Trapezius transfer in brachial plexus palsy. Correlation of the outcome with muscle power and operative technique.

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha's technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique. The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6 degrees (0 to 45) to 34 degrees (5 to 90) at the last review. The mean forward flexion increased from 12 degrees (0 to 85) to 30 degrees (5 to 90). Abduction (41 degrees) and especially forward flexion (43 degrees) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42 degrees of abduction and 56 degrees of forward flexion. Active abduction (28 degrees) and forward flexion (19 degrees) were much less in completely flail shoulders (n = 34). Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished. The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.

[The brachial plexus lesion. Management, consequences of palsy and reconstructive operations]. / Der Armplexusschaden. Management, Lähmungsfolgen und funktionsverbessernde Operationen.

The treatment of traumatic brachial plexus lesions follows sequential steps. After acute therapy (phase I), neurological diagnostics (phase II), neurosurgery and postoperative treatment (phase III/IV), reconstructive operations (phase V) can be indicated and performed. In most cases an insufficient grade of muscle power remains. Within 6 months after injury, neurosurgery must be performed in patients with brachial plexus palsy. After malfunction of the muscles, taking into account the individual neuromuscular defects, passive joint function and bony deformities, different procedures such as muscle transposition, arthrodesis and corrective osteotomy can be performed to improve the function of the upper extremity. The treatment of patients suffering from brachial plexus lesion requires interdisciplinary teamwork.

[Shoulder arthrodesis with plate fixation. Special features in cases of resection and defects]. / Plattenarthrodese der Schulter. Besonderheiten bei Defekt- und Resektionszuständen.

AIM: Shoulder arthrodesis following prosthesis explantation or resection of the acromion has not often been described in the literature. The presented article analyses the special features and problems of these preoperative circumstances in 4 cases and discusses them within the entire group. PATIENTS AND METHOD: Between 06/1987 and 02/2001, a total of 30 shoulder arthrodeses using plate fixation were performed in our clinic and then analysed after an average of 2.7 (0.5 - 8.7) years. Surgery was carried out on 5 (17 %) females and 25 (83 %) males with a mean age of 37 (17 - 82) years. Two patients underwent shoulder arthrodesis as a salvage operation following unsatisfactory arthroplasty, or after trapezius transfer with corresponding reduced bony conditions, respectively. RESULTS: The active extent of movement following arthrodesis was 56 degrees (20 degrees - 90 degrees ) abduction, and 60 degrees (20 degrees - 105 degrees ) anteversion. The most frequent complications following arthrodesis included pseudarthroses (3/10 %), infections (4/13 %), and fractures of the humerus (4/13 %). The rate of complications was especially high in the cases after explantation of a shoulder prosthesis and resection of the acromion. In two of the four patients, three or five revision operations, respectively, were necessary. Two of the three pseudarthroses of the entire group occurred in these two cases. CONCLUSION: Complications of shoulder arthrodesis after resection of the acromion or the proximal humerus are especially frequent. To avoid pseudarthrosis in such cases, primary spongioplasty is advantageous. A fixation with plates is superior to a simple screw arthrodesis. For postoperative immobilization a plaster cast instead of an orthotic device should be taken into consideration.

[Pattern of paralysis and reconstructive operations after traumatic brachial plexus lesions]. / Lähmungsmuster und funktionsverbessernde Operationen nach traumatischen Arm-Plexus-Läsionen.

The aim of this study was to evaluate persistent patterns of paralysis after traumatic brachial plexus lesions. As a result, consecutive reconstructive operations according to our differential therapy concept are presented. Between 04/1994 and 12/2000 in 104 patients with brachial plexus palsy, the grade of muscle power of the affected upper extremities was evaluated prospectively. The neuromuscular patterns of defect showed, in most cases, insufficient muscle power grades of 0-2 for the deltoid muscle (90%), supraspinatus muscle (82%), infraspinatus muscle (93%), elbow flexors (67% to 77%), hand and finger extensors (69% to 71%), and the abductor and extensors of the thumb (67% to 70%). In corresponding frequency, the following operations were performed between 04/1994 and 06/2002: shoulder arthrodesis (n 26), trapezius transfer (n 80), rotation osteotomy of humerus (n 10), triceps to biceps transposition (n 11), transposition of forearm flexors or extensors/Steindler operation (n 12), latissimus transfer (n 7), pectoralis transfer (n 1), teres major transfer (n 1), transposition of forearm flexors to the tendons of extensor digitorum (n 19) and of the extensor pollicis longus (n 9), and wrist arthrodesis (n 5). On malfunction of muscles following brachial plexus lesions, taking into account the individual neuromuscular defect, passive joint function, and bony deformities, different procedures such as muscle transposition, arthrodesis, and corrective osteotomy can be performed to improve function of the upper extremity.

