[Pain assessment in routine care : A prospective observational study in an orthopedic unit]. / Schmerzerfassung in der Routineversorgung : Eine prospektive Beobachtungsstudie auf einer orthopädischen Station.

INTRODUCTION: Although well-established guidelines give advice on how to use analgesics, measure pain, and organize pain treatment, many patients still suffer from avoidable severe pain. We assume one reason for this is that pain is inadequately addressed in routine patient contacts. Thus, we aimed to evaluate the extent to which pain was addressed during patient contacts in routine orthopedic care. MATERIALS AND METHODS: In a prospective observational study in an orthopedic unit of a university hospital, we invited physicians and nurses during their routine patient contacts to be observed by independent, trained monitors. The monitors systematically assessed all pain-related aspects, which were analyzed descriptively afterwards. RESULTS: The monitors documented 572 physician-patient contacts with 7 physicians and 108 patients and 578 nurse-patient contacts with 12 nurses and 102 patients. Physicians and nurses asked their patients about pain in 20 and 16 % of the patient contacts, respectively. While in physician-patient contacts, patients most frequently addressed their current pain situation (in 35 % of contacts), in nurse-patient contacts, patients most frequently addressed their need for analgesics (52 %). Patients rated their pain intensity in 16 % of physician-patient contacts vs. 17 % of nurse-patient contacts. CONCLUSIONS: Using a comprehensive external monitoring procedure, we found that systematic pain assessment was not optimally standardized and implemented for systematic, individualized pain therapy by physicians or nurses in our routine care setting.

[Infections of hip and knee endoprostheses. Spectrum of pathogens and the role of multiresistant bacteria]. / Infektionen von Hüft- und Knieendoprothesen. Erregerspektrum und die Rolle multiresistenter Bakterien.

BACKGROUND: Because of the rise in primary implantations in elective knee and hip arthroplasty, the number of complications, particularly due to prosthetic infections has increased. Partly due to multimorbidities, an increase in geriatric patients and often unnecessary use of antibiotics, a change in the spectrum of bacteria with an increase in multi-drug resistant pathogens is to be expected. For physicians this creates not only new medical and economic but also sociopolitical challenges. QUESTION: Has the spectrum of bacteria in prosthetic joint infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA) changed during the 12-year period 2001-2012 in our hospital and what role do multi-drug resistant bacteria play? INVESTIGATION COLLECTIVE: A total of 320 patients with prosthetic joint infections (PJI) following TKA or THA could be identified and were included in this study. The sample consisted of 172 patients with an infection after THA (56 % females n = 96 and 44 % males n = 76) with a mean age of 70.9 years (range 39-92 years) and 148 patients with an infection after TKA (55 % females n = 82 and 45 % males n = 66) with a mean age of 70.7 years (range 15-87 years). The bacteria detected and the development over the course of time were evaluated. RESULTS: An increase was found in the occurrence of coagulase negative staphylococci (CNS), in particular Staphylococcus epidermidis (2001-2003 n = 10 and 2010-2012 n = 27). The proportion of oxacillin and methicillin-resistant Staphylococcus epidermidis (MRSE) was also found to increase (0 % in 2001-2003 and 74 % in 2010-2012). A substantial increase in methicillin-resistant Staphylococcus aureus (MRSA) infections could not be found and there was a tendency towards reduction in the total number of Staphylococcus aureus infections. A total of five extended spectrum beta-lactamase (ESBL)-producing bacteria were isolated. CONCLUSION: The spectrum of bacteria has only slightly changed over the years from 2001 to 2012, whereby an increase was only found in the number of CNS infections. Multi-drug resistant bacteria, in particular MRSE have increased. The changes in MRSE found in this study do not appear to warrant a general rethinking of antibiotic prophylaxis.

[The impact of capsular repair on the dislocation rate after primary total hip arthroplasty: a retrospective analysis of 1972 cases]. / Der Einfluss der Kapselrekonstruktion auf die Luxationsrate nach primärer Hüftendoprothetik: eine retrospektive Analyse von 1972 Fällen.

