The HHS increased significantly to the averages of 86.6 (TPP) or, respectively, 91.69 (ESKA Cut) after revision. CONCLUSION: In comparison with the usually problem-free changing procedure of the TPP to a standard type stem, the revision surgery of the Cut prosthesis becomes substantially more complex and leads frequently to complications. In view of unacceptable survival rates, the Cut prosthesis does not represent an alternative implant in young patients. Except for the implantation technique, which does not allow a less invasive surgical procedure, the TPP fulfils the requirements of femoral neck prosthesis due to acceptable survival rates and good convertibility.

[Long-term results of the cementless conical balgrist expansion cup--comparison analysis to the Zweymüller-Alloclassic screw cup]. / Langzeitergebnisse der zementfreien konischen Balgrist-Spreizpfanne--Vergleichsanalyse zur Alloclassic-Schraubpfanne.

AIM: The press-fit fixation of the conical Balgrist expansion cup (Allo Pro, Baar, Schweiz) is realised by the help of a (titanium alloy) split ring and a metal-backed inlay. The results and fixation principles of the cement-free Balgrist hip socket are analysed within a clinical and radiological long-time study and compared with those of the conical Zweymüller-Alloclassic CFS (Zimmer-GmbH, Winterthur, Schweiz) screw cup for a concluding evaluation. METHOD: Between 1993 and 2003, 277 Balgrist hip sockets and between 1994 and 2000 130 Alloclassic-Zweymüller screw cups were performed consecutively in 364 patients considering similar indications with an average age of 54.6 years and 51.9 years, respectively. The clinical investigation was carried out with the Harris hip score (HHS). Radiological evaluation included a manual migration analysis according to Sutherland et al., Nunn et al. and Effenberger et al.; radiolucent lines were registered according to the zones of DeLee and Charnley. The survival rate of both cups was calculated on the basis of the Kaplan-Meier and the life-table analyses. RESULTS: Besides 4 (1.4%) aseptic loosenings, 5 Balgrist cups (1.8%) had to be replaced because of infection and another 1 (0.8%) because of persisting pain. Three Balgrist sockets (1.1%) showed a migration > 2 mm. In the Alloclassic group 1 cup (0.8%) was considered as being migrated, another cup (0.8%) had to be replaced due to infection. Considering aseptic loosening and radiological migration as an end point, the cumulative survival of the Balgrist cup at 13 years was 97.3%, that of the Zweymüller-Alloclassic cup at 10 years was 99.2%. In comparison with the Alloclassic group, the Balgrist hip sockets showed increased radiolucent lines of zone 1 (p < 0.001), without any effects on the survival time or the clinical result however. Both cups resulted in good to excellent clinical results in the HHS (91 points). CONCLUSION: The long-term analysis of the Balgrist hip socket proved that the concept of the retightening conical expansion cup leads to good clinical results and fulfils the minimum survival rate of 95% at 10 years as demanded by Delaunay and Kapandji. The good results obtained with the aid of this concept are comparable to those of the Alloclassic screwing cup.

[Clinical and radiological results of the thrust plate prosthesis in patients with aseptic necrosis of the femoral head]. / Klinische und Radiologische Ergebnisse nach Implantation der Druckscheibenendoprothese (DSP) bei Patienten mit Femurkopfnekrose.

