[The non-vascularised fibular transfer - indications and limits in infancy and adulthood]. / Die freie, nicht vaskularisierte Fibulatransplantation - Indikationen und deren Grenzen im Kindes- und Erwachsenenalter.

BACKGROUND: The non-vascularised fibular transfer is an established surgical procedure whose indication limits are verified and discussed. PATIENTS/MATERIAL AND METHODS: 12 patients with an average age of 17.9 years have been treated with a non-vascularised fibula transfer. The results are evaluated critically in comparison with those in the relevant literature. RESULTS: In ten cases a bone tumour and in two cases a chronic osteomyelitis have been treated. 11/12 patients showed a complete osseous integration. In one case a rigid pseudarthrosis of the ankle joint was observed. Clinical results were evaluated by the MSTS score (results 83.3-100). CONCLUSION: The non-vascularised fibula transfer is a reliable method to span bony defects of up to 25 cm in length. Unlike the autologous spongiosa graft it ensures a mechanical support because of the high cortical proportion. A temporarily occurring absorption of the transplant can be solved by a vascularised transfer, also the indication can be extended for covering combined osseous-soft tissue-defects or for reconstruction of the growth plate through epiphyseal transplantation. Indeed a strikingly increased extraction morbidity by resection of the peroneal artery and an essential elevated surgical effort are associated with these procedures. In consideration of the excellent results, the indication limits of the non-vascularised fibula transfer need to be defined. It can be successfully applied, especially in infancy, under the following conditions: unstable osseous defects with vital soft tissues, appropriate shape of the fibula for reconstruction as well as appropriate osseous requirements for a stable incorporation or osteosynthesis.

[Benign subcutaneous emphysema after nail penetration. Case report and important differential diagnoses]. / Benignes subkutanes Emphysem nach Nagelpenetration. Fallbeschreibung und wichtige Differentialdiagnosen.

Crepitus under the skin after penetrating injuries: harmless benign subcutaneous emphysema or life-threatening infection with gas-producing bacteria (gas gangrene because of Clostridium perfringens, crepitating cellulitis because of anaerobic Streptococcus or other coliforme bacteria)? We report a case of a 74-year-old male who developed massive crepitation of the left upper extremity and the lateral thoracic wall and mediastinal emphysema after sustaining a laceration of the left thumb and forefinger from a nail. Because there was the suspicion of gas gangrene we performed generous skin incisions of the ventral and dorsal part of the hand, the forearm and upper arm and open wound treatment. A triple antibiotic therapy was initiated. Due to fast regression of the subcutaneous emphysema and the mediastinal emphysema, continuing lack of symptoms, negative smear test results from the beginning and low infection parameters in the blood all wounds could be closed 9 days after primary surgery. The suspicion of gas gangrene was not confirmed so the diagnosis of benign subcutaneous emphysema was made.

[Value of ultrasound, CT, and MRI in the diagnosis of slipped capital femoral epiphysis (SCFE)]. / Der Stellenwert von Sonographie, Computertomographie und Kernspintomographie bei der Epiphyseolysis capitis femoris.

Traditionally, radiographic assessment of the hip with anteroposterior and lateral views is the gold standard of diagnosis in SCFE. This paper evaluates the possible contributions of other methods of modern imaging to the early diagnosis and treatment. There is scientific evidence that ultrasound can diagnose the disease earlier than conventional radiography and also has the possibility to differentiate the classification between stable and unstable. MRI depicts marrow changes earlier than any other imaging method available and has a role in cases where the diagnosis is difficult to make as well as in assessing the risk of chondrolysis and avascular necrosis. To show the anatomic deformity, anteroposterior and lateral radiographs remain the mainstay of preoperative planning.

[Can TOF MRA replace duplex and Doppler sonography in preoperative assessment of the carotid arteries? A prospective comparison and review of the literature]. / Kann die Time-of-Flight-Angiographie in der MRT die präoperative Duplex- und Doppler-Untersuchung der Arteria carotis ersetzen? - Ergebnisse eines prospektiven Vergleichs mit Literaturübersicht.

