[Transfer of latissimus dorsi muscle for irreparable posterosuperior rotator cuff defects in older patients : Medium term results]. / Latissimus-dorsi-Transfer bei irreparablen posterior-superioren Rotatorenmanschettendefekten bei älteren Patienten : Mittelfristige Ergebnisse.

OBJECTIVE: Is transfer of the latissimus dorsi muscle (LDT) a good option in older patients with irreparable posterosuperior rotator cuff tears? MATERIAL AND METHOD: In 2010-2016 a total of 25 patients without glenohumeral arthritis and non-reconstructable supraspinatus and infraspinatus tendons, a recentered glenohumeral joint with remaining function in anteversion and irreparable posterosuperior rotator cuff defects were treated using LDT at the Rummelsberg Hospital. Of the patients 9 (36%) had in the past 1 or more attempts at reconstruction of the rotator cuff. All other patients (64%) underwent a primary reconstruction using LDT. The patients had an average age of 61 years and average follow up of 32 months. Of the 25 patients 24 (96%) were clinically followed up with the constant score (CS) and the visual analogue scale (VAS). The operation was performed in the technique described by Gerber to raise the latissimus dorsi but in the beach-chair position. Follow-up treatment was performed for 6 weeks using the ACRO-Assist splint (shoulder brace) in 90 ° abduction with daily limited external rotation exercises, followed by a regular regular rehabilitation on an outpatient basis. RESULTS: The average operating time was 112 min (68-199 min). Postoperatively the only complication was an tightly sutured drainage. The preoperative Constantpoint averaged 25 (2-59). The postoperative Constantpoint was 60. The average gain of improvement was 35 points. The age-corrected relative CS was 74 after surgery. Pain perception improved significantly from preoperatively severe to very severe pain to postoperatively minor to no pain. In the VAS score there was a reduction from preoperatively 6 to postoperatively 3 VAS points. The external rotation improved from average 3 points in the CS to 6 points in the CS. The preoperative Constantpoint in patients <60 years (n = 12) was 20, the postoperative 51. The gain was 31 Constantpoints. In patients ≥60 years (n = 12), the preoperative Constantpoint was 31, the postoperative 60. The gain was 29 points. The difference between the age groups was not significant. Previously operatively treated patients (arthroscopic or mini-open reconstruction) all showed an improvement in Constantpoints (26 vs. 32 in primarily non-reconstructed patients); however, on a lower level (45 points in previously operated patients vs. 69 CS points). CONCLUSION: With appropriate patient selection, a high gain in CS can be achieved even in older patients using latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. The VAS score and external rotation significantly improved. Previously attempts in rotator cuff reconstruction demonstrated a negative influence on the clinical outcome.

[Dynamic intraligamentary stabilization of acute anterior femoral cruciate ligament rupture : Preliminary and intermediate clinical results]. / Dynamische intraligamentäre Stabilisierung der akuten vorderen femoralen Kreuzbandruptur : Erste und mittelfristige klinische Ergebnisse.

BACKGROUND: The results of anterior cruciate ligament (ACL) reconstruction demonstrate excellent short and mid-term results; however, long-term follow-up results are compromized by high rates of osteoarthritis. Dynamic intraligamentary stabilization (DIS) focuses on preserving the cruciate ligament. The short and mid-term results of the dynamic ligamentary cruciate ligament suture from a nondevelopmental hospital are presented. MATERIAL AND METHODS: A total of 73 consecutive patients with an acute rupture of the ACL were included in this prospective study. Patients were surgically treated between July 2014 and October 2017 with DIS within 21 days after ACL rupture. All patients were reviewed before the operation, 60 patients reached a 3­month follow-up , 51 patients reached a 6­month follow-up and 38 patients a 12-month follow-up. The perioperative and postoperative complication spectrum was recorded. RESULTS: The positive results of the developmental clinics were confirmed. The Tegner, Lysholm and International knee documentation Committee (IKDC) scores showed very good results 12 months after surgery. The intraoperative and postoperative complication rates were low at 1.4% and 6.8%, respectively. Postoperative restrictions on movement required re-arthroscopy in 3 patients, 66% of the patients had concomitant damage to the knee joint, which could be treated simultaneously. CONCLUSION: The dynamic intraligamentary cruciate liament suture (Ligamys) is a successful additional option in the sugical treatment of acute femoral ACL rupture. A high proportion of collateral damage and injuries of the knee joint can be detected and simultaneously treated.

