[Meniscal degeneration score and NITEGE expression : immunohistochemical detection of NITEGE in advanced meniscal degeneration]. / Meniskusdegenerationsscore und NITEGE-Expression : Immunhistochemischer NITEGE-Nachweis in der schwergradigen Meniskusdegeneration.

BACKGROUND: Meniscal degeneration (MD) is a structural change of fibrous cartilage that is common in orthopaedic diagnostics and relevant for health insurance matters. So far, there has been neither a standardised scoring system nor an immunohistochemical marker for MD. MATERIAL AND METHOD: In this retrospective trial, the meniscal tissue of 60 patients was assessed immunohistochemically for NITEGE (G1 fragment of the proteoglycan aggrecan) expression. NITEGE expression was correlated with defined grades of MD: little (grade 0/1), medium (grade 2), or severe (grade 3). RESULTS: Detection of extracellular NITEGE deposits in grade 2 or 3 MD had a positive predictive value and specificity of 100%, whereas no deposits were found in grade 0/1 MD. Sensitivity in advanced MD was 55%. Detection of extracellular NITEGE correlated positively with the grade of degeneration, as did patient age and the grade of degeneration. The patient age of those with grade 0/1 MD was significantly lower than for grade 3 (p<0.0001). CONCLUSION: The thoroughly defined degeneration score (grade 1 - grade 3 MD) is suitable to assess the severity of degeneration. Extracellular NITEGE deposits can be regarded as an immunohistochemical marker for advanced (grades 2 and 3) MD.

[Histopathological degeneration score of fibrous cartilage. Low- and high-grade meniscal degeneration]. / Histopathologischer Degenerations-Score des Faserknorpels. Low-grade- und High-grade-Meniskusdegeneration.

Although histopathology of meniscal degeneration plays an important role, no criteria to assess severity of the degeneration are available to date. Our aim was to create a histopathological scoring system for meniscal degeneration with good interobserver variability, taking matrix degradation and cellularity in meniscal tissue into consideration. Degeneration is classified as follows: grade 1 (low), grade 2 (intermediate), grade 3 (high). The pattern of NITEGE deposits (G1 fragment of aggrecan) was assessed immunohistochemically (n=38) and compared with the grades of degeneration. In 48% of the patients with grade 2 or 3 degeneration extracellular NITEGE deposits (specificity 100%) were found, whereas grade 1 patients showed no deposits. Extracellular NITEGE deposits correlated positively with the grade of degeneration. In all, 30 cases (10 per grade) were assessed by three pathologists (A, B, C). Grading conformity was 70% for grade 1, 66% for grade 2 and 100% for grade 3. Cohen's Kappa coefficient was 0.6--0.7 between pairs of observers. Combining grade 1 and 2 to low-grade degeneration, compared to a grade-3 high-grade degeneration achieved Kappa coefficients of between 0.93 and 1.0. This reproducible degeneration score for fibrous cartilage could form the basis for the standardized assessment of meniscal degeneration.

[The area of conflict between the surgeon's duty to inform about diagnosis, prognosis, operation, complications, time schedule, alternative methods and the patient's right of self-determination]. / Das Spannungsfeld zwischen der Aufklärungspflicht des Chirurgen über Diagnose, Prognose, Operation, Komplikationen, zeitlichen Ablauf, alternative Methoden und dem Selbstbestimmungsrecht des Patienten.

The surgeon's duty to inform patients determines the indication to a therapeutic and/ or diagnostic procedure. Despite ongoing information made available by the professional associations, the complaints against surgeons providing treatment are on the increase. Only careful health education information with records kept of the course of treatment adopted will safeguard the doctor in charge from patients' claims for damages. Case law demands that the doctor put the patient in a position to understand what is happening to him or her and for him or her to be able to make a decision freely. The patient's compliance after being provided with health education information makes the corpus delicti of bodily harm void. A special form is the matter of fact of "transfer negligence", when the doctor and/ or the hospital is aware, prior to execution of the treatment, that treatment is not possible lege artis. What continues to be applicable to health education information is that the more urgent the operation, the less information is indicated, so that in emergencies such operation can be completely done without. Apart from general risks, such as wound infection and/or the danger of thrombosis, information must also be provided about special risks and the course of any follow-up treatment. Legal practice shows that simply handing over forms is not sufficient. The patient may forgo treatment. Aborting an operation for purposes of providing health information is balancing between the patient's interests in immediate execution of the indicated measure, on the one hand, and the right of self-determination on the other. Should the operation be able to be aborted without any serious consequences for the patient, then it is to be thus done.What does principally apply in civil litigation is the rule of the burden of proof.