BACKGROUND: Dislocation is the second most frequently encountered complication in primary total hip arthroplasty (THA) and occurs more commonly in the early postoperative rehabilitation phase. Sir Charnley recommended the "avoidance of resection of the capsule" and emphasised its contribution to hip joint stability in THA. Several authors, however, doubted its significance and considered resection of the capsule to be essential. Since 2002, some surgeons increasingly adopted a modified, less invasive technique of THA via Bauer approach, including the preservation and repair of the hip joint capsule with focus on maintaining its acetabular origin. Another group of surgeons applied the traditional technique including the resection of the joint capsule via an anterolateral approach. In this case-control study we investigated whether the dislocation rate can be reduced through joint capsule reconstruction and whether any negative impact on patient satisfaction, functional results or revision rate is observed. MATERIAL AND METHODS: All cases of primary THA performed in our institution in a timeframe between 2002 and 2009 were included with the only exceptions of resurfacing arthroplasty, dual mobility and tumour hip replacements. Joint capsule repair cases were gathered in the study group (SG), capsule resection cases in the control group (CG). Additional patient-related data were taken from the anaesthesia records. The WOMAC score and a questionnaire focusing on detection of dislocations and revision surgeries was sent out for each case. Further targeted research was conducted that included requesting records and reports from external hospitals. In the case of non-responding patients, all available data (operating room documentation, electronic files, archive, X-rays) were reviewed for incidents of dislocation and revision surgery. Groupings and classifications were exclusively performed by senior surgeons. SG and CG were compared regarding epidemiologic, implant-associated and surgery-specific data. Statistical evaluations were performed using the Chi-squared test and the Mann-Whitney U test. RESULTS: 1972 cases of primary THA were included: 992 in the SG and 980 in the CG. The follow-up rates were 92.7 % in the SG and 76.4 % in the CG, the mean follow-up times 33.5 months and 73.4 months, respectively, with a follow-up of at least 12 months in all cases. In the SG, the dislocation rate was 0.3 % (n = 3) and thus significantly lower than the 2.55 % in the CG (n = 25, p < 0.001). Both the WOMAC score (SG: 1.46 ± 1.73; CG: 1.53 ± 1.80; p > 0.05) and the revision rate (SG: 5.24 %; CG: 6.84 %; p = 0.139) showed no significant differences. CONCLUSION: Preservation and repair of the hip joint capsule causes an 88-%-reduction of the dislocation rate in primary THA in this large series including 1972 cases, operated via the Bauer or the anterolateral approach. Several authors reported comparable results after THA using similar techniques of soft tissue and capsular repair through the posterior or posterolateral approach. Sparing and reconstructing the hip joint capsule therefore seems to reduce the dislocation rate after primary THA by one order of magnitude regardless of the surgical approach and, especially, if the acetabular origin is preserved. Capsule-related specific complications such as an increased revision rate, malfunction or pain were neither recorded in our study nor by others. Thus, careful preservation and reconstruction of the hip joint capsule may be expressly recommended in primary THA.

[Correction of pronounced plagiocephaly with orthosis : results of a prospective follow-up control]. / Korrektur der ausgeprägten Plagiozephalie mittels Orthese : Ergebnisse einer prospektiven Verlaufskontrolle.

For the treatment of pronounced deformational plagiocephaly in infants different therapeutic options are under discussion in the literature. This article presents a prospective observational study of 45 infants enrolled with distinct plagiocephaly and treated with a custom-made helmet orthosis. Treatment with the helmet orthosis was indicated by a difference in the skull diagonals of more than 0.5 cm or a cranial vault asymmetry (CVA) index > 3.5. The follow-up results were controlled with the help of a mobile spatial laser scanner and the CVA index and the skull deformity were measured. The average duration of treatment was 131 days. The CVA index improved from 9.95 to a normal value of 3.35 (median) and the skull deformity improved from 1.3 cm to 0.5 cm (median). The only side effects observed were easily treatable pressure marks. The results of this study reveal that pronounced deformational plagiocephaly can be successfully treated with a custom-made helmet orthosis and closely controlled monitoring.

[Acute hip pseudoparalysis with calcific tendinitis at the insertion of the psoas muscle. Case report and first description of an atypical location]. / Akute Pseudoparalyse der Hüfte bei Tendinitis calcarea der Psoassehne. Falldarstellung und Erstbeschreibung einer ungewöhnlichen Lokalisation.

