Three-dimensional acetabular orientation during periacetabular osteotomy: a video analysis of acetabular rim position using an external fixator as navigation tool during reorientation procedure.

INTRODUCTION: Bernese periacetabular osteotomy is an effective procedure for treating acetabular dysplasia. However, limited visual control of the acetabular position during surgery may result in under- or overcorrection with residual dysplasia or femoroacetabular impingement. Thus, we wanted to find a simple method to control the effect of correction in the sagittal and coronal plane. METHOD: The acetabular coordinates are shown by two perpendicular tubes of an external fixator mounted onto a third tube that is fixed to the acetabular fragment with two Schanz screws. This method enables the isolated acetabular reorientation in the coronal, sagittal, and transverse plane. In a sawbone pelvis model, the acetabular rim is marked with a copper wire and a silicon adherent. To show the radiographic effect on acetabular parameters and the rim position, we visualized correction in the coronal and sagittal plane under fluoroscopic control. RESULTS: Lateral rotation of the acetabular fragment had the highest impact on radiographic lateral coverage of the femoral head. But also ventral coverage increased during isolated lateral rotation. Anterior rotation showed almost no effect on lateral coverage and just a little effect on ventral coverage but caused severe total acetabular retroversion. CONCLUSION: Three-dimensional control of the acetabular orientation during periacetabular osteotomy is important to avoid over- and under-correction. Isolated lateral rotation of the acetabular fragment should be the predominant direction of correction during periacetabular osteotomy. Ambitious anterior correction may be the main source for severe acetabular retroversion following periacetabular osteotomy.

Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios.

INTRODUCTION: In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. METHODS: Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°. RESULTS: No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. CONCLUSION: The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Operative therapy for rheumatoid arthritis of the hand]. / Operative Therapie bei rheumatoider Arthritis der Hand.

The need for operative treatment of severe rheumatic deformities of the hand and wrist is decreasing due to the increased use of disease-modifying drugs; however, some patients do not tolerate or do not sufficiently respond to these drugs, which often results in the hands being affected and in advanced stages to severe deformity and loss of function. In these cases operative surgery can help to slow the progression of rheumatic destruction and restore the function of the patient's hand. This article describes the principles of surgery for rheumatoid arthritis of the hand. A meticulous synovectomy or tenosynovectomy is the first stage of treatment. With progression of rheumatic destruction various salvage procedures are necessary to preserve the best possible functional state.

[Operative treatment of the rheumatic shoulder]. / Operative Therapie der rheumatischen Schulter.

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

[Wrist arthroscopy : challenging procedure of modern hand surgery]. / Handgelenksarthroskopie : Herausforderndes Verfahren der modernen Handchirurgie.

Arthroscopy of the wrist has developed in the shadow of arthroscopy of the large joints. Nowadays, wrist arthroscopy has a relevant importance in the diagnostics and therapy in hand surgery and is indispensable for serious surgery of the wrist. Special equipment and extensive knowledge of the surgeon are necessary for carrying out the procedure.

[Operative joint-preserving therapy of gonarthrosis]. / Operative gelenkerhaltende Therapie der Gonarthrose.

The guiding principle of operative joint-preserving therapy of gonarthrosis is the search for a safe, minimally invasive, efficient and ultimately reasonably priced therapeutic procedure to preserve or restore joint integrity. A comprehensive analysis and treatment of pathologies adjacent to and distant (axis deviations) from the joint are prerequisites for success of treatment. A comparison of results from the current literature with respect to the operative treatment of arthritis is limited due to the divergence of indications, terminologies used, techniques of the therapeutic procedure, inhomogeneity of patient collectives and the different follow-up and control schemes (scores). Conclusive, prospective, randomized double blind studies with large case numbers are associated with a high degree of organizational effort in planning, patient recruitment and execution and remain a rarity. Long-term prognosis depends on the stage of arthritis at the time of the arthroscopic intervention. Operative measures, such as correction osteotomy can be effective in the early stages. A short duration of symptoms, mechanical blocking and low-grade cartilage damage are factors which have a favorable prognosis. Cell-based cartilage repair techniques can reduce secondary degenerative alterations only in cases of local cartilage damage representing a prearthritic condition. Advantages of autologous chondrocyte transplantation compared to microfracturing have been found depending on the size of the defect and the follow-up time period. Furthermore, preservation and replacement of primary knee stabilizers, such as the anterior cruciate ligament and meniscus, have an important function for secondary prevention. A one-for-all therapy for joint-preserving operative treatment of gonarthrosis is lacking.

Proximal interphalangeal joint replacement with an unconstrained pyrocarbon prosthesis (Ascension(R)): a long-term follow-up.

