[Characteristics in treatment of the hip in patients with Down syndrome]. / Besonderheiten in der Behandlung des Hüftgelenks bei Kindern mit dem Down-Syndrom.

BACKGROUND: The treatment of hip instability in patients with Down syndrome is challenging. We have performed different pelvic osteotomies and corrections at the proximal femur for this indication. This retrospective study was conducted to evaluate the clinical and radiological outcome of each intervention. MATERIAL AND METHODS: All in all, 166 patients with Down syndrome were treated at our orthopaedic department in the observation period. Problems related to the hip joint were diagnosed in 63 of those patients. Only patients who underwent surgery were included in this study. The charts and X-rays of these 31 patients were evaluated with respect to the following parameters: incidence of the hip problem, concomitant diseases, temporal progress, kind of operation method and date, duration of stay in the hospital, after-care, follow-on surgery related to complications, AC angle, CE angle, ACM angle, CCD angle, index of migration according to Reimers, classification of Bauer and Kerschbauer and general morphology of the femoral head. The group was compared with an age-matched group of 21 patients with hip dysplasia. Those patients underwent the same sort of operation in the same year. RESULTS: In the Morbus Down group, we performed surgery for preservation of the hip in 49 cases. This included 13 osteotomies according to Chiari, 11 triple osteotomies according to Tönnis, 10 corrections by femoral varus derotation osteotomy, 8 pelvic osteotomies according to Pemberton, 5 pelvic osteotomies according to Salter and 2 open reductions of the hip. With respect to the moment of surgery, we detected three peaks of age. There was no difference in course of disease and quantity of complications between the groups. Satisfactory results concerning clinical and radiological outcome were achieved predominantly by complete redirectional acetabular osteotomies. Half of the patients who were solely treated by femoral varus derotation osteotomy needed follow-on surgery in the form of pelvic osteotomy. Comparison of preoperative and postoperative range of motion of the hip joint between groups detected capsular insufficiency, increased ligamentous laxity and muscular hypotonia in patients with Down syndrome. Comparison of pelvic radiographs demonstrated significant improvement concerning measured angles in both groups. Preoperative values with respect to AC angle and CE angle were demonstrated to be lower in the hip dysplasia group (p < 0.01); whereas values for ACM angle were comparable between groups. CONCLUSION: Hypermobility and secondary dislocation of the hip joint is a common problem in patients with Down syndrome, which often requires surgical intervention at an early stage. According to our data and clinical results we suggest a complete redirectional acetabular osteotomy in combination with capsular plication for treatment of this challenging condition.

[Retrospective calculation of the workload in emergency departments in case of a mass accident. An analysis of the Love Parade 2010]. / Retrospektive Abschätzung der Belastung einer Notaufnahme beim MANV. Eine Analyse am Beispiel der Loveparade 2010.

BACKGROUND: For the clinical planning of mass events the emergency departments are of critical importance, but there are still no data available for the workload in these cases. As this is essential for an effective medical preparation, we calculated the workload based on the ICD codes of the vicitims at the Loveparade 2010 in Duisburg. MATERIAL AND METHODS: Based on the patient data of the Loveparade 2010 we used a filter diagnosis to estimate the number of shock room patients, regular admittances, surgical wound treatments, applications of casts or splints, and diagnosis of drug abuse. In addition every patient was classified to a Manchester Triage System category. This resulted in a chronological and quantitative work-load profile of the emergency department, which was evaluated by the clinical experiences of the departmental medical staff. RESULTS: The workload profile as a whole displayed a realistic image of the real true situation on July 24, 2010. While only the number, diagnosis and chronology of medical surgical patients was realistic, the MTS classification was not. The emergency department had a maximum of 6 emergency room admittances, 6 regular admittances, 4-5 surgical wound treatments, 3 casts and 2 drug abuse patients per hour. CONCLUSION: The calculation of workload from the ICD data is a reasonable tool for retrospective estimation of the workload of an emergency department, the data can be used for future planning. The retrospective MTS grouping is at present not suitable for a realistic calculation. Retrospective measures in the MTS groups are at present not sufficiently suitable for valid data publication.

[Current Diagnostics and Treatment of FAI in Germany]. / Aktueller Stand der Behandlung des FAI in Deutschland.