Calcific tendinitis is a common and widespread disease. It is most common in the rotator cuff especially in the supraspinatus tendon. In some cases it may also involve other locations such as the hips, particularly at the trochanter minor. In particular calcific tendinitis of the iliopsoas muscle tendon has not yet been described. Because of uncharacteristic symptoms and ambiguous diagnostic imaging the differentiation between traumatic, infectious and neoplastic genesis is often difficult. Because of artefacts the typical calcareous spots near the insertions are often underdiagnosed in conventional diagnostic x-ray images. In this case report the differentiation from an infection of the hip was only possible with positron emission tomography computed tomography (PET-CT) imaging and negative microbiological testing of an aspirate. There are various therapy options, such as systemic and local medication, extracorporeal shock wave therapy up to surgery. However, calcific tendinitis is a self-limiting tendinopathy that can be treated with conservative therapy to complete remission in most cases.

The short stem GHEs in total hip replacement - experience after 380 implantations.

INTRODUCTION: Standard straight stems have been recognized as a gold standard implant in the field of hip replacement surgery. However, lately uncemented bone-preserving short stems started to gain more and more popularity. This was reflected in the increasing variety of available models. Up till now, short and mid-term results are available. PATIENTS AND METHODS: In 2002, the cementless short stemmed GHEs was introduced. 380 patients were included in our study between 2002 and 2008. Only GHEs short stems were implanted. The clinical and radiological evaluations were performed in the Orthopaedic Department, Leipzig University Hospitals, on the average of 24 months (3 to 60 months) postoperatively. RESULTS: 365 primary implantations and 15 revision implantations were carried out. Average age 60 years. Favourable clinical and radiological outcome was seen in 361/380 patients (95%). Postoperative complications were seen in 19/380 patients (5%): 8 fissures/fractures (2.1%), 5 infections (1.3%), 4 aseptic loosenings (1.1%), 2 dislocations (0.5%). CONCLUSIONS: Short stem implants, including our own experience with GHEs model, are satisfying and promising. They represent a valuable supplementation of the treatment modalities in hip replacement surgery. However, long term results are still awaited.

[Multilocular Paget's disease in IBMPFD syndrome. A case report with 14-year follow-up]. / Multilokulärer Morbus Paget bei IBMPFD-Syndrom. Darstellung eines Krankheitsverlaufes über 14 Jahre.

Paget's osteodystrophia deformans is a monoostotic or polyostotic disease of the skeletal system with increased bone remodelling, structural modifications and skeletal deformation, typically arranged like a chessboard. The unusual case of a patient is described who had suffered from generalized Paget's disease of the bone for 14 years and also developed progressive myopathy and a behavioural variant frontotemporal dementia. Further cytogenetic diagnostics revealed a point mutation in the valosin-containing protein (VCP, p97) gene on chromosome 9p13-p12 consistent with the finding of inclusion body myopathy with early onset Paget's disease and frontotemporal dementia (IBMPFD syndrome). A causal therapy of this disease is not known. Conservative treatment with bisphosphonate therapy, intensive physiotherapeutic exercise and psychotherapeutic treatment was performed to retard the progression of the disease.

[Nora's lesion. Discussion of a rare bone proliferation]. / Die Nora-Läsion. Diskussion einer seltenen Knochenproliferation.

Nora's lesion, also known as "bizarre parosteal osteochondromatous proliferation" (BPOP), was first described in 1983 by the pathologist Nora. This lesion is defined as a proliferation of the bone. In most cases the lesion emanates from the intact cortical substance of short bones. It used to be assigned to reactive, heterotopic ossifications. More recent publications described constant genetic alterations supposing a tumorous genesis. Nora lesions are mostly found in the third or fourth decade of life; a preference of sexes is not described in the literature. They are characterized by a typical appearance in radiological diagnostics, but the diagnosis is ultimately determined by histopathological examination. Surgical resection is the therapy of choice.We report the case of a 29-year-old patient with an undetermined proliferation of the proximal ulna. The diagnosis of a Nora's lesion was made. The therapeutic approach, differential diagnosis and corresponding literature are presented and discussed.