AIM: To examine the quality and usefulness of time-of-flight MR-angiography and duplex-doppler sonography, respectively, in assessment of the extracranial arteries before cervical spine operations. METHODS: Patients scheduled for operations of the cervical spine had an MRI plus TOF as well as a duplex and Doppler scan. At the time of the examination the radiologist and the neurologist in charge were blinded for the study. Endpoints were not only the accuracy of the procedures but more so which method improved the preoperative process most. RESULTS: Twenty patients were examined so far. Only in one case did the result differ when a complete occlusion diagnosed sonographically was judged as a severe stenosis on MRA. One patient did not tolerate the MRA for the extra 5 minutes necessary, therefore a contrast-enhanced MRA was performed. MRA eased the preoperative process as imaging of the pathology and the carotids were realised in one step. The costs were slightly higher for MRA than for duplex-doppler sonography. CONCLUSION: TOF-MRA can replace the duplex-doppler examination in the preoperative assessment of the carotids and has the potential to streamline the preoperative time schedule. Similar to duplex and doppler, in order to be accurate enough the method requires a high degree of expertise from the radiologist.

[MRI diagnosis of intervertebral disk disease]. / Diskusdiagnostik im MRT.

Magnetic resonance imaging (MRI) is the leading diagnostic procedure for disk pathology and has overtaken other imaging modalities in frequency of use. However, one must be cautious not to overinterpret small abnormalities that are also frequent in asymptomatic subjects. There is conflicting evidence about the correlation of high-intensity zones with clinical symptoms. Bulging disks and protrusions are a common finding in asymptomatic individuals, whilst extrusions are almost always accompanied by back pain and sciatica. In patients with back pain or sciatica, MRI is indicated after failure of conservative management or neurological deterioration. Contrast-enhanced MRI is well suited to differentiate a recurrent disk extrusion from epidural fibrosis. In all cases suspicious of tumor or infection, MRI is indicated as a first-line investigation. The indications and pitfalls of the state of the art of MRI are delineated in this article.

[Efficacy of MRI--whole spine image in diagnosis of vertebral metastases--results of a prospective study]. / Die Effizienz der MRT--Wirbelsäulenganzaufnahme in der Diagnostik von Wirbelmetastasen--Ergebnisse einer prospektiven Untersuchung.

AIM: To prospectively investigate the outcome efficacy of whole spine MRI for diagnosis and treatment in patients with suspected metastases of the spine. METHODS: All patients older than 50 years with newly diagnosed back pain and/or newly diagnosed spine-related neurological symptoms without a diagnosis by other imaging modalities were accepted in this study. A whole spine MRI and a detailed MRI per spine region with suspicious lesions were performed using a Siemens Magnetom Expert 1.0 Tesla machine. Outcome efficacy was determined by assessing further therapy and result for the patient. RESULTS: In all 15 patients of the year 1999 whole spine MRI allowed us to determine the definite diagnosis and treatment. Plain X-ray and 99mTc bone scanning gave a diagnostic suspicion but no definite diagnosis or therapeutic consequence. CONCLUSIONS: MRI of the spine including whole spine images allows clear cut decision making in diagnosis and treatment of cases suspicious for metastatic disease of the spine. Careful history taking and clinical examination provide enough information to opt for whole spine MRI as the first choice investigation. This will provide maximum benefit to the patient and avoid examination cascades.

Failure of osteosynthesis and prosthetic joint infection due to Mycobacterium tuberculosis following a subtrochanteric fracture: a case report and review of the literature.

We report a patient with a subtrochanteric fracture, for whom internal fixation failed and a prosthetic joint replacement was complicated by a local reactivation of a Mycobacterium tuberculosis infection. After hip replacement with revision and adequate medical therapy, a full recovery was attained without the necessity of removing the artificial joint.

Changes of sonographic, magnetic resonance tomographic, electromyographic, and histopathologic findings within a 2-month period of examinations after experimental muscle denervation.

