[Anterior cruciate ligament rupture in children with open growth plate : Diagnostics and treatment]. / Vordere Kreuzbandruptur beim Kind mit offener Wachstumsfuge : Diagnostik und Therapie.

Anterior cruciate ligament (ACL) ruptures in pediatric patients with open growth plate are of concern and the number of injuries is increasing. The possibilities for diagnostics using magnetic resonance imaging (MRI) have improved and are without radiation exposure to the growing skeleton. The MRI should be performed routinely in every case of adequate trauma also to recognize additional injuries to the knee joint. Joint effusion represents an urgent indication for further clarification. Real ACL ruptures have to be distinguished from bony avulsion injuries. Although there are different forms of treatment, biomechanically an ACL insufficiency is present. A permanent instability leads to degenerative changes of the cartilage and meniscus. Despite the different surgical techniques, the general recommendation is for replacement of the ACL. Extensive procedures with an increased risk of epiphyseal injury should be avoided and anatomical techniques should be preferred. The results are good to very good and with adequate knowledge of the special features of children, complications are rare.

[Traumatic posterior dislocation of the sternoclavicular joint. A case report of joint stabilization with gracilis tendon graft]. / Die traumatische posteriore Luxation im Sternoklavikulargelenk. Fallpräsentation einer Stabilisierung mit Grazilissehnenplastik.

Dislocation of the sternoclavicular joint is an uncommon injury. Especially posterior dislocations with potentially life-threatening complications present a challenging situation for the treating surgeon regarding diagnosis and therapy. Reduction and fixation of the joint is the treatment of choice. We present the case of such an injury in an adolescent judoka who was treated by open reduction and reconstructive surgery using the gracilis tendon graft technique.

Intramedullary nailing for the treatment of dislocated pediatric radial neck fractures.

INTRODUCTION: Pediatric radial neck fractures represent 5-10% of all elbow fractures. Open reduction allows anatomic fracture fixation but compromises the vulnerable blood supply of the radial head. Intramedullary nailing combines the advantages of closed reduction and stable internal fracture fixation. MATERIAL AND METHODS: During a 6-year-period the medical records of all children sustaining a radial neck fracture treated operatively at our institution were analyzed retrospectively. RESULTS: Forty-two patients with dislocated fractures of the radial neck were treated with intramedullary nailing. The average age of the patients was 8 years. Thirty-eight patients (90%) could be treated with closed fracture reduction and retrograde nailing. Open fracture reduction was required in 4 (10%) patients, and in 2 patients necrosis of the radial head occurred. Loss of reduction was seen in 7 (17%) patients. Excellent results were found in 38 patients, good results in 2 patients, and poor results in another 2. CONCLUSION: The retrograde nailing technique for the treatment of dislocated fractures of the radial neck in pediatric patients is a simple, short and safe procedure.

[Treatment of pediatric radial neck fractures: consideration of patient age and fracture dislocation]. / Behandlung kindlicher Radiushalsfrakturen: Berücksichtigung von Patientenalter und Frakturdislokation.

Fractures of the radial neck represent approximately 5-10% of all injuries of the elbow in children. Depending on the degree of radial head displacement, either an operative intervention or conservative treatment is recommended. The medical records of 168 children treated between 1999 and 2008 were analyzed and fractures were classified according to the Judet classification system. The fractures were treated according to an algorithm depending on age and fracture dislocation and 103 type I, 21 type II, 30 type III and 14 type VI fractures were found. Conservative treatment was possible in 124 patients and 44 were treated operatively. The overall outcome was good.

[Operative corrections of posttraumatic deformities of the elbow joint in children]. / Posttraumatische Korrekturoperationen am kindlichen Ellenbogen.

Posttraumatic deformities with need for surgical correction are rare and demanding in the pediatric population. The consequences of a bad outcome may last a life time. The best prevention of deformities around the elbow joint is proper initial treatment. The most common deformities are cubitus varus, cubitus valgus, chronic dislocation of the radial head and pseudarthrosis of the radial condyle. In contrast to the wide spread opinion to await the effect of the further growth, the deformity should be treated contemporarily to the underlying injury. This strategy will optimize the outcome. In special cases treatment with delay is justified.

[Non-accidental injuries in childhood and the nature of their appearance]. / Die nicht akzidentelle Verletzung des Kindes und deren Erscheinungsformen.