External auditory canal stenosis after radiation therapy.

OBJECTIVES: To determine whether the risk of external auditory canal stenosis from external-beam radiation therapy is dose dependent. STUDY DESIGN: Retrospective chart review. METHODS: The presence of external auditory canal disease was recorded for patients who received low-dose (e.g., lymphoma [20-40 Gy]), medium-dose (e.g., chemodectoma [40-55 Gy]), or high-dose (e.g., parotid and nasopharyngeal neoplasms [55-75 Gy]) external-beam radiation therapy from 6 months to over 8 years following treatment. The incidence of external auditory canal disease was compared between groups. RESULTS: None of 13 low-dose, none of 19 medium-dose, and 8 of 91 (8.7%) high-dose external-beam radiation therapy subjects developed ipsilateral external auditory canal stenosis. No external auditory canal stenosis developed in patients treated with high-dose external-beam radiation therapy in the absence of parotid surgery. External auditory canal stenosis developed only in patients treated with parotidectomy and high-dose external-beam radiation therapy (P =.0059), and all of these cases of external auditory canal stenosis developed within 3 years of radiation therapy. CONCLUSIONS: High dose external-beam radiation therapy alone does not significantly predispose patients to external auditory canal stenosis. However, combined high-dose external-beam radiation therapy and surgery around the external auditory canal do significantly increase the risk of external auditory canal stenosis.

[Changes of biomechanical parameters in dysplasia of the hip by total hip replacement]. / Anderung der Biomechanik dysplastischer Hüftgelenke durch Implantation einer Hüfttotalendoprothese.

AIM: Dysplastic hips or dislocated hips lead to loss of muscle strength claudication, and finally to coxarthrosis. This study analytically compares the hip joint forces in normal, dysplastic hips and hips after implantation of a hip prosthesis for several positions. METHOD: The results of 173 total hip replacements in 153 cases of either severe congenital dysplasia or dislocation were analyzed. A 2 dimensional mathematical model of the hip was developed to evaluate the effects of surgically achievable mechanical alterations such as acetabular placement, femoral shaft-prosthetic neck angle, and neck length of the femoral prosthesis. RESULTS: 63 % of the hip prosthesis were implanted on the right, 72 % on the left. Before implantation, the femoral shaft-prosthetic neck angle in mean was 146 degrees +/- 10 degrees, after implantation it was 135 degrees. The hip centre was displaced on in average 10 mm distally. Postoperatively hip joint force was increased 21 %. CONCLUSION: Minimum joint contact forces occurred when the femoral shaft prosthetic neck angles were small. The loads on the hip were lowered significantly by placing the centre of the acetabulum as far inferiorly and medially as possible. Another important finding is that displacement of the hip centre distally has a great effect on muscle performance and hip joint force.

[Transposition operation in paralysis of extensor muscles of the hand--intermediate-term results]. / Transpositionsoperation bei Lähmung der Streckmuskulatur der Hand--mittelfristige Ergebnisse.

AIM: The surgical reconstruction of the dorsiflexion of the wrist and the abduction of the thumb in paralyzed radial nerve for the improvement of the useability of the hand is described. Likewise, the early functional subsequent treatment is described. Indications and contraindications are represented in detail. METHOD: Between October 1997 and May 2000 we treated 10 patients by the following method: The musculus flexor carpi ulnaris tendon is cut near the pisiform bone, transferred subcutaneously and fixed on the tendons of the extensor communis digitorum communis muscle. The tendon of the palmaris longus muscle is fixed on the tendon of the extensor pollicis longus muscle. After the swelling in the hand has subsided, the patients are supplied with a dynamic splint in order to avoid adhesions. RESULTS: According to the score suggested by Haas, 9 patients achieved a very good result (median: 30 degrees dorsiflexion), one patient had a good result (0 degree dorsiflexion). CONCLUSION: Adhesions could be avoided and the time of rehabilitation could be shortened by the operation method described. The operations result in an improvement of hand function and as well as patient satisfaction.