This study compares sonographical, histopathological, magnetic resonance imaging (MRI), and electromyographical (EMG) findings following acute muscle denervation. We performed an experimental denervation of the supraspinatus and infraspinatus muscles on 35 New Zealand white rabbits by segment resection of the suprascapular nerve. The sonographical appearance of the supraspinatus muscle was followed and documented at short time intervals within a 2-month follow-up period. The sonographical, histopathological, and MRI changes due to denervation suggest a regular pattern. Apart from the reduction of the muscle diameter, there were considerable sonographical signs of denervation with an increase of echointensity and inhomogenicity of echotexture that appeared on day 14 after injury, and progressed continuously with time. MRI revealed a remarkable increase in signal intensity 3 weeks after denervation and reproducible T2 times. Pathological spontaneous activity on EMG could also be detected from day 14 after injury. Conventional histopathological staining methods (H&E, NADH, ATPase, basic and acid phosphatase) confirmed denervation and absence of reinnervation. The first nonspecific histopathological changes were seen 11 days after denervation in the form of moderately atrophic fibers. Typical histopathological signs of denervation appeared 3 weeks after nerve dissection. In summary, EMG, ultrasound, MRI, and histopathology each showed first abnormalities after about 2 weeks. In addition to EMG, sonography and MRI can document the course of muscle atrophy and mesenchymal abnormalities in neurogenic muscle lesions.

[Current role of ultrasonography in orthopedics. Results of a nationwide survey]. / Der heutige Stellenwert der Sonographie in der Orthopädie. Ergebnisse einer bundesweiten Umfrage.

The purpose of this study was to determine the current position of diagnostic ultrasound imaging in the day to day orthopaedic practice. A questionnaire was sent to all the 387 conservative and operative orthopaedic hospitals and orthopaedic university departments in Germany. 167 of these hospitals completed the forms and provided the basis for this evaluation (response rate 43.2%). Screening of the fetal hip for CDH was by far the most common indication, the shoulder was ranking second, the knee and the hip joint in children and adults rank third and fourth. Other frequent indications were injuries of the achilles tendon, the menisci of the knee, the knee in rheumatoid arthritis and muscle injuries. Ultrasound imaging is clearly established as a diagnostic tool at least in the named areas. It is therefore of importance to include ultrasound examination techniques in the curriculum of the orthopaedic training scheme.

[Sonographic diagnosis of anterior syndesmosis rupture]. / Die Sonographische Diagnostik der vorderen Syndesmosenruptur.

In a prospective trial we evaluated the diagnostic value of ultrasound imaging in the diagnosis of injuries to the anterior syndesmosis of the ankle joint. In an initial series of 20 patients using a basic standard ultrasound machine (Siemens Sonoline SL 1 with a 7.5 MHz piece) and a simple dynamic testing protocol as described in this article we found a significant difference between the ultrasound result for the ruptured syndesmosis versus non rupture and a specificity similar to that of arthrography. We conclude that ultrasound imaging is a useful tool in the diagnosis of syndesmotic rupture. Given the statistical significance of these results we feel confident that-despite the small amount of patients of this series and after an individual learning curve-ultrasound will eventually replace arthrography as the standard of investigation for this type of injury.

Sonography and MRI of experimental muscle injuries.

After sonographical examination with a 7.5-MHz linear array scanner, we created an experimental muscle injury of known site and location on 28 New Zealand white rabbits by stabbing them with a scalpel in the supraspinatus muscle. The changes in the healing process were followed and documented by sonography and magnetic resonance imaging (MRI) before and 2, 5, 11, 14, 36 and 64 days after injury. The changes in sonography and MRI followed a regular course. Ultrasound revealed an echo-poor area after injury with ever increasing echogenicity from the 14th day. Strong reflexes were found after 2 months. MRI showed few changes, only a slight increase of signal intensity, but a characteristic curve of calculated T2-times (a program of the MRI software). The interpretation of the sonographical picture in histopathological terms remained limited. The development of a hematoma and of fibrous scars can be followed up by sonography, but it is not possible to determine the point of time after injury very accurately. Nevertheless, sonography is a method of great value in the diagnosis of muscle injuries and, given certain limits, in the follow-up of the healing process, too. The significance of MRI can be increased by calculations with the implemented software, as in our study calculated T2-times produced a characteristic curve reflecting the shift of fluids after muscle injury.

[Ultrasound follow-up after experimental muscle denervation]. / Sonographische Verlaufskontrolle nach experimenteller Muskeldenervierung.

AIM: To describe sonographical results following acute, experimental muscle denervation. METHOD: Denervation of the supraspinatus and infraspinatus muscles was performed in 28 New Zealand white rabbits by segmental resection of the suprascapular nerve. The changes in the sonographic image of the muscles were follow up and documented at short intervals over 2 months. RESULTS: The sonographically detectable changes following denervation follow a definite pattern. In addition to the reduction in muscle diameter, sonographical signs of denervation include an increase of echodensity and an inhomogeneity of echotexture that appeared on day 14 after injury and became more prominent at larger intervals. CONCLUSION: Sonography may play a supportive role in the diagnosis and follow-up of neurogenic muscle atrophy.