[Ankle osteosynthesis infection: vacuum therapy as the treatment of choice]. / Die infizierte Osteosynthese am oberen Sprunggelenk: Vakuumtherapie als Mittel der Wahl.

BACKGROUND: Should osteosynthesis infection occur after ankle fractures in patients with microangiopathy, the infection needs to be cured quickly and safely to protect implants, bone, and tendons. Vacuum therapy (TNP) provides a perfect treatment plan that keeps the inpatient time low whilst ensuring high patient comfort. METHODS AND PATIENTS: Four angiopathic patients with deep wound infection after ankle osteosynthesis were treated. At admission, loss of stability and spread of the infection were the immediate risks. To prevent this, we treated the patients with vacuum therapy after initial debridement until skin cover was achieved. RESULTS: In all cases stability was secured and after 2 dressing changes, the swabs were sterile. The inpatient time was 13 days; overall vacuum therapy time was 59 days. Patient satisfaction was high. DISCUSSION: Vacuum therapy is a perfect strategy after surgical debridement and before secondary mesh grafting. It protects the stability of the bone and open-lying delicate structures in patients with infected osteosynthesis of the ankle and angiopathy and offers an easy, safe, and successful treatment path with a short inpatient time.

Population pharmacokinetics of methylprednisolone in accident victims with spinal cord injury.

OBJECTIVE: High-dose methylprednisolone (MP) is used to treat acute spinal cord injury (ASCI). The objective of the present study was to determine the pharmacokinetics of the pro-drug methylprednisolone hemisuccinate (MPHS) and MP in accident victims with ASCI. METHODS: The patients (n = 26) were treated with a bolus intravenous loading dose of 30 mg/kg MPHS within 2 h after injury and this was followed by a maintenance infusion of 5.4 mg/kg/h up to 24 h. Blood, CSF and saliva samples were collected up to 48 h after the initial dose and the samples were analyzed by HPLC. Concentration-time data of MPHS and MP were analyzed using population pharmacokinetic analysis with NONMEM software. RESULTS: MPHS and MP could be monitored in plasma and CSF. MP but not MPHS was present in saliva. High variability was seen in the MPHS levels in CSF. The pharmacokinetics of the pro-drug and the metabolite were adequately described by a 2-compartment model with exponential distribution models assigned to the interindividual and the residual variability. At steady state, the average measured MP concentration in plasma was 12.3+/-7.0 microg/ml and 1.74+/-0.85 microg/ml in CSF. The CSF levels of MP could be modeled as a part of the peripheral compartment. CONCLUSION: This study demonstrated that CSF concentrations of MP were sufficiently high after i.v. administration and reflected the concentrations of unbound drug in plasma. Salivary levels of MP were about 32% of the plasma level and may serve as an easily accessible body fluid for drug level monitoring.

[Control of disordered wound healing using sonography based on postoperative follow-up after TEP implantation]. / Kontrolle von Wundheilungsstörungen mittels Sonographie anhand postoperativer Kontrollen nach TEP-Implantation.

Clinical diagnosis of early postoperative complications remains a major issue in patients undergoing total hip replacement. Early diagnosis is essential because (clinical) signs of inflammations as fever or elevated white blood count already reflecting late complications. The goal of our study was to evaluate postoperative monitoring for early detection and treatment of hematoma and abscess following total hip replacement. 308 patients undergoing total hip replacement were postoperatively monitored for the development of hematoma and abscess, comparing routine ultrasound to on demand ultrasound in case of clinical signs of infection. The diagnostic puncture was 6.5% (10/154) in group A (on demand ultrasound) versus 11.7% (18/154) in group B (routine ultrasound). Infections were seen in 5.2% (8/154) of patients in group A compared to 0.6% (1/154) in group B, leading to surgical intervention in 3.3% (5/154) group A, respectively 0.6% (1/154) in group B.

[Compensation behavior after fractures of the thoracic and lumbar spine in children and adolescents]. / Korrekturverhalten nach Frakturen der Brust- und Lendenwirbelsäule bei Kindern und Jugendlichen.

UNLABELLED: Spinal column trauma with a fracture of the breast and lumbar spine is with 2-3% relatively uncommon in the pediatric patient population (from birth-16 years). In a review of 22 patients (7-15 years old) treated between 1978-1988 the individual management of treatment is reported. The goal of our study was to describe the absolute indications for the operative treatment and the difference between conservative and operative procedure depending on the age of the patient. The follow-up study after an average of 7 years and 8 months demonstrated an improvement of the neurological status (neurological status of Frankel) of 8 patients and a spontaneous correction of kyphotic angle from 21 degrees after treatment to 3 degrees. THE CONCLUSION: The treatment must be individual and depends on the age of the patient.