There have been limited publications that report long-term outcomes of pyrocarbon implants. This report describes both clinical and radiographic long-term results for patients who have been treated with pyrocarbon proximal interphalangeal implants. Thirteen implants in ten patients are reported for an average follow-up of 8.3 years (range 6.2-9.3). All patients were suffering from degenerative joint disease. Five of the 13 digits were free of pain, the remaining eight digits had mild to moderate pain (visual analogue scale 2-5). The average active range of motion was 58° (SD 19°) at latest examination. X-ray results were unremarkable in six digits with an acceptable position of the prosthesis. However, in seven patients significant radiolucent lines (≥ 1 mm) were observed. Three prostheses demonstrated a migration of the proximal component, and one a subsidence of the distal component. Our study does not support the use of this implant for treatment of osteoarthritis of the finger joint owing to high complication rates and limited range of motion.

[Radiological findings, evaluation and treatment of patellofemoral pain after total knee arthroplasty]. / Radiologische Diagnostik, Beurteilung und Behandlung des patellofemoralen Schmerzes nach primärer Knieendoprothetik.

Total knee arthroplasty (TKA) is one of the most successful operative procedures over the last decades in orthopedic surgery; however, some patients suffer from pain, limited range of motion, instability, infections or other complications postoperatively. Patellofemoral pain (PFP) in particular is a common problem after TKA and often necessitates revision surgery. Mainly increasing and localized contact pressure and patella maltracking are held responsible for PFP but the reasons vary. Diagnostics and therapy of PFP is not easy to manage and should be treated following a clinical pathway. The authors suggest that patients with PFP should be categorized after basic diagnostic measures according to the suspected diagnosis: (1) tendinosis, (2) mechanical reasons, (3) intra-articular non-mechanical reasons and (4) neurogenic/psychiatric reasons. Efficient application of special diagnostic measures and further therapy is facilitated by this classification.

[Postoperative treatment strategies after rheumatic orthopedic operations of the shoulder. A suggestion]. / Nachbehandlungsstrategien nach rheumaorthopädischen Operationen an der Schulter. Ein Vorschlag.

Although surgical treatment of rheumatoid patients is quite common for disorders of the shoulder, less is known about the efficacy of the postoperative regimens. Clear therapeutic standards are still missing; however, without systematic and intensive postoperative physical therapy, a good postoperative outcome cannot be achieved. This article shows our postoperative treatment regimens and describes our preferred techniques in physical therapy.

[Orthopedic operations and postoperative treatment of rheumatic elbows]. / Orthopädische Operationen und Nachbehandlungsregimes am rheumatischen Ellenbogen.

This article gives an overview of the indications for operative treatment and the respective post-treatment of rheumatic elbows. The goal should be to preserve the function of the elbow joint and freedom from symptoms to prevent joint destruction which unfortunately can still be seen nowadays.

[The role of hyperlaxity in open stabilisation of post-traumatic shoulder instability]. / Der Einfluss der Hyperlaxität auf die Ergebnisse offener Stabilisierungsoperationen bei posttraumatischen Schulterinstabilitäten.

BACKGROUND: Chronic post-traumatic shoulder instabilities as well as post-traumatic shoulder instabilities in association with joint laxity are accepted reasons for open capsular shift and labral refixation. However, it remains unclear whether hyperlaxity influences clinical outcome and reluxation rates. MATERIAL AND METHOD: A total of 60 patients (48 men and 12 women) with diagnosed post-traumatic anterior glenohumeral instability were included in the study. Average follow-up was 3.6 ± 0.2 years (median 3.1 years, minimum 2 years, maximum 8 years). 37 patients (61 %) had a joint hyperlaxity grade II or more. In 77 % of the cases glenoid osseus defects were observed (< 20 % of the glenoid fossa). RESULTS: Three cases of shoulder dislocations (5 %) recurred after surgery, following a massive trauma during sports activities. One patient was excluded from the study due to other reasons. The average Rowe scores were 88.7 points. No significant differences were observed between patients with and without concomitant hyperlaxity. From 56 patients without postoperative redislocations 55.2 % had a very good, 34 % a good, and 10.3 % a satisfactory result (Rowe score). The relative constant score and force measurement values were significantly lower in hyperlax shoulders. The average loss of external rotation was 3.9 degrees with the arm at the side and 11 degrees with the arm in 90 degrees of abduction. CONCLUSION: Our study shows that hyperlaxity does not lead to a higher redislocation rate following open anatomic refixation of the capsule-labrum complex in combination with a capsular shift.