[The modular endoprosthetic system Munich-Luebeck (MML): potential applications and results in the lower extremities]. / Modulares Endoprothesensystem München-Lübeck (MML) : Anwendungsmöglichkeiten und Ergebnisse an den unteren Extremitäten.

The modular endoprosthetic system Munich-Luebeck (MML) has been in clinical use since 1994. A total of 2.118 pelvic and lower extremity surgeries using the MML system were carried out up until 2010. The modular construction allows substituting or bridging any kind of bone defect. We analyzed 572 operative interventions, which were performed in 5 centers. The most frequent indications were tumors (50.3%) followed by revision arthroplasty due to loosening, periprosthetic fractures, and joint resection surgery due to infection (43.3%). Proximal and distal femoral replacement amounted to 78% of cases, whereas partial pelvic replacement accounted for 10.4% of the cases. Complications were reported in 27.27% of the cases, where dislocations (14.9% of the cases with simultaneous hip replacement) and infections (10.48%) were the most common, as expected. Revision surgery was necessary in 140 (24.8%) of the 572 patients, of which 68 were partial or total replacement of the implants, 16 removal of the implants and 10 above-knee amputations or rather exarticulations of the hip.

[Sport-medical aspects concerning Asian martial arts Aikidô and Ving Tsun]. / Sportmedizinische Aspekte bei den asiatischen Kampfkünsten Aikidô und Ving Tsun.

INTRODUCTION: Asian martial arts became very popular in Germany during the last years, nevertheless there are only few clinical inquiries concerning sportorthopaedic or -traumatological aspects. In this study we analyzed the risk and the prevalence of sport-injuries and sport-damages in Aikidô and Ving Tsun. METHODS: 19 Aicidôca and 24 Ving Tsun athletes were to undergo broad survey and sport-orthopedic inspection. In this process an especially adapted examination-sheet after Baumann was used. RESULTS: 68.4 % of the Aikidoca and 79.2 % of the Ving Tsun athletes reported injuries, whereupon soft injuries dominated, severe injuries like luxations, ligamental und muscular ruptures appeared infrequently, the incidence of fractures was 1 % resp. 0.2 %. 37 % resp. 33.3 % of all injuries where related to the lower limb, 14.8 % resp. 16.7 % to the head and neck. Disorders dominated with 60 % resp. 50 % in the range of the knees. Persistent sport-damages could not be found in the clinical examinations. CONCLUSION: There is even just a low risk for severe sport-injuries and sport-damages while intensely practicing martial arts Aikidô and Ving Tsun for years. In the range of prevention the consequent use of protective gear (specificly bump cap and footwear) is important.

[Pitfalls and difficulties in interpretation of bone densitometry]. / Fehlermöglichkeiten und Interpretationsprobleme der Osteodensitometrie.

The clinical relevance of osteoporosis as a frequent systemic skeletal disease is to be found in fractures and their consequences. For prevention of these disease manifestations great importance must be attached to a safest possible diagnosis even before the occurrence of the first fracture and osteodensitometry is a well established technique for this purpose. Among the different measurement procedures DXA (dual-energy X-ray absorptiometry) has become the gold standard worldwide. This method is seen as very reliable and adequately precise. Prerequisites for these characteristics are the correct interpretation of the measurement data obtained by taking into consideration all potential influencing factors which can either false positively or false negatively influence a single value as well as the calculated mean value and the T and Z scores. Thus, exact knowledge of potential sources of error is of crucial importance. The present study shows important sources of error and difficulties in interpretation as well as a discussion of the options for their prevention. For the clinical practice osteodensitometry is to be seen as an important diagnostic component, which can only been interpreted meaningfully with respect to the clinical data.

[The significance of the acetabular labrum for hip joint stability--an experimental study]. / Die Bedeutung des Labrum acetabulare für die Hüftstabilität--eine experimentelle Studie.