Child abuse has been the leading cause of death in pediatric patients for a long time. The subject is complex in its etiology, appearance, consequences and prognosis. To be confronted with the patient is emotional. Inpatient treatment at a pediatric centre should be performed in any suspicious cases of non-accidental injury. The child protection group consists of one pediatric specialist as well as four ward physicians, one psychotherapist, two staff nurses and one graduated social worker. The team's aims are the early detection of violence towards children, the safeguarding of child protection policies and the provision of family centred, interdisciplinary treatment. During a 6-year period (2001-2006) 476 children were treated at our department. Cruelty was found in 47%, sexual abuse in 28% and willful neglect in 25%. Only 12% of the patients presented obvious injuries. In 88% secondary symptoms resulted in the correct diagnosis. Child protection groups are important institutions for dealing with the complex matter of child abuse. The burden and responsibility for the single person can be reduced within the team. Medical practitioners outside the hospital may give a referral without a loss of confidence.

[The tele-visit as a telemedical technique in daily clinical practice. First results for elbow joint arthrolysis]. / Die Televisite als Anwendungsform der Telemedizin im klinischen Alltag. Erste Ergebnisse bei der Ellbogengelenkarthrolyse.

Technologies in telecommunication and information are being increasingly applied in the public health system of the western world. Also responsible for this development is the cost factor in the field of financing and maintenance of such a system of superior medical supply, as well as the concurrent patient' demand for optimized medical "24 h care and treatment". Pioneers in the use of telematic projects have, up until now, been large states such as the USA, Canada, Norway or Australia. Such projects have been used to provide, guarantee and maintain medical care in geographically remote regions with few medical facilities. After breaking the obstacle of geographic distance, telemedical solutions in general, and especially the tele-visit, represent a new form of treatment for patient care after discharge from hospital. In the year 2002, a prospective randomized two-armed study was initiated including patients after surgical intervention by arthroplasty in posttraumatic contracture of the elbow. The system of the tele-visit was used for 6 weeks after discharge and the patients were controlled as outpatients after 6 months, including a physical examination. The functional outcome, duration of stay in hospital and the costs for treatment arising were determined. A standardized questionnaire was developed and the degree of satisfaction of the patients surveyed. A shorter stay in hospital was found together with lowered costs in medical treatment, while no differences in functional outcome could be found in comparison to the control group, although there was an additionally high grade of satisfaction with the new system.

[Oblique osteotomy for post-traumatic fibula incongruity]. / Schrägosteotomie der Fibula bei posttraumatischer Inkongruenz. Einsatz zur Wiederherstellung der Symmetrie in der Knöchelgabel des Sprunggelenkes.

BACKGROUND: Injuries of the ankle joint are common and, considering that this joint is highly mechanically stressed, it seems obvious that therapy requires restoring the joint to a physiological, anatomically functional unit. In case of post-traumatic shortening, rotation and talar tilt arthritis may result because of the changed biomechanics. Before this occurs, typical clinical symptoms are recurrent swelling, pain, and limited range of motion, together resulting in reduced mobility and quality of life. With prompt indication and revision lengthening the lateral ankle and thus restoring joint congruity, patient complaints are significantly reduced and the development of advanced arthritis can be avoided. PATIENTS AND METHODS: Within a period of 7 years, 16 patients with post-traumatic shortening of the fibula were treated with oblique osteotomy and lengthening of the fibula at our department. The mean time between trauma and reconstructive surgery was 10 months, and the median follow-up period to clinic and radiological examination was 3.7 years. RESULTS AND CONCLUSION: Comparison of results before and after correction showed significant subjective improvements, and the development or continuation of post-traumatic arthritis could be hindered, of critical importance to which is prompt indication for operative joint correction, because clinical symptoms of advanced osteoarthritis of the ankle joint cannot be expected to improve.

[The televisit system in patients care after discharge in clinical use--first experiences]. / Das System der Televisite zur poststationären Patientenbetreuung im klinischen Einsatz-erste Erfahrungen.

The televisite is a form of application of telemedicine, that allows a communication between the patient and the family doctor or specialist in the clinic after discharging of hospital. Pioneers for the use of telematic projects have been up to now wide states like the USA, Canada, Norway or Australia to provide, guarantee and maintain by the means of telemedical solutions medical care in geographic regions hardly reachable and of little medical attention. In central Europe and Germany telemedicine is gaining in significance on the one hand because of increasing importance of the cost factor and resulting pressure on the public health system and on the other hand because of the rising demand of the patients for optimised medical care. It specially represents a new form of treatment in patients care after dischargement of hospital. In the year of 2002 a prospective randomised two-armed study was initiated including patients after operative intervention by arthroplasty in posttraumatic contracture of the elbow. The system of the Televisite is used for 6 weeks after dischargement and patients had been controlled ambulant after 6 months including a physical examination. The functional outcome will be scored, the duration of stay in hospital measured, the arising costs for treatment calculated and the satisfaction of the patients in handling the Televisite surveyed. Over this first results showed a shortened stay in hospital together with lowered costs in medical treatment on the one hand and on the other no difference in functional outcome could be found in comparison to the control group by additionally high grade of satisfaction with the new system.