AIM: Femoroacetabular impingement (FAI) is a recently proposed mechanical concept for the development of osteoarthritis of the hip. Aim of this nationwide survey is the description of the current status of diagnostics and therapy of FAI in Germany. MATERIAL AND METHODS: All orthopedic and traumatological hospitals listed in the "list of German hospitals 2006" were invited via e-mail to take part in this anonymous survey. RESULTS: The questionnaire was answered by 682 departments (50.5 %). 98 (14.3 %) of these departments treated FAI in 2007. CONCLUSION: In Germany, diagnostics and treatment of FAI were performed inconsistently in a small number of specialized hospitals.

Incorporation of osteoblasts (MG63) into 3D nanofibre matrices by simultaneous electrospinning and spraying in bone tissue engineering.

Nanofibre scaffolds are suitable tools for bone tissue engineering. Mimicking the extracellular matrix, they allow for cell growth and differentiation. However, in large 3D scaffolds, uniform cell colonisation presents an unsolved problem. Our aim was to design and analyse a method of colonising nanofibre scaffolds, combining electrospinning of fibres and electrospraying of cells, to determine its impact on cell survival, growth, and gene expression. The osteoblast-like cell line MG63 was suspended in medium and electrosprayed into growing scaffolds of poly-(l-lactic acid) (PLLA) or PLLA/Col-I blend nanofibres. Fluorescein diacetate (FDA) staining was used to determine survival and growth over a 22 d culture period. Expression of osteocalcin (OC) and type I collagen (Col-I) genes was determined by real time PCR. Fluorescence microscopy was used to analyse Col-I and OC deposition, as well as cell densities. While spraying distance and cell density in the spraying solution influenced survival and cell density, the combination of electrospinning and electrospraying did not negatively influence the maintenance of the osteoblast phenotype. Furthermore, VEGF induction in response to hypoxia was not suppressed, but modulated by polymer composition. Therefore, simultaneous electrospinning and electrospraying is a suitable tool in producing nanofibre based 3D cell seeded scaffolds.

Increased glenohumeral translation and biceps load after SLAP lesions with potential influence on glenohumeral chondral lesions: a biomechanical study on human cadavers.

PURPOSE: The aim of the study was to evaluate the stabilizing function of the long head of biceps tendon (LHB) and its tension, both without and with the presence of SLAP lesion to analyze a potentially occurring humeral chondral print of LHB with consecutive glenohumeral chondral lesions in SLAP lesions. METHODS: Testings were performed on 21 fresh frozen human cadaver shoulders with intact shoulder girdle by a 5 axis industrial robot with a force/moment sensor and 20 N joint compression, 50 N force in anterior, posterior, anterosuperior, and anteroinferior direction, and 0°, 30°, 60° of abduction. LHB was connected over a force measuring sensor with 5 N and 25 N preload. A type IIC SLAP lesion was created arthroscopically. RESULTS: A significant increase in anterior and anteroinferior translation was evaluated, whereas the LHB tension increased significantly in at most anterior and anterosuperior direction. The highest increase in translation and LHB tension after SLAP lesion was measured in anterior translation in at most 60° of abduction. The glenohumeral translation was significantly higher in SLAP lesions without LHB tenotomy than after isolated LHB tenotomy. CONCLUSIONS: SLAP lesions lead to increased glenohumeral translation and concurrently LHB tension and load in at most anterior direction. The increased anterior glenohumeral instability and the increased LHB load pressing on the humeral head might cause glenohumeral chondral lesions with a typical chondral print-like lesion on the humeral head underneath the LHB.

[Primary hip and knee replacement: time required for surgical training]. / Elektive Hüft- und Knieendoprothesenimplantation: Zeitlicher Aufwand der operativen Weiterbildung.

BACKGROUND: The aim of the present study is to analyse the increased surgical time required due to supervised surgery as an element of costs of education. MATERIAL AND METHODS: Incision to closure times of 353 primary hip and knee prostheses were evaluated according to educational level. Differences between planned and real operation times were recorded, and the mean DRG proceeds per minute of surgical time were determined. RESULTS: The difference between incision to closure times of the board certified surgeons for the respective surgical interventions and that of the supervised surgery is statistically significant (p<0.01) and clinically relevant (+15 min for THA, +13 min for TKA). The correlation between planned and real operation time was significantly lower in the category of supervised surgery. CONCLUSION: There is an increased surgical time required for surgical training. It is the responsibility of health care policy to ensure an appropriate financial compensation.