[Mid-term outcome after implantation of a pyrocarbon endoprosthesis in patients with degenerative arthritis]. / Mittelfristige Ergebnisse nach Implantation einer Pyrocarbonprothese bei Fingermittelgelenksarthrose.

AIM: The aim of this study was to make a mid-term evaluation of an unconstrained pyrocarbon prosthesis (Ascension®) in the treatment of idiopathic degenerative arthritis of the proximal interphalangeal joint of the hand. METHOD: 13 implants (10 patients) were clinically and radiologically studied after a follow-up period of 71 months (range: 48-92 months). RESULTS: The average ROM was 52° (± 27°STD). A luxation of the components did not occur and all implants are still in-situ. However, X-ray examination was unremarkable in only six fingers. In seven patients significant radiolucent lines (≥ 1 mm) were detected. Three prosthesis demonstrated axial subsidence and in one patient a loosening of the proximal component with axial rotation was observed. CONCLUSION: The results of this study show a high complication rate after an average of 6 years after implantation. Radiolucent lines in half of the cases may be explained by a lack of osteointegration of the prosthesis. The average ROM differs significantly from patient to patient, which has to be taken into account when discussing different treatment options.

[Arthroplasty for rheumatic elbow joints]. / Endoprothetik des Rheumatischen Ellenbogengelenks.

Without proper treatment rheumatoid arthritis can lead to pain, instability and destruction of the elbow joint. As with artificial knee replacement various designs are available and in general non-constrained and semi-constrained designs are preferred. Fully constrained designs should be avoided due to high loosening rates. Results have shown a significant pain reduction, however, a restricted range of motion has to be expected. Restrictions in load-bearing and mobility are among the major problems after elbow arthroplasty in patients with rheumatoid arthritis which have to be discussed with the patient before surgery. Future studies will have to evaluate the effectiveness of new modular designs.

[Littler tenodesis for correction of swan neck deformity in rheumatoid arthritis]. / Die Littler-Tenodese zur Behandlung der Schwanenhalsdeformität bei rheumatoider Arthritis.

PURPOSE: The aim of this study was to assess the results of operative treatment for rheumatoid swan neck deformity using Littler's technique consisting in the reconstruction of the oblique retinacular ligament. PATIENTS AND METHOD: From 2004 to 2007 twenty rheumatoid patients with 30 PIP-joints affected by swan neck deformity underwent surgical correction. In all cases the tenodesis described by Littler was used. Modification of the operative procedure because of insufficiency of the Cleland ligament or the A2-pulley was in no case necessary. Twenty six PIP-joints in 17 patients could be examined after an average follow-up of 22 months. In two PIP-joints the deformity was contract and in 12 PIP-joints partially contract. In 10 joints a dorsal arthrolysis had to be performed and in one a lengthening of the central slip. All PIP-joints were transfixed in 30 degrees flexion. After 6 weeks the transfixing wire was removed and active PIP- joint mobilisation was allowed. Active extension was limited to 20 degrees of flexion until the end of the 12 (th) postoperative week. During this time an extension blocking splint was used. After the 12 (th) week free active and passive mobilisation of the PIP-joint was allowed. In a retrospective study pre- and postoperative range of motion, X-ray findings, pain and patient's content were examined. RESULTS: Swan neck deformity was corrected in all cases. Preoperative hyperextension of 21 degrees on average was corrected to 24 degrees of flexion. Thereby the ROM of 48 degrees was shifted from the extension sector to a ROM of 51 degrees towards the flexion sector. Recurrence of the deformity or complications were not noted. Pain could be reduced except in one patient. Radiologic changes were classified Larsen grade 2.2 before and 2.3 after operation. CONCLUSION: With the oblique retinacular ligament repair described by Littler reliable results can be achieved in rheumatoid swan neck deformity. It is indicated in contract and non-contract rheumatoid swan neck deformity when th PIP-joints are radiologically in a stage of less than Larsen grade 3. It corrects the deformity at the level of the PIP-joint as well as the DIP-joint.

[Mid-term results after scaphoid excision and four-corner wrist arthrodesis using K-wires for advanced carpal collapse]. / Mittelfristige Ergebnisse nach Skaphoidresektion und mediokarpaler Teilarthrodese unter Verwendung von K-Drähten bei fortgeschrittenem karpalen Kollaps.