[Which patients benefit from transport with ongoing cardiopulmonary resuscitation? : Retrospective analysis of 70 patients with refractory preclinical cardiac arrest]. / Welcher Patient profitiert von einem Transport unter laufender kardiopulmonaler Reanimation? : Retrospektive Analyse von 70 Patienten mit refraktärem präklinischem Herzstillstand.

BACKGROUND: Mortality in patients with out-of-hospital cardiac arrest (OHCA) remains very high despite advances in resuscitation algorithms. Most of these patients die at the scene and do not reach hospital. It is currently the subject of discussion whether transport to hospital with ongoing cardiopulmonary resuscitation (CPR) improves survival and neurological outcome in patients with OHCA. OBJECTIVE: The aim of this study was to identify predictors of survival and good neurological outcome in patients after OHCA who were transported to hospital with ongoing CPR. PATIENTS AND METHODS: A total of 70 consecutive patients with refractory OHCA (mean age 54.7 ± 15 years) transported to hospital with ongoing CPR were retrospectively analyzed. Neurological outcome was assessed after 30 days based on the Glasgow-Pittsburgh cerebral performance category (CPC). RESULTS: After 30 days 82.9% of the patients enrolled in the trial died (CPC score of 5), 8 patients (11.4%) showed a good neurological recovery with CPC scores of 1-2 and 4 patients (5.7%) had a poor neurological outcome with CPC scores of 3-4. Predictors of good neurological outcome were witnessed arrest, initial defibrillatable rhythm and serum lactate levels on admission. In all patients with good outcome, the index event for OHCA was from cardiac causes. CONCLUSION: Selected patient collectives can benefit from transport to hospital with ongoing cardiopulmonary resuscitation (CPR).

[Proximal humeral fractures in the elderly : Quality of life, clinical results and institutionalization following primary reverse fracture arthroplasty]. / Proximale Humerusfraktur im fortgeschrittenen Lebensalter : Lebensqualität, klinische Ergebnisse und Institutionalisierung nach primärer inverser Frakturprothesenimplantation.

BACKGROUND: Treatment of humeral head fractures in the elderly remains a challenge. Within the framework of demographic change the incidence as well as the direct and indirect consequences of injuries will rise. The analysis of an optimal treatment should include functional parameters as well as global health parameters, e.g. quality of life. OBJECTIVE: The aim of this study was the evaluation of functional outcome, institutionalization (necessity of placement in a residential care home for the elderly, even if temporary), the influence of cognitive deficits, quality of life and the pattern of complications after primary reverse shoulder arthroplasty. MATERIAL AND METHODS: The study included a total of 34 patients (mean age 79.8 ± 6.7 years, 29 female) after implantation of a reversed modular fracture arthroplasty. The mean follow-up was 23 ± 10.6 months). The functional Constant-Murley score (CS), radiology results as well as the extent of institutionalization and quality of life as measured by the EQ-5D questionnaire were collated. RESULTS: The clinical examination showed good results in the CS (54 points, SD ± 9). In comparison to the age and gender-related CS according to Gerber the patient scores amounted to 78.9 %. The comparison of patients with and without cognitive deficits did not show any differences (53 vs. 54 points, p = 0.6525). The rate of institutionalization after treatment of humeral head fractures by reversed fracture arthroplasty was 2.94 %. The quality of life measured with EQ-5D showed a health-related quality of life (HRQoL) of 0.801. The rate of complications was 2.94 % involving an incomplete lesion of the radial nerve which was in regression. CONCLUSION: The results of this study showed good to moderate functional results, very low rates of complications and institutionalization and very good results according to the HRQoL. In comparison to conservative treatment or plate osteosynthesis, better results were achieved in this study with respect to HRQoL.