[Pathology of acute and chronic tendon injuries]. / Pathologie der akuten und chronischen Sehnenverletzung.

The load limit of a tendon is expressed by the not linear force/lengthening behavior. It is determined by the interrelation between load and load-bearing capacity. The load of a tendon results from exogenous, endogenous and temporal factors. The property factors and the aging influence the load-bearing capacity of a tendon. Partial ruptures show necrosis, calcification and fiber swelling. The attachment area shows a mineralization of the cartilage zone, a loss of the collagen fibrils and calcifications. The tendon rupture knows extrinsic and intrinsic causes. Primary are micro and macrovascular tendon alterations, usually favour the rupture of tendons.

[Tendon suture: surgical techniques]. / Die Sehnennaht. Operative Techniken.

Tendon sutures belong to the bases of surgical activity. Particularly in the last decades these sutures experienced a substantial upswing by the introduction of new techniques and materials. Target is to reestablish the tendon function. In order to achieve this target, it requires knowledge of tendon healing. An outline of suture materials, in particular specific suture techniques as well as the subsequent treatment is given. With different localizations of the tendon lesions one deals.

A comparative study of two cerclage systems.

Intraoperative femoral fracture is a well recognized technical complication of cementless total hip arthroplasty (THA). The aim of this study was to establish an in vitro model for initiation of fractures of the femur in cementless THA and to assess the effect of fracture fixation by cerclage wiring. An in vitro comparison of two methods of cerclage fixation was performed using steel wire (Protasul) versus multifilament Vitallium alloy cable. Ten fresh human femur specimens were studied. Longitudinal fractures were created on a material testing machine. The force to create a longitudinal fracture in the femur was 1915 N to 9288 N (median 6531 N). This force corresponds 3 to 15 times (median 11 times) the body weight. The femoral cortex was fractured in 5 cases ventrally, in 6 cases medially and in 1 case laterally. After monofile cerclage wire application, the force required to press the prosthesis 5 mm deeper into the medullary canal was 0.3-2.7 times body weight. After Vitallium alloy cable application in other specimens, the force was 1.3-2.7 times body weight. The difference was not statistically significant. After monofile cerclage wire application, a force of 1.8-8.1 times body weight was necessary to press the prosthesis 30 mm deeper into the medullary canal. After polyfile Vitallium alloy cable application in other specimens, the force was 7.7-12 times body weight. The difference was statistically significant (U-test, alpha < 0.025).

Drill hole position in endoscopic anterior cruciate ligament reconstruction. Results of an advanced arthroscopy course.

In 24 cadaver knees the anterior cruciate ligament (ACL) was replaced by a bone-tendon-bone patellar tendon autograft in an endoscopic technique. This was carried out during an advanced arthroscopy course after intensive instruction and practice on a plastic model. When the knees were opened and evaluated according to the recent orthopaedic literature, only four good results with correct tunnels and a non-impinging graft were found. In 12 knees the femoral tunnel was too far anterior (10) or had broken through the posterior femoral cortex (2). In 6 knees the tibial tunnel was too far anterior (2) or too far posterior (4). The notchplasty was insufficient in 6 knees. We conclude that endoscopic ACL reconstruction cannot be mastered after attending a course alone. Expert help is necessary during the first clinical cases.

[An in vitro model for producing femoral fractures and for the study of primary stability of cerclage]. / Ein in-vitro Modell zur Erzeugung von Femurfrakturen und zur Untersuchung der Primärstabilität von Cerclagen.

PURPOSE: Intraoperative femoral fracture is a well recognized intraoperative complication of cementless total hip arthroplasty (THA). This study was designed to establish an in-vitro model for initiation of fractures of the femur in cementless THA and to assess the effect of fracture fixation by cerclage wiring using steel wire (Protasul). METHODS: Ten human femur specimens were studied. Longitudinal cracks were created by pressing a well fixed conical stem deeper into the femur in a material testing machine. RESULTS: The force necessary to propagate a longitudinal crack in the femur was 1915 N to 9288 N (median 6531 N). This forces are according to 3 to 15 times (median 11 times) body weight. There was no difference of force between left and right femurs from the same individual (U-test). The femoral cortex fractured in 5 cases ventrally, in 6 cases medially and in 1 case laterally. After monofile cerclage wire application the force required to press prosthesis 5 mm deeper into the medullary canal was 0.3 to 2.7 times body weight. After monofile cerclage wire application pressing in the prosthesis 30 mm needed 1.8 to 8.1 times body weight. CONCLUSIONS: During insertion of a conical stem the orthopaedic surgeon should look for fractures of the medial cortex of the femur which is the most frequent location for fractures. This in-vitro model provides a reproductable method for the initiation and propagation of longitudinal femoral fractures in press-fit noncemented THA system and to assess the effect of fracture fixation in the form of cerclage wiring.