[Anterior shoulder instability--the current situation]. / Vordere Schulterinstabilität--Aktueller Stand.

AIM: The aim of the study was to survey the current state of the conservative and operative treatment of anterior shoulder instability and its rehabilitation in German hospitals. METHODS: A previously evaluated online questionnaire was sent out to all German hospitals with orthopaedic or trauma surgery departments. The Federal Statistical Office's hospital list was the basis for the selection of hospitals. The questions referred to the year 2007. The survey, including 3 reminders, was conducted over 3 months. The questionnaire consisted of 6 response categories: always (100%), almost always (99-81%), predominantly (80-51%), rarely (50-21%), almost never (20-1%) and never (0%). RESULTS: The response rate was 41% and 67% of these had carried out shoulder stabilisations. In total, 99.2% of the 67% were evaluable. The proportion of shoulder surgery was 8.4% of the total number of operations. Shoulder stabilisations represented 10.6% of these operations. A specialised shoulder department existed in 22.9%. Conservative treatment was carried out with an immobilisation of the arm "predominantly", "almost always" and "always" for internal rotation in 70.8% and in 23.4% for external rotation. The shoulders were "predominantly", "almost always" and "always" stabilised in an arthroscopic technique in 68.2% and in an open one in 31.8% of the clinics. With 92.9%, the Bankart repair was the most common operation. Shoulder instability was principally treated with the arthroscopic technique, regardless of the care level and department and is considered the best surgical technique. Physiotherapy was prescribed "always" and "almost always" in 99.3%. The rate of reluxation after conservative treatment was estimated at 35.5%, after operative open anterior shoulder stabilisation at 9.1% and after arthroscopic shoulder stabilization at 10.6%. Nevertheless, 49.4% of respondents expected the best results after arthroscopic treatment. Participants, who mainly applied the arthroscopic technique, expected a lower rate of reluxation in comparison to other techniques (p<0.001). CONCLUSION: The operative shoulder stabilisation is most frequently carried out as arthroscopic Bankart repair. A standardised, subsequent treatment is well established.

CD44: survival and metastasis in chondrosarcoma.

OBJECTIVE: Recent studies have shown abnormal expression of CD44s and some of its isoforms in many human malignancies, but little is known about the presence of CD44 in chondrosarcoma. In this study the expression of CD44s and two variant isoforms was evaluated. It was assumed that abnormalities in these receptor proteins may be associated with clinical outcome of the patients. METHOD: Thirty paraffin-embedded chondrosarcoma samples were immunostained with monoclonal antibodies for CD44s, CD44v5 and CD44v6. Two independent examiners who were unaware of the clinical status of the patients evaluated the immunohistochemical results. The percentage of CD44-positive cells was scored semiquantitatively. A rate of higher than 10% was considered as overexpression. RESULTS: Among the 30 patients (median age 50 years) there were 22 conventional chondrosarcomas, two dedifferentiated chondrosarcomas, two extraskeletal chondrosarcomas, and one periostal, mesenchymal, clear cell and myxoid chondrosarcoma each. In the immunochemistry staining overexpression (>10% of cells) of CD44s was shown in 56.7% (17 of 30), of CD44v5 in 43.3% (13 of 30) and of CD44v6 in 6.7% (two of 30) of the tumors. Four grade III chondrosarcomas (80%) and 10 (71.4%) grade II chondrosarcomas showed overexpression for CD44s, whereas CD44s was overexpressed in only three (27.3%) grade I chondrosarcomas. Cox regression suggests overexpression of CD44s to be an additional prognostic marker for chondroid bone tumors independent of grading and other covariates. CONCLUSIONS: Overexpression of CD44s correlated significantly with metastatic potential and with poorer survival in patients with chondrosarcoma. CD44s might be an independent additional marker, but small sample size remains to be considered.

[From natural growth to artificial composition: the use of artificial materials in endoprosthetics from a cultural-historical perspective]. / Verwendung von Fremdmaterialien in der Endoprothetik: Ein medizinhistorischer Beitrag.