[Magnetic resonance tomography and histopathologic findings after muscle denervation. A comparative animal experiment study during a two month follow-up]. / Kernspintomographische und histopathologische Befunde nach Muskeldenervierungen. Eine vergleichende tierexperimentelle Studie während einer zweimonatigen Verlaufsuntersuchung.

Recently, MRI was described as a method in the diagnosis of changes of muscle after acute neurogenic muscle atrophy. This study was performed to compare MRI results with myopathological findings, to document the appearance of the MRI changes and to check the sensitivity of this method. We performed a segment resection of the suprascapular nerve resulting in a denervation of the supraspinatus and infraspinatus muscles on 18 Newzeeland white rabbits. MRI changes were followed and documented for two months in short periods of time. The results were compared with histological findings. In myopathology and MRI we found systematical changes: Apart from the reduction of the muscle diameter visual assessment revealed increased signal intensities on the 21st and 35th examination day after denervation. On the 2nd, 5th, 11th and 64th examination day signal intensities were normal. The changes were represented by calculated T2 times, too.

[Possibilities and limits of interpretation of muscle sonograms. An experimental study of standardized muscle injuries]. / Möglichkeiten und Grenzen der Interpretation von Muskelsonogrammen. Eine experimentelle Studie standardisierter Muskelverletzungen.

After sonographical examination we performed surgically an experimental muscle injury of known size and location on 28 New Zealand white rabbits by a stab with a scalpel into the supraspinatic muscle. The changes in the healing process were sonographically followed and documented for 2 months in short periods of time. The sonographically detectable changes during the healing process underlie a regularity. The changes in sonography can be explained by histopathology with respect to the theoretics of ultrasound physics. The development of a hematoma and of fibrous scars can be followed up by sonography with respect to some limits. Sonography is shown to be a supporting method of high value in the diagnosis of muscle injuries and with respect to certain limits in the follow-up of the healing process, too.

[Ultrasound follow-up of experimental muscle injuries]. / Sonographische Verlaufskontrolle von experimentellen Muskelverletzungen.

Experimental muscle lesions were produced in 28 rabbits by stab incision, thus creating a lesion of known extent and site. The changes in the course of healing were followed up and documented at short intervals for a period of two months via sonography. The changes take place in regular course and can be explained by fine tissue changes, taking into consideration the fundamentals of theoretical ultrasound physics. Sonography renders both valuable assistance in diagnosing muscular lesions and in following up the healing process--the latter, however, with some reservations due to the clinical terminology defining the extent of muscular lesions.

[MRI results in experimental muscle injuries]. / MRT-Ergebnisse bei experimentellen Muskelverletzungen.

We performed an incision of standardized size and location on the suprascapularic muscle of 18 rabbits by a stab with a scalpel and measured the signal intensity of the muscle 2, 5, 11, 21, 35 and 64 days after injury (3 rabbits on each day). We did not find any detectable changes in the MRI pictures but a characteristic graph of the calculated T2-times (a mathematical procedure of the MRI software). The MRI changes correlate with the histopathological changes after muscle injury. The MRI method allows the evaluation of minor muscle trauma by the detection of a changed liquid content by using calculated T2 times.

[Possibilities of ultrasound diagnosis in Tossy type III acromioclavicular joint injuries in comparison with loaded roentgen images]. / Möglichkeiten der sonographischen Diagnostik bei Akromioklavikulargelenk-Verletzungen Typ Tossy III im Vergleich mit gehaltenen Röntgenaufnahmen.