[The postoperative control CT after a fracture of the acetabulum. A useful quality control measure or an unnecessary exposure to radiation?]. / Die postoperative Kontroll-CT nach Acetabulumfraktur. Sinnvolle Qualitätskontrolle oder unnötige Strahlenbelastung?

Fractures of the acetabulum are severe injuries of the hip joint. Exact preoperative management is necessary to make possible an anatomical reconstruction. Postoperative quality control is done best with computed tomography. Is the higher radiation exposure caused by this routine examination justified?During the 5 years from 1995 to 1999, a total of 154 patients with fractures of the acetabulum were examined postoperatively at our clinic using CT to control reconstruction, implant position and the remaining free fragments in the joint. Thirteen of these patients (8.4%) had to be re-operated after postoperative CT control. The causes of the re-operation were four cases of an intra-articular implant position, three of free fragments remaining in the joint, and in 6 patients showed inadequate reconstruction. The mean radiation exposure was 25 mGy per patient. The low mean age of the patients and the long lasting consequences of a probably unrecognised complication, justify routine, postoperative CT control, even though the radiation exposure is about 10 mGy higher than the conventional radiological diagnosis. The use of CT diagnosis as a routine postoperative measure is an appropriate control procedure that allows an objective assessment of the quality of the result for the patient as well as for the surgeon.

[Importance of the cross-sectional area of the spinal canal in thoracolumbar and lumbar fractures. Is there any correlation between the degree of stenosis and neurological deficit?]. / Die Bedeutung des Wirbelkanaldurchmessers im thorakolumbalen und lumbalen Bereich nach Trauma. Korreliert der Grad der Einengung mit dem neurologischen Defizit?

A relationship between traumatic spinal canal stenosis and the degree of neurological deficit is known for the cervical spine. However, this has not been proven for the thoracolumbar and lumbar spine. During a period of 4 years, from 1996 to 1999, 1168 patients with a spinal injury were treated at our department, 473 of these by operation. Thirty-five were examined in a separate group. They showed a single fracture of the thoracolumbar and lumbar spine with stenosis of the spinal canal. All fractures were single burst fractures after blunt trauma. All patients were conscious and fully oriented at the time of admission and a thorough neurological examination could be performed. The fractures were diagnosed by conventional X-ray in two views and computed tomography (CT). Using the transverse CT scans in horizontal view, the sagittal diameter was measured and the degree of stenosis calculated in percent at the level of the fracture and one below and above. The group included 25 male and 10 female patients, with a mean age of 38 years (range: 17-61 years). Of the 35 patients, 19 (54.3%) showed neurological deficits after spinal cord injury,and 16 (45.7%) were without any neurological complications at the time of first admission to the hospital. There was no correlation between the extent of spinal canal stenosis and the degree of the neurological deficit. One patient with stenosis of 20% suffered from neurological dysfunction, others with stenosis up to 80% were without spinal cord injury. The average stenosis of the spinal canal was 49.6% in cases with cord injury and 46.3% in patients without neurological dysfunction. No correlation and no predisposing anatomical structures could be found between stenosis and neurological deficit.

Failure of the serological determination of HLA-B27 due to antigen masking in patients with ankylosing spondylitis.

In patients suffering from ankylosing spondylitis (AS) HLA-B27 determination by means of the microlymphocytotoxicity test (MLCT) sometimes gives equivocal or false-negative results even though it has been performed with meticulous care. These failures of the test did not arise when the isolated mononuclear cells (MNC) were incubated in lymphocyte culture medium at 37 degrees C under sterile conditions for 24 h. To objectify these observations two methods of HLA class I typing were implemented before and after incubation of the test MNC in culture medium: a bioluminescence method based on the loss of adenosine triphosphate (ATP) in lysed cells in a modification of the usual MLCT and a flow cytometric (FC) test using direct immunofluorescence with an anti-HLA-B27 monoclonal antibody (MAB). In this study 50 patients with AS and 12 healthy volunteers were typed by the usual MLCT according to the NIH standard method and with both of the quantitative methods. In most of the AS patients the discrimination between positive and negative typing results became more distinct after 24 h incubation in culture medium. In the entire group of AS patients tested three false-negative typing results were prevented by this method. Although the MAB against HLA-B27 is cross-reactive with HLA-B7 and HLA-B22, errors in the FC analysis could be avoided by calibration of the flow cytometer with standard calibration beads. Possible explanations for masking of the HLA-B27 in AS patients are discussed.