AIM: In this study, we investigated the results after implantation of the thrust plate prosthesis (TPP) in patients with femoral head necrosis. We intended to answer the question if the femoral neck prosthesis, inaugurated by Huggler and Jacob in Switzerland, which needs a good bone stock for a successful implantation, is a recommendable alternative to other cementless intramedullary fixed prostheses. METHOD: In a prospective study, 62 patients who had received 70 TPP because of femoral head necrosis as a result of various aetiologies between 1993 and 2004 were examined clinically and radiologically. The follow-up examinations were carried out 3 and 6 months postoperatively and subsequently once a year. The mean follow-up interval was 6.0 +/- 1.9 years (1.0-10.2 years). Clinical examination was carried out using the Harris hip score; the radiological examination was performed according to predefined criteria in an exact a.-p.-view. Four sectors can be distinguished: A corresponds to the femoral neck stump, B to the bony stock cranial (= 1) and caudal (= 2) to the mandrel of the prosthesis, C is the region above and under the bolt and D is the cortical area around the lateral plate. Furthermore, we performed a Kaplan-Meier survival rate analysis. RESULTS: We found excellent clinical results. The preoperative Harris score increased from 48.3 to 91.6 +/- 6.6 at 24 months after the operation. Radiolucencies of various relevancies were detected depending on the localisation. We often saw bony atrophy under the thrust plate (sector A: A 1 21.4%, A 2 9.9%) and small radiolucencies along the bolt (sector C 30 % in general). As a pathological finding we interpreted progressive radiolucencies of sector B, which was considered to be a sign of loosening, when they showed a thickness of > or = 2 mm. Therefore, we had to change one TPP. In two additional cases we saw an extended atrophy under the lateral plate, which was also interpreted to be a sign of loosening. The Kaplan-Meier survivorship analysis for 5 and 10 years was 95.1% (95% - 0.95 +/- 0.05). Our study suggests that, in spite of a slightly higher aseptic loosening rate in comparison with cementless stem prosthesis, the thrust plate prosthesis proved worthwhile. On account of our previous experience we consider the TPP to be a good alternative implant, especially for young patients. CONCLUSION: Due to excellent clinical results and nearly identical findings in the survivorship analysis in comparison to cementless stem prostheses, the TPP is also a good alternative implant for total hip arthroplasty in patients with femoral head necrosis. For a successful implantation of the TPP a good bone quality of the proximal femur is necessary. Therefore we cannot recommend the use of a thrust plate prosthesis in patients with femoral head necrosis and simultaneous osteopeny.

[Radiological analysis of the thrust plate prosthesis (TPP)]. / Radiologische Verlaufsanalyse der Druckscheibenendoprothese (DSP).

AIM: The various radiological changes after implantation of the thrust plate prosthesis (TPP) are demonstrated and, with the help of a standardized radiological classification, divided in pathological and non-pathological findings. METHOD: The radiological follow-ups of 167 TPP implanted between 1993 and 1998 was analyzed in this study. The follow-up examination was carried out postoperatively, after 6 months and subsequently every year. The radiological assessment was carried out in an exact a.p. view. We subdivided the images into four sectors: A corresponds to the femoral neck stump, B to the bony stock cranial (=1) and caudal (=2) to the mandrel of the prosthesis, C is the region above and under the bolt and D the cortical area around the lateral plate. RESULTS: Radiolucencies were especially seen in sector A (A 1 = 34.7 %; A 2 = 18%) and sector C (44 %). As a pathological finding, we saw progressive radiolucencies of sector B (6 %), which were interpreted to be a sign of loosening, when they showed a thickness of = 2 mm. Furthermore, in some cases we observed extended atrophy under the lateral plate, which was also judged to be a sign of loosening. CONCLUSION: The radiological changes of the bony stock of the TPP can be divided into physiological adaptation processes because of changed biomechanics and signs of loosening. As a stress-shielding phenomenon we see a progressive atrophy under the thrust plate and simultaneously a sclerosis of the spongious bone above the calcar femoris. An indication for a loosening of the prosthesis is a progressive radiolucency of sector B.

[Midterm results and revisions of the thrust plate prosthesis (TPP)]. / Mittelfristige Ergebnisse und Wechseloperationen nach Druckscheibenendoprothesen (DSP).

AIM: Although already in use for 20 years, the concept of the metaphyseal anchored thrust plate prosthesis has not yet gained general acceptance. Clinical and radiological follow-up examinations were carried out 5 to 8 years after implantation of a TPP. We tried to answer the question if the metaphyseal anchorage of the cement-less TPP is equal to a diaphyseal anchorage of a cement-less stem prosthesis and to define the advantages of the TPP. METHODS: We included 170 of the patients from our clinic with an implanted TPP in this study. Furthermore we reviewed the results of 30 revision hip arthroplasties of the TPP. The clinical examination were carried out using the Harris hip score while the radiological examinations were performed on the basis of predefined criteria. RESULTS: We found good clinical results. The preoperative Harris score of 48.7 increased to 93.7 at 24 months postoperatively. Radiolucencies were detected and were of varying relevance in dependence on their localization. The Kaplan-Meier survival analysis at 8 years was 90.5 %. The clinical results after changing the TPP were also good to excellent. The mean Harris hip score was 87.3. CONCLUSION: Our study suggests that in spite of a slightly higher aseptic loosening rate in comparison to the cement-less stem prosthesis, the thrust plate prosthesis proved to be worthwhile. On the basis of previous experience we assume that the TPP is a good alternative implant especially for young patients.