[Epilepsy and transverse sternum fractures: sternum fractures in drug-induced osteopenia]. / Sternumfraktur bei medikamenteninduzierter Osteopenie: Epilepsie und Sternumquerfraktur.

Fractures of the sternum are a very rare injury. The combination of indirect trauma and transverse fracture in case of an epileptic seizure has been described only in one case. A sternal fracture in a 32-year-old woman was treated by plate osteosynthesis because of progressive pain. In the current literature, there are no clear recommendations for the treatment of such fractures. Plate osteosynthesis, as an alternative to conservative treatment of such fractures, is presented and discussed.

Gender influence on the outcome of an unisex total knee arthroplasty system.

BACKGROUND: Controversy exists on whether gender-specific anatomic differences in the human knee have to be taken into account by gender-specific design in total knee replacement (TKR). We evaluated total knees that were implanted in both genders. OBJECTIVE: This paper will describe the influence of gender on the outcome after a unisex total knee arthroplasty. METHODS: 52 total knee prostheses (mobile bearing Brehm Precision Knee®, BPK) were implanted in 48 patients (16 male, 32 female, 4 bilateral). Median follow-up was 15 months. HSS score, KSS score, ROM, VAS, and radiologic axis were used as outcome measures. We also obtained preoperative scores of these parameters, creating difference parameters respectively. All surgeries were performed by a single surgeon. RESULTS: No significant difference could be determined between genders for postoperative parameters and difference between preoperative and postoperative parameters between both groups. Women scored higher on HSS score preoperatively and postoperatively with 50.0 and 91.0 points versus 47.0 and 88.0 points in the male group. On KSS score, the female group scored higher preoperatively and postoperatively as well, with 79.0 and 174.0 points versus the male group with 74.0 and 168.0. CONCLUSION: As the results obtained with this unisex prosthesis system were not statistically significant when compared for gender, we conclude the BPK currently addresses gender-specific anatomic differences sufficiently.

[Locking, multidimensional plate osteosynthesis of midshaft clavicle fracture]. / Winkelstabile, mehrdimensionale Plattenosteosynthese der Klavikulaschaftfraktur.

BACKGROUND: The goal of this consecutive, retrospective clinical follow-up study was to analyse the quality of treatment with a multidimensional, anatomical locking plate osteosynthesis after comminuted clavicle shaft fracture (Robinson 2B). PATIENTS AND METHODS: Of 38 operated patients, 35 were examined after locking plate osteosynthesis, with a median follow-up of 32 months (11-65). Four patients had suffered a 2B1 Robinson fracture and 31 patients a 2B2 Robinson fracture. The clinical and functional results were determined based on the standard clinical examination of the shoulder, the Constant and DASH scores, an analogue visual scale and a patient survey. RESULTS: The clinical examination yielded a mean DASH score of 1.25, a mean Constant score of 98 and a mean VAS score on the visual analogue scale of 0.4 (with a range of 0-6). Neither nonunion nor implant failure was observed. We did, however, have one case of infection of the soft tissue. CONCLUSION: The treatment of comminuted shaft fractures of the clavicle by means of a multidimensional locking plate is a safe treatment option that includes early functional postoperative care with free range of motion.

[Nickel allergy and painful unicondylar knee arthroplasty]. / Nickelallergie und schmerzhafte monokondyläre Kniegelenksschlittenprothese.

A 56-year-old woman with unicondylar knee arthroplasty (Oxford III, Biomet) complained of persistent, burning pain in her knee. The arthroplasty failure was caused by a nickel allergy. The diagnosis was confirmed by positive patch testing, lymphocyte transformation test and histological analysis of the neosynovia around the implant. The unicondylar knee arthroplasty was explanted and replaced by a titanium-coated knee prosthesis (INNEX CR, Zimmer).

[Prehospital trauma care training course. Integration of emergency physician and rescue services]. / Schulungskonzept präklinisches Traumamanagement. Integration von Notarzt und Rettungsdienst.