[Chronic venous insufficiency after open tibial fracture. An underestimated problem]. / Chronisch venöse Durchblutungsstörungen nach offenem Unterschenkelbruch. Ein unterschätztes Problem.

There is a wide range of alternatives for primary bone reconstruction in the treatment of open lower leg fractures with soft tissue damage of the type Gustillo II and III. The primary objective should always be the protection of soft tissue damage whether one uses the fixateur externe, or an unreamed nail or primary bone shortening with secondary callus distraction. In recent years, this approach has produced better results and a reduction in the rate of major amputations. The overall effects of the initial treatment can only be analysed after a number of years. Research results indicate long-term soft tissue complications of the lower leg, varying from harmless swelling to venous ulcer. We conducted a clinical investigation which compared 80 patients, who were treated between 1985 and 1994 using the venous-occlusion plethysmography, to 50 healthy individuals. Clinically significant damage of the deep venous system was found in over 50% of cases. There was a direct correlation between the number of years since the initial treatment and the degree of damage found. Based on these findings, we recommend that the initial treatment of this condition and the preventative treatment of the secondary trauma diseases should follow regulated surgical guidelines and be recognised for insurance purposes.

[Nonbacterial osteomyelitis of the clavicle]. / Die nichtbakterielle Osteomyelitis der Clavicula.

Osteomyelitis can be subdivided into a bacterial exogenic (post-traumatic/postoperative), bacterial endogenic (hematogenous) and an abacterial type, including the rare group containing primary chronic sclerosing osteomyelitis, which is typically localized in the clavicle. In a review of the literature, the criteria for the various types of chronic sclerosing osteomyelitis are analyzed. Out of a group of 17 patients with osteomyelitis of the clavicle treated between 1978 and 1996, three cases of primary chronic sclerosing osteomyelitis are demonstrated. In the differential diagnosis, primary chronic sclerosing osteomyelitis of the clavicle has to be taken into consideration despite its rareness. After establishing a diagnosis by biopsy, in contrast to the other forms, drug therapy will be the treatment of choice and not an operation.

Supination trauma. A classic case.

Sprains in the lateral ligaments of the ankle produce the most common ligamentous injuries of the human body. The mechanism of injury is complex, while supination represents the main component of foot movement. Classifying lateral ankle ligament injuries, many authors use a system of three degrees, which includes mild, moderate and severe sprains. Despite this scientific categories, in our opinion is the differentiation between elongation and complete ruptures of practical relevance. Under a biomechanical point of view, ligamentous trauma of the lateral ligaments lead to acute antero-lateral rotational instability (ALRI). Following the retrospective clinical study of Zwipp with 1235 patients, in 70 % of complete disruptions, the anterior talo-naviculare and fibulo-calcanear ligaments are involved together. Syndesmotic injuries have been reported at a rate up to 10 % of ankle sprains with deltoid ligaments at 2,5 %. Rarely, the classic ankle sprain leads to injuries which affect the foot on a so called "supination fracture line". A rate of 7,4 % is reported for these accompanying injuries. Therefore, clinical examination of ankle sprains should not only address on the distal tip of the fibula. Critical bony and ligamentous structures like the fifth metatarsal base, the calcaneo-cuboideal ligament, the ligaments of the anterior calcaneal process, the talus and syndesmotic ligaments have to be screened for pain and swelling. In our opinion, careful clinical examination and plain radiographs in two plains are sufficient for diagnosing ankle sprains and functional therapy.

[Malposition of healed distal radius fracture. Indications, technique and timing of correction]. / In Fehlstellung verheilter distaler Speichenbruch. Indikation, Technik und Zeitpunkt der Korrektur.

Typical complications of distal radius fractures include post-traumatic malalignment in about 20%. This is associated with ulno-carpal pain and impaired wrist function. Various corrective procedures have been recommended. Between 1972 and 1986, 96 patients with posttraumatic disorders after distal radius fractures underwent surgical treatment. Three different procedures were carried out: simple corrective osteotomy of the distal radius, combined correction of the radius and ulna, as well as isolated correction of the ulna (distal resection, step-cut osteotomy, hemiresection arthroplasty). 83 (86.5%) of the patients were followed up for an average of 7 years postoperatively. The functional results were evaluated according to Lidström. Excellent and good results were found in 58 (69.9%), fair in 20 (24.1%) and bad results in 5 (6.0%). The best results were mostly seen in cases with a short interval between trauma and corrective procedure. Distal ulna resection has not been performed in our department since 1986 because of poor results and concommitant wrist-instability. We recommend combined correction procedures in those patients with painful deformities within a period of no more than six to nine months after trauma. The indication should also take individual aspects such as profession, age, activities, complaints, and radiological findings into account. Signs of osteoarthrosis and wrist disorders due to severe soft tissue problems are contra-indications to any of the aforementioned correction procedures.