The use of artifical materials in joint replacement is not self-evident. A paradigm change can be observed. Beginning in the 18th century orthopedic surgery became possible because of a change of the idea of man. Natural growth was seen as ideal solution in orthopedic surgery until the 19th century. Yet in the aftermath the point of view changed to a more technical determined approach. Until the middle of the 20th century the terms "efficieny" and "ability" became more and more important. Joint replacement with artificial materials was generally accepted and led to an enormous accelaration in the development of new materials and surgical techniques.

[Modular noncemented femoral stem system in revision total hip arthroplasty]. / Zementfreier Femurschaftwechsel mit einem modularen Hüftendoprothesenrekonstruktionsschaft.

BACKGROUND: In most cases, loosening of a prosthesis stem is accompanied by periprosthetic osteolysis. This article presents the short-term clinical and radiological results after revision of total hip arthroplasty (THA) with bone substance deficiencies using a modular noncemented femoral stem system (LINK MP). PATIENTS AND METHODS: Between March 2003 and November 2005, 91 LINK MP modular revision stems were implanted in 90 patients. Eighty-one patients (51 stem revisions, 24 revisions of stem and shell, and six reimplantations after a Girdlestone situation) were available for prospective clinical and radiological evaluation at an average follow-up time of 16.7+/-6.5 (6-36) months. The average patient age at revision was 67.2+/-10.5 (31-87) years. RESULTS: Bone defects in the proximal femur were evaluated according to the Paprosky classification and showed type 2 in five cases, type 3A in 73 cases, and type 3B in three cases. The Merle d'Aubigné score increased significantly from 10.4+/-2.3 (4-15) preoperatively to 14.7+/-2.2 (9-18) at the latest follow-up (p<0.001). Migration analysis in conventional radiographs revealed an average stem subsidence of 3.4 mm. Thirty-one intraoperative and postoperative complications were noted in 28 (34.5%) patients. CONCLUSION: After a short-term follow-up, the modular noncemented femoral stem system LINK MP was shown to be a reliable tool for revision of THA with bony defects of the proximal femur. Our results are comparable to those for other modular noncemented revision stems. As expected, complication rates were higher than with primary THA.

[Incidence and mechanism of injuries in cable-wakeboarding: a prospective study]. / Verletzungsarten und Verletzungshäufigkeiten beim Cable-Wakeboard: eine prospektive saisonbegleitende Studie.

UNLABELLED: Cable-wakeboarding has become more and more popular in the last years in Germany and worldwide as well. The mechanism, frequency and severity of injuries is still unclear and not described in the literature yet. Thus to compare the injuries of cable-wakeboarding with similar sports we decided to perform this prospective study during a six months summer season. The study included 122 actives with a mean age of 25 years (15 - 42, +/- 5.876), 81,1 % male, sending an online questionnaire to us every month. 98 % of the participants suffered 277 injuries during 8647 hours of activity, 108 (39 % 12 / 1000 h) had to be treated medically. We found out most frequently mild injuries (61 % 19.5 / 1000 h), 15 % very severe injuries (4.8 / 1000 h), 14 % severe injuries (4.5 / 1000 h) and 10 % medium-severe injuries (3.2 / 1000 h). Injuries of the knee and the shoulder dominated in more than 20 % each with more than 70 % distorsions and contusions. CONCLUSION: Cable-wakeboarding is not more dangerous in regard to injuries than similar trendy sports even though the rate of mild injuries not treated medically is quite higher.

[Operative and follow-up treatment of rotator cuff tears--the current situation]. / Operative Therapie und Nachbehandlung der Rotatorenmanschettenruptur--Aktueller Stand.