[Staged diagnosis of septic hip endoprosthesis loosening with laboratory parameters and antigranulocyte scintigraphy]. / Stufendiagnostik septischer Hüftendoprothesenlockerungen mittels Laborparametern und Antigranulazytenszintigraphie.

AIM: The value of serial diagnosis of septic loosening of hip endoprosthesis using laboratory parameters and antigranulocytes scintigraphy was investigated and compared to joint aspiration. METHOD: In 35 patients with intraoperative verification of infection, we calculated sensitivity, specify and prevalence dependent positive and negative predictive values for antigranulocyte scintigraphy, laboratory tests and the most suitable combination of both. We also calculated predictive values of joint aspiration using sensitivity and specify values given in the literature. RESULTS: From negative and positive predictive values, of the sedimetation rate and leukocyte count provided no increase of information. We found the same result for positive predictive values of C-reactive protein. For antigranulocyte scintigraphy alone, we found a distinct but still unsatisfying increase of information. Nevertheless, in both cases infection could be excluded definitely. Therefore, the combination of C-reactive protein and antigranulocyte scintigraphy was suitable and the positive predictive values of this combination were only about 5% lower than those of joint aspiration. But with joint aspiration, infection could not be excluded. CONCLUSION: A positive result in serial diagnosis using C-reactive protein and antigranulocyte scintigraphy leads to an distinct increase in the probability of infection which is comparable to that of joint aspiration. The additional advantages of this procedure are the certain exclusion of infection and the absence of invasiveness.

[Antigranulocyte scintigraphy of septic loosening of hip endoprosthesis: effect of different methods of analysis]. / Antigranulozytenszintigraphie bei septischer Hüft-Endoprothesen-Lockerung: Einfluss unterschiedlicher Auswertemethoden.

AIM: Diagnosis of infection with help of antigranulocyte scintigraphy near body stem is difficult because of contemporary visualisation of bone marrow. Therefore, we investigated, whether it is possible to improve the accuracy in diagnosing septic loosening of hip endoprosthesis by changing the analyzing methods. METHODS: In 28 patients, the results of a visual interpretation of late scan, a visual interpretation and a quantitative interpretation of time-activity-course were compared. These results were verified by histology respectively microbiology. RESULTS: Histological and microbiological verification found 14 septic loosening and 14 aseptic loosening of the hip prothesis. Therefore, sensitivity, specificity, negative and positive predictive value for the visual interpretation of late scan were 0.86, 0.57, 0.80 and 0.67. For visual and quantitative interpretation of time-activity-course we found 0.86, 0.79, 0.85 and 0.80 respectively 1, 0.93, 1, 0.93. For interobserver agreement we found kappa coefficients of 0.28 +/- 0.2 for visual interpretation of late scan, 0.48 +/- 0.17 for visual interpretation and 1.0 +/- 0 for quantitative interpretation of time-activity-course. CONCLUSION: In all investigated values quantitative interpretation of time-activity-course was superior to the other analyzing methods. Therefore, antigranulocyte scintigraphy for septic loosening of hip endoprosthesis should be interpreted quantitatively.

[Expert assessment within the scope of the severe disability regulation and social compensation law]. / Begutachtung im Rahmen des Schwerbehindertengesetzes und des sozialen Entschädigungsrechtes.

In the wake of the First and Second World Wars, an extensive system of social compensation and assistance for the war disabled evolved in Germany and later on also for civilians. Depending on the origin of the disability, the benefits are composed either of revenues and pensions and/or tax reductions and nonfinancial assistance. In any case, the extent of these benefits depends on the grade of disability (GdB/MdE) determined by medical examination and on expert opinions in accordance with detailed legal regulations.

[Activity leakage and radiation exposure in radiation synovectomy of the knee: influence of different therapeutic modalities]. / Aktivitätsabtransport und Strahlenexposition durch die Radiosynoviorthese des Kniegelenkes: Einfluss unterschiedlicher Therapiemodalitäten.