AIM: Aim of our study was to create artificial labra for joint models of different diameters (28, 32 and 36 mm) and to measure their stability potential at rest (SPR). The experiment was performed under the same conditions as a previous one with capsulated joint models. Our target was to prove the hip stabilising effect of the atmospheric pressure (AP) as well as the parameters for joint stability and to test the function of the artificial labra. METHOD: Uncapsulated joint models having 28 (A), 32 (B) and 36 (C) mm diameters were sealed with moulded preformed silicone labra. An increasing traction force was applied under water on the fixed joint. Using specially designed software, the exerted force and the dislocation distance were simultaneously and continuously recorded on a computer. The SPR of the examined joint models was calculated as the difference between the maximal exerted force and the weight of the ball-neck component. RESULTS: Statistical analyses showed that SPR had mean values of 58.12 +/- 2.23 N for the 28 mm joint model (n = 118; A), 75.66 +/- 2.75 N for the 32 mm model (n = 88; B) and 99.91 +/- 1.30 N for the 36 mm model (n = 82; C). CONCLUSION: The traction force required for dislocation agreed closely to the expected precalculated SPR values of 58.6 N (A), 76.4 N (B) and 96.7 N (C), which proves the joint stabilising effect of AP in the presence of the essential prerequisites (spherical ball articulating in a hemispherical socket, hermetically closed joint capsule and/or labrum, which contains a small amount of fluid and excludes air). The measured SPR was directly proportional to the square of the joint diameter. Indirectly, it was concluded that the dislocation work at rest is directly proportional to the joint diameter cubed. Consequently, the risk of dislocation after total hip arthroplasty (THA) can be reduced by applying bigger, size-adapted hip balls, whose diameter grows according to the outer diameter of the cup. The increasing range of motion is a favourable side-effect. With careful reconstruction of the capsule and insertion of an intracapsular drain, the risk of dislocation in the early postoperative period could be furtherly reduced. Theoretically, artificial labra could be a useful alternative to augment joint stability in THA with a high dislocation tendency instead of constrained liners.

[Painful enlargement of the 2nd toe due to an osteoid osteoma in the distal phalanx]. / Schmerzhafte Hypertrophie der zweiten Zehe infolge Osteoidosteom des Endgliedes.

The rare case of an osteoid osteoma in the distal phalanx of the 2nd toe resulting in painful enlargement and hypertrophy of the entire toe in a 12-year-old girl is discussed. The tumour was excised and the oversize of the toe was corrected by exarticulation of the distal phalanx. 18 months postoperatively the patient demonstrates normal function of her forefoot without complaints or signs of inflammation.

[Metastatic malignant choroidal melanoma: a case report about 18 years with palliative operative treatment]. / Metastasierendes malignes Aderhautmelanom: Einzelfalldarstellung eines protrahierten Verlaufs über 18 Jahre durch palliative operative Therapie.

Bone metastases are found in 29% of patients with metastatic malignant choroidal melanoma, which is associated with poor prognosis. However there are several reports about prolonged survival. The unusual case of a patient is described, who suffered from a melanoma with orbital invasion and survived more than 18 years. Metastases were found 12 years after initial therapy. Three palliative operations made a survival of further 7 years with high quality of life possible. Therefore moderately palliative operations are recommended in case of metastatic malignant choroidal melanoma.

[Operative treatment of an expansive enchondroma of the distal phalanx of the thumb]. / Operative Therapie beim expansiven Enchondrom der Daumenendphalanx.

Enchondroma is the second most common benign bone tumour and the most common tumour affecting the bones of the hand. In the hand, they are most frequently found in the proximal phalanges. The case presented here is that of an expansive enchondroma in the distal phalanx of the thumb, which is rare. By operative treatment (curettage, reduction plastic and cancellous bone allografting) we were able to correct the deformity of the distal phalanx and the thumbnail almost completely, as well as improving the stability and achieving a good cosmetic result.

[The stabilizing effect of atmospheric pressure (AP) on hip joint subject to traction force--an experimental study]. / Die stabilisierende Wirkung des atmosphärischen Druckes auf das Hüftgelenk bei Einwirkung einer Zugkraft--eine experimentelle Studie.