BACKGROUND: With the emergence of a trauma network in the metropolitan area of Nuremberg, Germany, the question arose whether prehospital trauma management and emergency department management could be better integrated. A training scheme was designed for prehospital trauma care by the rescue services of the Workers' Samaritan Federation Germany (ASB), the Bavarian Red Cross, Maltese Ambulance, St. Johns Ambulance, representatives of the emergency physicians, and physicians of Rummelsberg Hospital. MATERIAL AND METHODS: A detailed search of the international literature was done for all subjects regarding prehospital trauma management, and the American training systems (ITLS, PHTLS) were studied. The review was followed by a critical evaluation of the reality of on site-care, and the German and American systems were compared. RESULTS: A 2-day course with 6 sessions (accident place and kinetics, trauma investigation, pathologies, resuscitation, practical training, and evaluation) was developed, adapted from the Advanced Trauma Life Support (ATLS) algorithm. Special attention was given to the integration and position of the emergency physician in Germany, as well as to the defined authority of the rescue services. CONCLUSION: Conversion into practice was facilitated by teamwork. The course is free of charge to all rescue services and members of the concept group. With a qualified prehospital system that works smoothly with the ATLS concepts, improved prehospital care for trauma patients seems possible.

[Norian SRS augmentation in revision of acetabular cup of total hip arthroplasty. A follow up of six patients]. / Norian-SRS-Augmentation bei Revision der Hüfttotalendoprothesen-Pfannenkomponente. Eine Nachuntersuchung von 6 Patienten.

This article reports on bony acetabular reconstruction combined with load-bearing cementation of the acetabular components in revision hip arthroplasty. In six cases bone defects were filled with osteoconductive cement Norian SRS--if needed after cancellous bone grafting. Thereupon the primary load stable cementation of an acetabular reconstruction ring or an acetabular basket was done in combination with cementation of an inlay. Patients were examined according to the scores of Harris and Merle d'Aubigné. The patient's satisfaction was used as another criterion and X-rays were taken upon consent. Four of five patients included in the evaluation achieved good or excellent results.

Bone-implant interface shear modulus and ultimate stress in a transcortical rabbit model of open-pore Ti6Al4V implants.

This experimental study on laser-textured implants aimed to evaluate periimplant bone elasticity and ultimate stress of the bone-implant interface in a rabbit femur model. After randomization, two cylindrical Ti6Al4V samples (3.5 mm wide, 5.5 mm long) were transcortically implanted in each femur of 15 female New Zealand White Rabbits. Polished implants had been laser-textured with 100, 200, and 300 microm diameter pores, and another corundum blasted implant was additionally textured with 200 microm pores. Twelve weeks into the experiment, a modified push-out test was performed. The median shear modulus indicating the elasticity of the periimplant bone was 41.12 MPa for the proximal implant location and 25.38 MPa for the distal, without evidence for significant differences between implant types. Taking into account the median ultimate shear stress for 200 microm implants with and without corundum blasting, no significant difference could be demonstrated. However, for blasted 200 microm implants a statistically significant (p<0.025) relative gain in ultimate shear stress of 41% and 17% was proven in comparison with 100 and 300 microm implants, respectively. Non-blasted 200 microm implants reached 48% relative gain in respect of 100 microm samples.

The composite vastus medialis-patellar complex osseomuscular flap as a salvage procedure after complex trauma of the knee--an anatomical study and clinical application.