AIM: The aim of this study was to evaluate the current situation of rotator cuff repair and follow-up treatment in German hospitals. METHODS: An evaluated survey, enquiring about the year 2006, was sent to all 777 German orthopaedic and/or trauma surgery departments. The hospitals were chosen using the official index of hospitals from the German Federal Statistical Office. RESULTS: 44 % of the surveys were sent back, whereby 40 % were of use. Within the 309 departments, 26 % of the total number of 59,957 shoulder operations were rotator cuff repairs. Mini-open was the operation method in 49 %, open in 29 % and arthroscopic in 22 % of cases. Regarding the operational methods, there were differences between the departments and level of care. The arthroscopic technique was used sometimes in 48 % of the departments, whereas 52 % never used it. Specialised shoulder departments employed the total arthroscopic procedure more often. A set follow-up treatment occurred in 79 % of departments. CONCLUSION: Rotator cuff repair is mainly carried out using the mini-open method, which is nowadays regarded as gold standard.

[Matched pair analysis: Innex FIXUC vs. NexGen LPS]. / Matched-Pair-Analyse: Innex FIXUC vs. NexGen LPS.

AIM: The aim of the present retrospective matched pair study was to compare the clinical results of patients undergoing total knee arthroplasty (TKA) with 2 different operation strategies: tibia first vs. femur first for ligament balancing and rotational alignment of the femoral component. METHODS: In this study 30 patients underwent TKA with the fixed bearing prosthesis Innex FIXUC between 2003 and 2005. In the same period of time the posterior stabilised prosthesis NexGen LPS was implanted in 123 patients. Out of these, 30 patients were matched to the 30 patients of the Innex group based on the parameters age, gender, height, weight and BMI. All implants were cemented. Clinical examination was rated using UCLA score, Knee Society score, Lequesne score for knees, a visual analogue scale (VAS) for pain and the Feller patellar score. Three patients in the Innex group were lost to follow-up, and 27 matched pairs could finally be analysed. RESULTS: At a mean follow-up of 25 months (Innex) and 3 years (NexGen) statistically significant differences (p < 0.05) with advantages for the NexGen were found in the UCLA activity score (4.9 vs. 5.9, p = 0.013), in part A (knee score) of the Knee Society score (78.9 vs. 91.0, p = 0.002) as well as the total score (153.9 vs. 173.2, p = 0.012), VAS (2.1 vs. 0.6, p = 0.003) and in the Lequesne knee score (5.7 vs. 3.6, p = 0.024). No statistically significant differences (p < 0.05) were found in the function score of the Knee Society score and the patellar score (Feller). CONCLUSION: In the described setting there were functional advantages for the NexGen prosthesis (femur first) at a comparable revision rate. However, satisfactory results with the Innex FIXUC are possible, too.

[Parental enquiries before frequenting the outpatient paediatric orthopaedic consultation--focus Internet]. / Elterliche Recherche vor Aufsuchen der kinderorthopädischen Sprechstunde--Schwerpunkt Internetinformationen.

PURPOSE: Every day several million people are seeking for answers to medical problems via the internet. In particular parents, whose children are affected by systemic diseases, orthopaedic defective positions, anomalies or deformities, use the internet to increase their knowledge. Concerning this situation there is a lack of studies in the current literature. METHODS: We investigated parental preparation to the outpatient paediatric orthopaedic consultation at our University Hospital with respect to internet enquiries or further sources of information using a standardised questionnaire. We assessed age and educational background of the parents, local hardware equipment and general habits of internet use. In particular, we retrieved parental use of search machines (e.g., Google.de, Yahoo.de), general medical websites (e.g., netdoktor.de) and websites from self-help groups (e.g., klumpfusskinder.de). RESULTS: In total, 288 out of 300 questionnaires (96%) were evaluated. More than half of the parents (57%) were over 35 years of age and 78% were women. 82% of the study population had access to the internet at home and 70% used the internet regularly. More than 80% obtained information about the orthopaedic diseases of their child beforehand. Age and educational background of the parents were not significantly correlated with the extent of enquiries (p > 0.05). 90% of the parents, using the internet as source of information, frequented internet search machines; approximately one third used general medical websites. In particular in clubfeet we observed a highly significant (p < 0.001) tendency of parents to frequent websites from self-help groups. 60% of the study population assessed the internet information as useful; 92% will frequent the internet as source of information again. One third of the respondents is going to discuss the obtained internet information with the physician. CONCLUSIONS: The internet is an important source of information for parents in the field of paediatric orthopaedics. Treating physicians will be increasingly confronted with the results of parental internet enquiries.