We inform about 20 patients (19 men, 1 woman) with acute acromioclavicular striking, type Tossy III, which were operated. By usual preoperative diagnostic and physical examination, x-ray standard pictures of the shoulder in two planes and x-ray panoramic picture (loaded with 10 kp and unloaded) in ap-axis we made an additional sonographic examination of the hurt shoulder. This is practiced in the commendable standardised pattern of DEGUM (German Society of Ultrasound in Medicine). After the standardised sonographic examination we focussed the acromioclavicular joint sonographically in a modified lateral vertical axis. All of the 20 examined shoulder joints belong to the stage Tossy III. In the preoperative diagnosis the difference in elevation between the lateral portion of the clavicula and the medial portion of the acromion amounts in comparison to the two shoulders (loaded versus unloaded shoulder joints) sonographically 6.2 +/- 2.6 mm (max. difference of the sides 10 mm), by the radiological examination 6.5 +/- 3.7 mm (max. difference of the sides 14 mm). The sonographical examination of the shoulder joint makes it possible to get more information about the acromioclavicular lesion, especially by an AC examination according to Tossy degree III. At present there is no possibility of substituting the standardised x-ray pictures in two axes to diagnose or exclude fractures.

[Ultrasound follow-up of experimental partial Achilles tendon rupture]. / Sonographische Verlaufskontrolle von experimentellen partiellen Achillessehnenverletzungen.

We performed surgically an experimental partial Achilles tendon dissection on 28 New Zealand white rabbits. The changes in the healing process were sonographically followed and documentated in short periods of time for 2 months. The sonographically detectable changes during the healing process underlie certain rules. The changes in sonography can be explained by the histopathology with respect to the theoretics of ultrasound physics. Hematomas and the fibrous scars can be followed closely with sonography. Sonography is a method of high value in the diagnosis of partial and complete tendon tears and with respect to certain limits in the follow-up of the healing process, too. Certain limits in the evaluation of tendon injuries and their follow-up by sonography remain.

Fibre type specific expression of Leu19-antigen and N-CAM in skeletal muscle in various stages after experimental denervation.

Leu-19 antigen, which seems to be identical with neural cell adhesion molecule (N-CAM), plays a major role in the innervation of muscle cells, and in adult muscle appears after denervation and during regeneration of muscle fibres, where it acts as part of a signalling system increasing the probability of re-innervation. This combined enzyme-histochemical and immunohistochemical study examined whether this signalling process was regulated in a uniform or differential pattern for type 1 and type 2 muscle fibres. The subscapular nerve of 18 rabbits was transsected with subsequent complete denervation of the supraspinatus muscle. Leu-19 and N-CAM immunohistochemistry was performed 2 to 64 days after surgery. Whereas in normal muscle there are virtually no Leu-19/N-CAM positive muscle fibres; from day 2 after denervation an increasing proportion of fibres expressed Leu-19/N-CAM, prior to any neurogenic atrophy. In the early stage of denervation Leu19/N-CAM expression was confined to type 1 fibres. After 11 days nearly all fibres were Leu19/N-CAM positive irrespective of their fibre type. Sixty-four days after denervation type 1 fibres became Leu19/N-CAM negative, while atrophic type 2 fibres showed intensive staining. Thus, expression of Leu-19 antigenicity is differently regulated in both fibre types.

[Ultrasound image of the Lachman test in lesions of the anterior cruciate ligament]. / Sonographische Darstellung des Lachman-Tests bei Läsionen des vorderen Kreuzbandes.

The sonographic examination of the knee-joint can, in many pathological alterations of the knee-joint, supply additional informations. In the standardized ultrasound examination of the knee-joint ventral and dorsal sectional planes will be adjusted (4, 7, 14, 17). For the examination of the lesions of the anterior cruciate ligament direct adjustment techniques in the aere of origin of the anterior cruciate ligament (15, 16) and indirect examination methods are known (7, 8, 9, 20). While Hien chose a direct medial parapatellaric horizontal sagittal sectional plane in the course of the lig. patellae (8), we carry out our examination in a ventral infrapatellaric sagittal plane. The examinations were conducted with an ultrasound unit of the type Siemens Sonoline SL 2 with a linear transducer with a frequency of 5 MHz without a stand off pad. In the course of a prospective clinical examination an anteromedial test of stability of both knee-joints was conducted on 360 patients with the help of a sonographic Lachman-test. Two examination groups were formed: in group 1 60 patients with a arthroscopically secured lesion of the anterior cruciate ligament were registered and set against 300 probationers with "empty" anamnesis of the knee-joint of group 2. In the group of patients with a cruciate ligament injury a tibia translation of 5.3 mm in the Lachman-test was found; the side difference between the leg injured and the one uninjured amounted to 3.0 mm. In the control group the tibia translation amounted to 2.9 mm with a side difference of 0.9 mm.(ABSTRACT TRUNCATED AT 250 WORDS)