AIM: We aimed to prove the stabilising effect of atmospheric pressure (AP) on the hip joint experimentally. METHOD: In the experiment, model joints of 28 mm, 32 mm und 36 mm diameter were subjected to increasing traction force. The acting force and the resulting dislocation distance were measured both with the capsule hermetically sealed, as well as with the capsula open. RESULTS: For the hermetically sealed capsule we measured maximum resistances of 7.6 kp for the 28 mm joint, 10.4 kp for the 32 mm joint and 12.4 kp for the 36 mm joint. With the capsule open we found resistances from 0.4 kp to 1 kp. Our experimental results exceeded the predicted resistances of 6 kp, 7.8 kp and 9.9 kp. Increased amounts of synovial fluid reduced the stability. CONCLUSION: Our measurements confirm the continual stabilising effect of AP on the hip joint, which can be quantified as the resting potential of stability (RPS) or luxation work (LW). The RPS is calculated by multiplying the difference of AP and saturated vapour pressure of synovial fluid with the cross-sectional area of the femoral head. It represents the force, necessary for luxation of the joint against the resistance of AP. The RPS is proportional to the square of the joint diameter. The LW, calculated by multiplying RPS with the luxation distance, is proportional to the joint diameter cubed. That is why a small increase of joint diameter leads to a significant increase of stability, while the rate of the increase of range-of-motion decreases. To achieve stability of a total hip arthroplasty the size of the joint components should depend on the size of the resected femoral head. Also the hermetically sealed capsule should be reconstructed carefully.

[Short-stemmed endoprostheses in total hip arthroplasty]. / Kurzschäfte in der Hüftendoprothetik.

Short-stemmed endoprostheses in total hip arthroplasty are anchored exclusively in the metaphysis and the proximal part of the diaphysis. Therefore, they are much shorter than the classic standard stems. These implants are specially favourable in terms of eventual revision surgery, and also due to the fact that with close diaphyseal bone marrow spaces a sufficient proximal size dimensioning is possible. In this study, the best known short-stemmed systems in clinical use are introduced. Positive long-term results are so far available only with the Pipino and Mayo stems, short and partially medium-term experience with the remaining short stems (C.F.P.(R), Metha, PROXIMA, ESKA) are--with the available learning curve--encouraging. Despite the call for sufficient experience and scientific evaluation, short-stemmed endoprostheses already represent a valuable alternative in endoprosthetics for younger patients.

[Extragenital endometriosis leading to piriformis syndrome]. / Piriformissyndrom infolge einer extragenitalen Endometriose.

We report on a 44-year-old woman with a history of sciatica fluctuating with her menstrual cycle and going back over 10 years; ultimately it was present continuously and became disabling. Over the years the patient developed ipsilateral foot-drop, a sensory disorder in the lateral aspect of the lower limb and back of the foot, and atrophy of the gluteus muscle. MRI confirmed the suspicion of extragenital endometriosis, which had caused piriformis syndrome by compression with consequent damage to the sciatic and inferior gluteal nerves. After hormonal therapy had been tried without success, the endometrioma was excised to relieve the pressure on the nerves, and the diagnosis was confirmed histopathologically. The motor deficit remained up to the 15 months since surgery, but the patient is now free of pain.

[Retransfusion of unwashed drainage blood after total hip and knee arthroplasty]. / Retransfusion ungewaschenen Drainageblutes nach Hüft- und Knieendoprothesenimplantationen.

The method of retransfusion of drainage blood as known from the literature was investigated in a prospectiv study regarding effectivness and rate of side effects. 200 patients who underwent total hip and knee arthroplasty were investigated concerning hemoglobin, hematocrit, amount and quality of the retransfused drainage blood, the amount of autologous and homologous transfusions as well as complications and costs. 100 of these patients were selected as the control group. The amount of the retransfused drainage blood after hip arthroplasty amounted an average of 387 +/- 194 ml and after knee arthroplasty 595 +/- 250 ml. The retransfused blood had an average hemoglobin of 5,2 +/- 0,9mmol/l with a hematocrit of 0,24 0,05. No complications directly associated to the retransfusion were found. The need of transfusion was reduced for patients with knee arthroplasty about 30% and for hip arthroplasty about 25%. The retransfusion of unwashed drainage blood is a sufficient method to reduce perioperative homologous blood transfusion in patients with arthroplasty of hip and knee. Substantial complications were not observed, so that this method seems to be save enough for clinical usage. The method is easy to handle and usable without special technical devices. The autologous retransfusion of drainage blood can contribute to lower costs in patients treatement.