The effects of ibuprofen and diclofenac on the chemotaxis and adenosine triphosphate level of polymorphonuclear cells in vitro.

Investigations were carried out to determine the effect of ibuprofen and diclofenac on the chemotaxis of human polymorphonuclear cells. The experiments were done with the drugs alone as well as in the presence of leukotriene B4 (LTB4). A modified quantitative bioluminescence assay was used to measure chemotaxis, which allowed the calculation of differences in the spontaneous migration in contrast to the effects of the drugs, and simultaneously, also, the evaluation of whether the inhibition or augmentation of the chemotaxis was due to influences on the adenosine triphosphate (ATP) level of the cells. It was found that high concentrations (10 mM) of either ibuprofen or diclofenac destroy the intracellular ATP of polymorphonuclear cells (PMN). Therefore, the reported inhibition of the chemotaxis by ibuprofen at a concentration of 10 mM cannot be understood as a part of the chemotactic process. In the range of 1 microM and 0.1 mM ibuprofen and diclofenac did not statistically affect the intracellular ATP level of PMN cells but at the same time a distinct inhibition of the chemotactic response of PMN cells was observed. This effect occurred even in the presence of a potent chemoattractant (leukotriene B4). Ibuprofen (0.1 mM) reduced chemotaxis to 67% and the same concentration of diclofenac reduced it to 56% of the values of LTB4 alone.

Ultrastructural changes of human amniotic cells induced by natural human interferon-alpha.

Human interferon-alpha (Hu-IFN alpha) and phorbol myristate acetate (PMA), a direct activator of protein kinase C (PK-C), induce the translocation of protein kinase C from the cytosol to the membrane fraction. By the use of transmission (TEM) and scanning (SEM) electron microscopy we have shown that treatment of human amniotic cells (UAC) with Hu-IFN alpha resulted in profound changes in the shape, volume and ultrastructure of the cells. Most treated cells had enlarged nuclei with marginal condensation of chromatin. Nucleolar segregation, disintegration and clumping of nucleolar components were also observed. The number of interdigitating cell processes decreased and the cell surface microvilli became shortened. Similar ultrastructural alterations were induced by PMA also. All these functional and morphological data strongly support the hypothesis that protein kinase C is a key factor in IFN-mediated cell reactions.

Methotrexate serum-level determinations during low-dose therapy of rheumatoid and psoriatic arthritis.

In 29 patients, 21 suffering from psoriatic arthritis and eight patients suffering from rheumatoid arthritis, methotrexate serum-levels were determined by means of radioimmunoassay. The aim of the investigation was to recognize an eventual dependence of the serum level of methotrexate on the total cumulative dose and to test the possibility of a concomitant therapy control. Beside the determinations of the serum levels of methotrexate, clinical examinations and laboratory tests were done at regular intervals. The values obtained showed no significant increase during the course of therapy compared to the values at the beginning of the treatment. Likewise no correlation to the total cumulative dose, the clinical picture or to the occurrence of side-effects could be found. Nor could any relationship between the changing of laboratory parameters and the methotrexate serum-levels be observed. No differences appeared in the methotrexate serum-levels during therapy of either rheumatoid or psoriatic arthritis patients. In conclusion it seems impossible to monitor a low-dose methotrexate therapy by continuous determinations of the serum levels of the drug.

Ultrastructural and autoradiographic investigations of cell cultures derived from tendons or ligamentous material from patients with fibromatous disorders.

Cell cultures were derived from tendons or ligamentous material from patients with carpal tunnel syndrome (CTS), Dupuytren's contracture (DP), tendopathia nodosa (TN) and hallux valgus (HV). The ultrastructure of the operation specimens as well as of the cell monolayers was investigated, using a floating sheet method in order to preserve both cell-to-cell contacts and the orientation of the monolayers. The histologic features of the tissues obtained in the operations were correlated with the ultrastructure of the cells in culture derived from these specimens. In DP, above all in the nodules, an activation of the capillary endothelium in the vicinity of myofibroblasts and mast cells was observed. In CTS the collagen fibrils varied extremely in diameter. In DP and TN biopsies a splicing process of helicoidly arranged fibrils could be seen. A disintegration of elastic fibers in the fibrillar and amorphous components was found in DP nodules, HV and TN tissues. Transitional forms between fibroblasts and myofibroblasts were observed not only in DP but also-though in a smaller percentage--in the cultures derived from the other patients. The cells showed organelles for active protein synthesis and transport. Autophagocytosis and the formation of multilamellated bodies took place in TN and HV cultures. In CTS, DP and TN cultures cells were connected via gap junctions. In some cultures, above all in those derived from CTS, monocilia were found. In CTS cultures the formation of intracellular collagen occurred. Growth parameters were rather low in HV cultures. PLmax (maximal pulse labelling index) values were higher in TN cultures than in DP and HV cultures. Plating efficiency (PE) values were higher in cultures derived from cell-rich and capillarized tissues than in biopsies with few cells.