[Radial head prosthesis - treatment of comminuted radial head fractures combined with elbow instability]. / Radiuskopfprothese - Behandlung von Radiuskopftrümmerfrakturen mit begleitender Bandinstabilität.

AIM: This cohort study shows the results after treatment of comminuted radial head fractures combined with elbow instability, using radial head arthroplasty. METHOD: Between 2001-2003, 25 patients with an unreconstructible comminuted fracture of the radial head and elbow instability were treated with a bipolar radial head prosthesis. Using the Mason/Johnston classification there were 15 type III and 10 type IV radial head fractures. In 17 cases the operation took place within a week. In 8 cases the prosthesis was implanted after 129 +/- 113 days. The mean follow-up time was 21 +/- 6 months. RESULTS: The range of elbow movement showed a loss of mean extention of 13 +/- 8 degrees and a mean flexion of 126 +/- 12 degrees . The mean pronation was 72 +/- 13 degrees and supination 76 +/- 12 degrees . According to the Morrey score there were 8 excellent results, 13 good, 3 fair and 1 poor. The mean DASH score was 21.3 (0-74). Compared to a reference group, similar in age and gender, the patients showed no notable differences in quality of life. In one case the prosthesis dislocated and another patient experienced an aseptic loosening of the stem. Seven patients were diagnosed with heterotopic ossification, stage I and II on the Ilahi scale. 96 % of patients were able to return to their preoperative working life. A comparison of acute and chronic radial head fractures, treated with prosthesis showed no difference in results. CONCLUSION: An arthroplasty with a radial head prosthesis can be recommended for unreconstructible comminuted radial head fractures with ligament injury.

[Arthroscopically-assisted combined anterior and posterior cruciate ligament reconstruction]. / Arthroskopisch assistierter simultaner vorderer und hinterer Kreuzbandersatz.

BACKGROUND: The best treatment of a combined rupture of the anterior and posterior cruciate ligaments is still unclear. METHODS: Nine patients with unilateral traumatic ruptures of both the anterior and posterior cruciate ligaments were treated by arthroscopically-assisted simultaneous reconstruction. The operation was done using hamstring tendon and patellar tendon autografts, an average of 235 days (range 52-567) after the initial trauma. Patients were followed up for an average of 37 months (range 24-58) after surgery. For this retrospective cohort study, we used the Lysholm knee score, the Tegner activity score, and the SF-36 questionnaire as a means of assessment. RESULTS: The evaluation at follow-up showed an average score of 74 points on the Lysholm scale. Using the IKDC evaluation, four patients could be placed in group B and five patients in group C. A significant increase, from 1.9 points before trauma to 5.0 points at follow-up, was observed on the Tegner activity score. Comparing the operated with the healthy knees, with respect to stability and isokinetic muscle strength, we noted significantly better scores in the healthy knees. Using the SF-36 questionnaire, patients showed a reduced level of physical well-being. CONCLUSION: The treated patients were able to carry out their activities of everyday life. However, none of them returned to their preinjury activity level.

[Balloon kyphoplasty for recent vertebral fractures in the elderly]. / Ballonkyphoplastie frischer Wirbelkörperfrakturen bei alten Patienten.

BACKGROUND: An increasing life expectancy is often accompanied by a possible increase of vertebral fractures. If operative therapy is necessary, open procedures might be problematic for elderly patients. In this case, balloon kyphoplasty might be an alternative. METHODS: We present our prospective data of 30 patients with an average age of 72 years (range 65-82). The patients suffered from isolated thoracic and lumbar fractures (T6-L4) without neurological deficits and were operated on with balloon kyphoplasty. They were followed up an average of 13 months after surgery. RESULTS: Before surgery, the patients' average kyphotic angle was 12 degrees . After reduction with balloon kyphoplasty, this angle was significantly improved to 7 degrees , and at follow-up it was 8 degrees . Back pain, which was determined by a visual analogous scale, showed a significant reduction from 8.2 to 2.6 points at follow-up. No significant relationship between preoperative pain and improvement of the kyphotic angle could be found. Patients with a bad fracture reposition showed significantly more pain at follow-up. However, there was no difference between the reference group and the examined patients' quality of life regarding general health. CONCLUSION: Recent fractures of the thoracic or lumbar spine in elderly patients treated by balloon kyphoplasty showed good early results.