BACKGROUND: In the setting of severe perigenicular trauma or complicated endoprosthetic knee surgery, primary knee fusion may be the last resort for salvage of the limp. In this case, the patella looses its destination as an anterior knee stabilizer and can become a substantial donor of bone substance, especially if osseous defects are involved. PATIENTS AND METHODS: 12 formalin fixated cadavers were studied in terms of vascular anatomy, pedicle reliability, arc of rotation and their relation to sex, age, and height. Moreover, the operation was performed on a suitable patient. RESULTS: The quadriceps with the vastus medialis and the patella can be raised from the tibial tuberosity up to the entrance of the osteoarticular branch of the superficial femoral artery into the vastus medialis muscle ca 16 cm (15-19 cm) from the inferior patellar pole. This distance correlated well to the overall height of the cadavers (P=0.009). The vascular prerequisites were always present. In the clinical case, there was a favorable outcome with knee fusion after 4 months, despite of the lateral condylar defect. DISCUSSION: The composite vastus medialis-patellar complex osseomuscular flap can be safely used as a source of vascularized femoral condyle substitute in the setting of primary knee fusion.

Influence of pores created by laser superfinishing on osseointegration of titanium alloy implants.

The aim of this study was to assess the osseointegration of copper vapor laser-superfinished titanium alloy (Ti6Al4V) implants with pore sizes of 25, 50, and 200 microm in a rabbit intramedullary model. Control implants were prepared by corundum blasting. Each animal received all four different implants in both femora and humeri. Using static and dynamic histomorphometry, the bone-implant interface and the peri-implant bone tissue were examined 3, 6, and 12 weeks postimplantation. Among the laser-superfinished implants, total bone-implant contact was smallest for the 25-microm pores, and was similar for 50- and 200-microm pore sizes at all time points. However, all laser-superfinished surfaces were inferior to corundum-blasted (CB) control implants in terms of bone-implant contact. Within the 12-week study period, remodeling of woven bone initially formed within pores occurred only in the implants with 200-microm pores. Implants with 25-microm pores showed the highest amount of peri-implant bone volume at all time points, indicating that the amount of peri-implant bone was not correlated with the quality of the bone-implant interface. At 3 and 6 weeks postsurgery, we did not find any differences in mineral apposition rates or bone formation rates between the various implant surfaces. However, the peri-implant bone formation rate at the end of the trial was 70 and 62% higher in implants with 50- and 200-microm pores compared with CB implants, respectively. We conclude that, although laser-superfinished implants were not superior to CB control implants in terms of osseointegration, our study has provided further insights into the mechanisms of bone remodeling within pores of various sizes, and may form a basis for future experiments to design optimal implant surfaces with the help of modern laser technology.

Effect of surface finish on the osseointegration of laser-treated titanium alloy implants.

It was the purpose of this study to examine the osseointegration of laser-textured titanium alloy (Ti6Al4V) implants with pore sizes of 100, 200, and 300 microm, specifically comparing 200-microm implants with polished and corundum-blasted surfaces in a rabbit transcortical model. Using a distal and proximal implantation site in the distal femoral cortex, each animal received all four different implants in both femora. The bone-implant interface and the newly formed bone tissue within the pores and in peri-implant bone tissue were examined 3, 6, and 12 weeks post-implantation by static and dynamic histomorphometry. Here we show that additional surface blasting of laser-textured Ti6Al4V implants with 200-microm pores resulted in a profound improvement in osseointegration, 12 weeks postimplantation. Although lamellar bone formation was found in pores of all sizes, the amount of lamellar bone within pores was linearly related to pore size. In 100-microm pores, bone remodeling occurred with a pronounced time lag relative to larger pores. Implants with 300-microm pores showed a delayed osseointegration compared with 200-microm pores. We conclude that 200 microm may be the optimal pore size for laser-textured Ti6Al4V implants, and that laser treating in combination with surface blasting may be a very interesting technology for the structuring of implant surfaces.

[The biofeedback sole tested is a suitable device for avoiding overload under partial load]. / Kontrollierte Teilbelastung unter Verwendung einer Biofeedbackschuhsohle.