Benign giant-cell tumor of the patellar ligament.

We report the symptoms, clinical findings, and treatment of a patient with an extra-articular benign giant-cell tumor of the patellar ligament. Between the years 1966 and 1996 no similar case has been found to be documented by a Medline search. On palpation, a soft, mobile lesion, the size of a pigeon's egg, was felt in the lateral region of the patellar ligament. There was no set of laboratory values to determine the diagnosis. In addition, there were no typical findings in diagnostic imaging procedures and it seems that the most important fact is that the clinician is aware of this type of synovial tumor. A clear diagnosis is only possible by means of a pathological investigation. The choice of therapy for giant-cell tumors is local excision. Arthroscopy is recommended exclusively for the diagnosis and therapy of a localized intra-articular giant-cell tumor.

[The value of leukocyte scintigraphy in suspected implant infection in patients with chronic polyarthritis]. / Nutzen der Leukocytenszintigraphie bei Verdacht auf Implantatinfekt bei Patienten mit chronischer Polyarthritis.

When infection of implants is suspected, optimal management requires accurate confirmation or exclusion of infection. However, in spite of demonstrative clinical signs cultures of smears or chemical parameters of inflammation frequently are ambiguous. Scintigraphy with indium-labeled white blood cells (WBC) has been reported to be sensitive and specific in the diagnosis of low-grade sepsis of the musculoskeletal system. Twenty-eight patients with possible infection were prospectively studied. Infection was suspected in 19 cases with total hip joint prosthesis, 14 cases with knee joint prosthesis and 1 case with shoulder joint prosthesis. All of them underwent scanning with indium-111-labeled WBC and subsequently underwent surgery. At surgery infections were determined by means of culture or histologic results. When correlated with culture and histologic results sensitivity of 111-indium-WBC imaging was 89% with a specificity of 67% and a predictive accuracy of 77%. In patients with rheumatoid arthritis, however, predictive accuracy of 111-indium-labeled WBC imaging was higher than with standard diagnostic methods. The difference was statistically significant (P < 0.05, chi(2)-test). In the patients examined as a whole, predictive accuracy of 111-indium-labeled WBC imaging does not differ from that of standard diagnostic methods. That is why expensive and time-consuming 111-indium-WBC imaging is not justified generally in diagnosis of infection of implants. 111-Indium-WBC imaging is well suited to supplement standard diagnostic methods in patients with rheumatoid arthritis.

Time-resolved Raman spectroscopy from reacting optically levitated microdroplets.

Time-resolved Raman spectroscopy is evaluated as a tool for studying reactions in aerosol microdroplets. As a test reaction, the absorption of D(2)O vapor by an optically levitated glycerol droplet is considered. With the present apparatus, time scales of the order of 1 s have been resolved. By considering the relative amplitude of various features, the composition of the suspended droplet can be estimated as a function of time. In addition, for the D(2)O-glycerol system the average temperature of the optically levitated droplet can be deduced.

Propagation of laser breakdown and detonation waves in transparent droplets.

A computer model is used to study recent experiments investigating laser-induced plasma formation and explosion of single liquid aerosol droplets. The model accounts for the formation and evolution of the plasma and the resulting fluid flow; it does not account for the initial breakdown. The model shows all the qualitative features of the experiment, including laser-supported detonation waves, which at high laser intensities rapidly convert the whole droplet into a plasma. In addition, quantitative agreement with measured velocities has been obtained to within approximately 50%.

Explosive vaporization of single droplets by lasers: comparison of models with experiments.

A computer model of the explosive vaporization of single water droplets by pulsed CO(2)-laser radiation is compared with the relevant experiments. The model shows excellent quantitative agreement with the experiments, to our knowledge the first time such agreement has been observed. The importance of fluid mechanics during the pulse is demonstrated, and a second computer model illustrates how a spherically symmetric explosion can evolve even under conditions of nonuniform heating. The two models reconcile the differences between predictions made by Mie theory and observations of droplet heating.