In rheumatic diseases, radiation synovectomy is a reliable method. Meanwhile, radiation synovectomy is an outpatient therapy. In addition, combination with arthroscopic synovectomy is an increasing therapeutic modality. In comparison to the hitherto inpatient modality, a greater lymphatic emigration of the radionuclide and, therefore, a higher radiation exposure is possible. In 35 patients we found radionuclide emigration in 17 cases by whole body scintigraphy, resulting in a 50%-percentile with 68.27%-confidence interval of 1.8 (0.45-4.78)% of the injected yttrium-90-activity. Comparison of 3 groups with the above mentioned therapy modalities resulted in no statistical difference (p>0.05). Because of the found radionuclide emigration, a radiation dose of 0. 1 (0.05-0,18) mSv in women and 0.2 (0.1-0.38) mSv in men was calculated. For lymph nodes, liver, spleen and whole body radiation doses of 619 (154-1644) mSv, 62 (15-165) mSv, 62 (15-165) mSv and 37 (9-99) mSv were calculated. Gonadal radiation dose can be neglected and the morbidity rate for tumors because of the whole body radiation dose is low with a value of 0.4 per thousand. Therefore, radiation synovectomy can be used unlimited by patients age and independent of the therapeutic modality.

Ten-year follow-up of a bicondylar unlinked knee endoprosthesis with particular reference to mid-term results.

This analysis, submitted retrospectively, evaluates 603 PCA-type or Duracon-type knee endoprostheses implanted in 527 patients over a 10-year period. In addition, the X-rays available in a group of 138 patients (100 women and 38 men) from the entire patient population were analysed. All of these 138 patients were invited to come in for a follow-up examination. The invitation was accepted by 80 patients. As well as radiological and physical examination, these patients were asked about their subjective physical condition in a semi-open questionnaire. The data obtained by the questionnaire is discussed in the Results section. The average age of the 397 women, of whom 61 were operated on in both knees, and 130 men, of whom 15 were operated on in both knees, was 68 years at the time of the operation. The 76 bilateral patients had the knee endoprostheses implanted within a mean interval of 17 months. The most frequent indications for surgery were primary and secondary gonarthrosis, followed by rheumatoid arthritis. The evaluation of the X-rays from the above population of 138 patients revealed no radiological signs of loosening. No correlation between the time after implantation and the formation of radiolucent margins could be established. Those knee endoprostheses which were implanted with a varus deviation of more than 10 degrees did not yield a poorer result than those implanted perpendicular. In comparison with the cemented implants, the cementless implants produced slightly better results.

[Recommendations for standardized radiologic follow-up of thrust plate endoprosthesis]. / Empfehlungen für die standardisierte radiologische Nachuntersuchung der Druckscheibenendoprothese.

The thrust-plate endoprosthesis (TPE) is a cementless, total endoprosthetic replacement of the coxal femur with metaphysical anchorage. A combination of the TPE with an endoprosthetic cup component, which is also cementless, is recommended based on the concept of the TPE. The TPE requires a special radiological technique. In radiological follow-up examinations, the positioning area of the TPE, particularly on the resected femoral neck, is especially important. A gap-free, level positioning of the implant on the resected and flat-ground femoral neck is ideal. In order to be able to exactly judge the positioning area, the bony area and the TPE that lies on it should have no overlap in the anterio-posterior optical path of the X-ray and must be hit exactly orthogonally by the central X-ray beam. As radiological examinations of human femoral preparations show, this succeeds best with an inner rotation positioning of the femur from 10 to 20 degrees. According to our experience, especially in freshly operated patients, the positioning of the legs with the femur in a slightly abducted position (about 10-20 degrees) is better tolerated. Only when the positioning of the TPE cannot be exactly judged with the above-mentioned examination method should the examiner use an X-ray image intensifier. Experience has shown that this is only necessary in exceptional cases. In the present examination, the special problems of radiological examination of the TPE are discussed. Recommendations for standardized radiological examinations, as well as findings following TPE implantation, are given.

[Differential indications for lumbosacral fusion and reposition operation in spondylolisthesis]. / Differentialindikation zur lumbosakralen Fusions- und Repositionsoperation beim Wirbelgleiten.

The indication for operative treatment in spondylolisthesis results from pain, progressive sliding and, in up to 60% of the patients with progressive dislocation, from radicular malfunction. The posterolateral fusion in situ is a safe procedure, but the deformation remains and in spondyloptosis plastic deformation of the fusion mass can lead to further dislocation. With the external fixator as an instrument for reduction and the internal fixator for stabilization the reduction of even serious spondyloptosis and the recovery of a normal spine alignement and posture is possible, with an acceptable neurological risk. Therefore a concept of treatment is suggested, which as a rule is aiming at the anatomical reduction of the dislocated vertrebra beside stabilization and nerveroot decompression. Depending on the extent of the slip, reduction and stabilization is to be performed in one, two or three stages. An anterior or posterior fusion is sufficient in grade I dislocation. In grade II-V a combined posterior and anterior surgical proceedure is recommended.