[Blood cell concentration of methotrexate in long-term therapy of inflammatory rheumatic diseases]. / Hämatozelluläres Methotrexate bei Langzeittherapie entzündlich rheumatischer Erkrankungen.

To verify the possibility of a concomitant therapy control in 31 patients (18 psoriatic arthritis [PA], 13 rheumatoid arthritis [RA]) the blood cell concentration of Methotrexate (MTX) was continuously measured over a period of 6 months. The determinations were carried out by using a RIA of the CIS Corp. At any time MTX was determined laboratory and clinical examinations were done and the P-III-P serum-level was measured by using a RIA of the Behringwerke. The cellular MTX showed to be statistically significantly elevated compared to baseline, whereas within ranges of total cumulative dosages only insignificant fluctuations could be noticed. Like in the treatment of Psoriasis a strict correlation between the weekly administered dose and the cellular MTX could be established, the total cumulative dose, however, had no influence on the cellular MTX-level. In the treatment of RA slightly higher weekly dosages were necessary, which caused significantly higher cellular MTX concentrations in RA patients. Some correlations between clinical as well as serological parameters of disease activity could be noticed, nevertheless they do not allow distinct interpretations. In both diseases a significant relationship between the cellular MTX-level and the P-III-P serum-level could be realized. A storage of MTX in blood cells, especially in erythrocytes, seems to be evident. To reach therapeutical benefit in RA slightly higher mean dosages may be necessary. A therapy monitoring by the means of continuous determinations of cellular MTX seems to be impossible. In contrast an approach to the early detection of liver fibrosis can be given by the correlation between cellular MTX and the P-III-P serum levels.

The influence of synovial fluids from patients with rheumatic diseases on chick embryo fibroblasts.

Primary chick-embryo fibroblasts (PCEF) were used as target cells to measure the influence of synovial fluids of patients suffering from osteoarthritis (OA; n = 5), rheumatoid arthritis (RA; n = 12) and psoriatic arthritis (PA; n = 2). The following metabolic cell products were measured: DNA, RNA, glycosaminoglycans (GAG), sulfated glycosaminoglycans, protein and collagen, with the same joint effusions being used in each test. Since it is not a single substance that provokes a stimulating or inhibiting effect in the joint, the crude synovial fluids were applied in these preliminary experiments. It was found that each type of synovial fluid showed an influence on the biological processes in the PCEF. The DNA, RNA and GAG syntheses were strongly influenced by the joint effusions, in contrast to the protein, collagen and sulfated glycosaminoglycan syntheses which were less affected. Generally, the nucleic acid synthesis differed significantly between the OA, RA and PA synovial fluids. The addition of heparin to the synovial fluids caused an additive inhibiting effect on the DNA synthesis but did not influence the other biochemical parameters. The synovial fluids of RA patients, and to a much greater extent those of PA patients, inhibited the thymidine incorporation whereas OA synovial fluids had a less pronounced effect. This result indicates a disease-dependent composition of the synovial fluids. RNA synthesis was diminished in all three groups, but again this effect was strongest in the case of the PA synovial fluids. GAG synthesis was markedly stimulated by the PA synovial fluids and somewhat, though to a lesser extent, by the OA and RA synovial fluids. The sulfated glycosaminoglycan synthesis in the PCEF, as revealed by 35S incorporation into the GAG, was less influenced and on the whole stimulated by the OA and RA synovial fluids. The same trend could be observed with regard to the collagen synthesis. The intracellular protein synthesis was less influenced by the OA (91.9%) and more strongly suppressed by the RA (78.7%) and the PA (76.7%) synovial fluids. PCEF therefore appear to be a convenient and sensitive target cell system to study alterations of biochemical processes caused by crude synovial fluids and also of different origin by individual factors isolated from synovial fluids.

Morphometric analysis of collagen fibrils in idiopathic carpal tunnel syndrome: Part 2.

Morphometric parameters were evaluated in order to analyze the relation between number and covered area of collagen fibrils in normal and carpal tunnel syndrome tissue. This analysis revealed that in normal tissue twice as many collagen fibrils as in pathological tissue occupy an equal area. Taking these facts into account, some hypotheses are advanced.