During healing of fractures and after implantation of artificial joints mobilization with partial load is a widespread and well-accepted therapeutic principle. Translating our recommendations into action, however, overtaxes many of the patients. The use of the biofeedback sole tested should guarantee avoiding overload under partial weight-bearing conditions. The distribution of the strain sensors in the biofeedback sole was primarily checked with the help of an established system controlling the distribution of strain (PAROTEC) in 17 voluntary, healthy people. Afterwards the biofeedback sole was connected to a digital recording system to analyze the number of steps overloaded in different test cycles in 50 volunteers while using crutches and performing partial load with 20 kg. The distribution of the strain sensors in the biofeedback sole is correct to control partial load under weight bearing with 20 kg. The permanent use of the biofeedback sole showed highly significant advantages in avoiding overload. The number of steps overloaded was reduced by 77%. This effect is independent from body weight or age.

A low-field MR system in acute traumatological imaging in radiology. Technical note.

PURPOSE: In this paper initial clinical observations with the application of a new low-field MR system in acute musculoskeletal imaging in radiology are presented. MATERIALS AND METHODS: This system is designed as a three-sided open permanent magnet with a revolving table. Main magnetic field strength is 0.2 T, maximal gradient field strength 20 mT/m, and minimal gradient rise time is 800 microseconds. First clinical experiences in 25 patients with acute trauma of peripheral joints were obtained. The following sequences were applied: gradient-echo (GRE) STIR, T1-weighted spin-echo, and PD- and T2-weighted turbo spin-echo. Correlation with the findings of high-field MR (1.5 T), plain radiograms (including stress views), CT or ultrasound was available in each patient confirming the low-field diagnoses. Furthermore, phantom measurements were performed to verify the spatial resolution of the system for some sequences with typical measurement parameters. DISCUSSION: This low-field system has several advantages: fast and economic installation, limited required space, easy operation, and high patient comfort. The medical benefit of such a system integrated in the traumatological suite of a radiological department seems to be evident due to the impact on the early initiation of the correct therapy which avoids additional diagnostic procedures and therefore may reduce costs. Implementation of such a system may be useful, if installation of an additional high-field scanner is not possible due to economic considerations.

[Resection of colorectal liver metastases. What prognostic factors determine patient selection?]. / Resektion colorectaler Lebermetastasen. Welche Prognosefaktoren bestimmen die Patientenselektion?

AIM OF THE STUDY: Based on a consecutive series of patients undergoing liver resection for colorectal metastases, indicators of prognosis and selection criteria were evaluated. PATIENTS AND METHODS: From 1960 to 1998, a total of 654 patients underwent resection of colorectal liver metastases. In 516 patients (78.9%) this was an R0 resection for initial metastatic disease. These patients form the basis for the investigation. RESULTS: 30-day mortality in this group was 5.8%, while the total procedure-related mortality was 8.3%. Significant morbidity was observed in 16% of patients. Follow-up information until 1 January, 2000 was achieved in 99.5% of patients. Including operative mortality, the actuarial 5-, 10-, and 20-year survival is 38 +/- 5%, 27 +/- 6% und 24 +/- 24%, rising to 41 +/- 5%, 29 +/- 6% and 26 +/- 26% after excluding operative deaths. Tumor-free survival is 35 +/- 5% at 5 years. In the multivariate analysis the following factors are associated with decreased crude survival: extrahepatic tumor (P < 0.0001), intraoperative hypotension (P = 0.0001), non-anatomical procedures (P = 0.0002), a metastasis diameter > or = 5 cm (P = 0.0002), unfavourable grading of the primary tumor (P = 0.0003), satellite metastases (P = 0.0069), mesenteric lymph node involvement (P = 0.0260), use of FFP (P = 0.0307) and synchronous diagnosis of metastases (P = 0.1240). With respect to disease-free survival metastasis diameter is first, followed by extrahepatic disease (P < 0.0001 each). Satellite metastases are removed, while the primary tumor site becomes important with inferior results for rectal cancer (P = 0.0188). The other factors remain stable and in the same order. The number of independent tumor nodules as well as the width of resection margin fail to be significant in both univariate and multivariate analysis. CONCLUSION: These results underline the paramount importance of an R0 resection, but diminish the relevance of most commonly used "contraindications". For the actual decision on liver resection, beside the possibility of achieving an R0 situation, safety aspects regarding comorbidity and acceptable extent of parenchyma loss represent the prime limitation.