Indication for lumbosacral fusion and reduction in spondylolisthesis.

The indication for operative treatment in spondylolisthesis results from pain, progressive sliding and, in up to 60 % of the patients with progressive dislocation, from radicular malfunction. The posterolateral fusion in situ is a safe procedure, but the deformation remains and in spondyloptosis plastic deformation of the fusion mass can lead to further dislocation. With the external fixator as an instrument for reduction and the internal fixator for stabilization the reduction of even serious spondyloptosis and the recovery of a normal spine alignement and posture is possible, with an acceptable neurological risk. Therefore a concept of treatment is suggested, which as a rule is aiming at the anatomical reduction of the dislocated vertrebra beside stabilization and nerveroot decompression. Depending on the extent of the slip, reduction and stabilization is to be performed in one, two or three stages. An anterior or posterior fusion is sufficient in grade I dislocation. In grade II-V a combined posterior and anterior surgical proceedure is recommended.

Cranio-cervical stabilization using contoured luque rectangles.

Cranio-cervical stabilization using preformed Luque rectangles supplemented by autologous bone grafts was performed in 18 patients. Stability at the cranio-cervical junction had been impaired by a number of diseases including rheumatoid arthritis in 12 patients. Metastatic tumour in 5 patients and post-operative swan neck deformity in one patient. In all patients immediate stabilization as well as long-term bony fusion could be achieved, paralleled by improvement of the preoperative neurological condition in differing degrees. Surgery related complications were rare, although, considering the patient population treated, medical and anaesthesiological complications as a result of accompanying diseases may pose serious problems. The technical details of the surgical procedure are described and its application for the treatment of cranio-cervical instability is discussed.

Indications for and results of operative treatment of spondylitis and spondylodiscitis.

We present a retrospective follow-up study of 24 patients with spondylitis or spondylodiscitis whose treatment included surgical intervention. Tuberculous spondylitis was diagnosed in 14 patients and 10 suffered from non-specific spondylitis. The average age of the patients was 50.2 years and average follow-up was 3 years. All patients were asymptomatic at the time of examination and showed radiographic evidence of solid fusion. We recommend radical debridement and spinal fusion through a ventral approach in patients with destruction of the ventral vertebral body, progressive neurological impairment, septicaemia and antibiotic-resistant, symptomatic infections of the spine. In the elderly patient, even in reduced states of health, early surgical intervention can be particularly valuable. Although surgical intervention should be reserved for specific indications, we were able to document favourable results in all 24 patients treated with debridement and spinal fusion.

[Differentiated surgical and conservative treatment of spondylitis and spondylodiscitis]. / Differenzierte operative und konservative Therapie der Spondylitis und Spondylodiscitis.

In the time from 1980 to 1987 58 patients underwent a conservative or operative treatment of spondylitis and spondylodiscitis according to the individual clinical and radiological features. In early or moderately advanced stages of the disease conservative therapy was performed. Under bedrest and antibacterial or tuberculostatic drug therapy bony fusion of the affected vertebral bodies was achieved in 50% of the pyogenic cases. In tuberculous spondylitis fusion rate was 83%. Persistent septic changes, progressive neurological symptoms and gross vertebral damage are indications for surgery. In those cases removal of the focus and intercorporal spondylodesis was performed. Bony union occurred in every cases. At follow-up examination, 3 years after the onset of therapy on an average, 42 patients had no complaints according to the vertebral column. As the results of our study show spondylitis and spondylodiscitis should according to the clinical and radiological features be lead to a differentiated operative or conservative treatment. Then good clinical results are to be supposed.

Operative therapy for recurrent shoulder dislocation with special regard to long-term clinical and radiological results using M. Lange technique.

Besides a general description of the operative techniques for the management of recurrent shoulder dislocation, a full description of the M. Lange procedure is given. We offer reasons for its variation from original methods and suggest limiting its indications with regard to clinical and radiological long-term results. After an average postoperative period of 13.5 years, clinical and radiological results of 21 shoulders in 20 patients were determined. In 19 of the 21 cases patients reported outstanding-to-satisfying postoperative results. Real postoperative redislocation was found in only one case, but striking radiological signs of osteoarthritis were seen in 57%. Despite the lack of comparable results, this should be taken into consideration in choosing an adequate operative procedure.