AIM: Successful four-corner fusion after scaphoid excision provides pain relief und preserves an acceptable movability of the wrist. However, this treatment option for advanced carpal collapse is not without complications, such as malunion, hardware impingement or incomplete correction of lunate extension. K-wires, staples, Herbert screws or, recently, locking plates are all possible fixation techniques after scaphoid excision. Only a few studies including mid-term results using K-wires are available. The aim of our study was to evaluate clinical and radiological mid-term results after scaphoid excision and four-corner arthrodesis using K-wires for stage II and III scapholunate and scaphoid non-union advanced collapse. METHOD: Twelve wrists of 11 patients (4/SNAC II degrees, 3/SNAC III degrees, 0/SLAC II degrees, 5/SLAC III degrees) were treated operatively by scaphoid excision and four-corner arthrodesis. Four K-wires were used for osteosynthesis. After an average follow-up of 60.25 months, reexamination included subjective, objective and radiological values. Clinical examinations covered wrist motion, grip strength and pinch strength. These parameters were compared with preoperatively collected data and values of the unaffected side. The DASH score (disabilities of the arm, shoulder and hand), Cooney score and the visual analogue scale (VAS 0-10) were analysed. Radiographic assessment of consolidation was verified by conventional X-rays. The carpal height was compared to the preoperative value by assessing the Youm index. RESULTS: All patients were satisfied, pain relief was reported and displayed on VAS from 7.4 (5-10) to 1.4 (0-5). The mean flexion-extension arc of 76.3 +/- 28.8 degrees (59.7% of the opposite wrist), preoperatively 75 +/- 17.3 degrees, was documented. The average total arc of ulnar and radial deviation was 37.5 +/- 9.2 degrees (51% of the opposite wrist). The preoperative value was 33.5 +/- 9.8 degrees. Further clinical evaluation yielded a mean grip strength of 39.3 kp (89.5% of the anaffected side) and pinch strength of 7.6 kp (81.7%). Total DASH score and Cooney score averaged 15 and 74.17 points, respectively. Osseus consolidation was observed radiologically in all patients already after 6 weeks. The Youm index decreased from 0.55 +/- 0.054 to 0.51 +/- 0.057. The radiolunate joint space remained unaltered in height. There were no infections. Except for wire removal, no additional surgery was necessary. CONCLUSION: Scaphoid excision and four-corner arthrodesis for advanced collapse of the wrist enjoy great satisfaction by the patients, with a high degree of pain reduction. This method shows persistent strength and movability in mid-term-results. Compared to alternative fixation techniques, the use of K-wires is a low-risk and low-cost treatment option, although removal of the K-wires is commonly necessary.

[Examination of the painful wrist]. / Diagnostik des schmerzhaften Handgelenks.

The anatomy of the wrist is complex. Mechanical, neurological or systemic causes are responsible for a painful wrist. In many cases a specific diagnosis can already be made by taking a precise medical history. Physical examination includes inspection, palpation of landmarks and a dynamic examination in regard to joint regions. Plane X-Ray examinations are the basic tools in diagnostic imaging. Additional radiographic adjustments, ultrasound-, MRI- and CT-examinations may lead to more detailed information in special cases. A diagnostic arthroscopy is accomplished, if a pathological cause for wrist-pain with non-invasive methods cannot be found.

[Emergency open surgical treatment of extravasations of cytostatic agents in the upper extremity]. / Sofortige offene chirurgische Behandlung von Zytostatika-Paravasaten der oberen Extremität.

Extravasations of cytostatic agents can create necrosis of soft tissues in the hand and forearm. The early emergency subcutaneous "wash-out" with liposuction is the treatment of choice to avoid the development of soft-tissue defects. The objective of this study was to evaluate the open surgical debridement as a possible alternative method since the liposuction device is not commonly available in every hospital. In our study 10 patients were treated for extravasations of cytostatic drugs with a high potential for necrosis by emergency open debridement. All patients were evaluated prospectively by photography and clinical examination. 9 patients out of ten had a primary wound healing, one displayed a wound dehiscence with pre-existing MRSA infection. Another patient developed a seroma postoperatively which was treated by puncture. The mean functional outcome was good. The Eemergency open surgical treatment is a simple, in every hospital suitable therapy to prevent soft-tissue necrosis after extravasation of cytostatic drugs.

[Examination of the painful wrist]. / Diagnostik des schmerzhaften Handgelenks.

The anatomy of the wrist is complex. Mechanical, neurological or systemic causes are responsible for a painful wrist. In many cases a specific diagnosis can already be made by taking a precise medical history. Physical examination includes inspection, palpation of landmarks and a dynamic examination in regard to joint regions. Plane X-Ray examinations are the basic tools in diagnostic imaging. Additional radiographic adjustments, ultrasound-, MRI- and CT-examinations may lead to more detailed information in special cases. A diagnostic arthroscopy is accomplished, if a pathological cause for wrist-pain with non-invasive methods cannot be found.