[Muscle power and shoulder joint function after removal of the latissimus dorsi muscle]. / Muskelkraft und Schultergelenkfunktion nach Entnahme des M. latissimus dorsi.

Free transplantation of the latissimus dorsi muscle has become the treatment of choice in extensive soft-tissue defects of the lower leg after trauma. However, neither the ability of the remaining muscles of the shoulder to compensate for the lost function nor the long-term effects of latissimus dorsi removal on the function of the shoulder have been objectively measured. Therefore, the postoperative shoulder function in 23 patients was compared after removal of the latissimus dorsi muscle with 23 control subjects. The evaluation included a questionnaire, physical examination, and instrumented muscle-testing (cybex system). No significant statistical differences in the function of the shoulders of all the patients and control subjects could be verified, with the exception that 16 patients exhibited weakness during isokinetic torque during extension of the shoulder in a 55 to 65 degree flexion (4.2 +/- 1.2%). The latissimus dorsi free flap can therefore be recommended as a procedure for soft-tissue coverage of extensive wounds resulting only in negligible loss of function and a slightly altered appearance of the shoulder-girdle.

[Vacuum therapy for deep wound infection after Achilles tendon repair]. / Vakuumtherapie bei tiefem Wundinfekt nach Achillessehnenrekonstruktion.

AIM: Vacuum therapy is a valuable option for wound healing complications. After reconstruction of the ruptured achilles tendon, deep wound infections are difficult to handle due to impaired circulation of the bradytrophic tissue which leads to infection and a protracted healing process. Consecutive necrosis of the achilles tendon results in a poor clinical outcome. We could prove that vacuum therapy is the method of choice for wound healing complications in this delicate area. METHODS: We treated 5 patients with deep wound infection and exposed achilles tendon after reconstruction. RESULTS: In all cases we achieved complete closure. The function of the achilles tendon was not impaired. Sonography confirmed the integrity of the tendon in all cases. Duration of therapy was 8.4 days for inpatient treatment and 64.4 days overall. 3 patients received a mesh-graft transplantation after wound ground preconditioning with vacuum therapy, all others achieved complete restoration with vacuum only. CONCLUSION: Vacuum therapy is a valuable option for the treatment of infected achilles tendon after surgical repair. After wound ground conditioning, it can protect mesh-graft transplants in this delicate area even in non-compliant patients.

[Exertional compartment syndrome of the lower leg and common peroneal nerve palsy as combined injury after weight lifting]. / Akutes belastungsinduziertes Kompartmentsyndrom der Tibialis-anterior-Loge und Druckläsion des Nervus peroneus communis als seltene Kombinationsverletzung beim Gewichtheben.

While the compartment syndrome after traumatic injury is a well-known entity and well recognised, an exercise-induced acute compartment syndrome is seldom and often missed. Delayed diagnosis and treatment can result in a poor outcome such as loss of function or limb. Early recognition and prompt fasciotomy are necessary. We would like to present the case of an exertional compartment syndrome of the tibialis anterior space after weight-lifting which was complicated by an acute pressure-induced palsy of the common peroneal nerve due to a self applied knee-support-bandage. A thorough case history provided the clue to understand the resulting pathology. This case shows again the necessity of good medical assistance for athletes in leisure-time sport activities.

[Augmentive plate fixation in femoral non-unions after intramedullary nailing. Strategy after unsuccessful intramedullary nailing of the femur]. / Die additive Plattenosteosynthese bei Femurpseudarthrosen nach intramedullärer Stabilisierung.

INTRODUCTION: Intramedullary nailing is a standard procedure to treat femoral fractures in patients without polytrauma. Nevertheless, non-union in femoral fractures is a common complication with an incidence of 12.5 percent, mostly arising for mechanical reasons. The aim of this study is to find out whether the increase of stability through an augmentive plate fixation (if necessary with bone grafting) with leaving the nail in situ is adequate to treat the non-union successfully. MATERIALS AND METHODS: Between January 2001 and July 2005 32 patients with femoral non-unions after intramedullary nailing were treated in our hospital. Mean age was 42 years (min 22 and max 75). Distribution of gender was about (2/3) male and (1/3) female. In 17 patients the fractures were localised in the middle of the femur shaft, in 8 patients in the proximal third and in 7 in the distal third. The results were evaluated retrospectively by reviewing the patients' records and X-ray-films. If the success of treatment was not clearly determined through the records the patients were contacted by telephone and, if required, invited for a personal examination. RESULTS: In 29 cases our procedure led primarily to a definite consolidation of the non-union within 5 months on average. The nail was changed eight times, in three patients an additional operation was necessary due to screw breakage. Bone grafting was performed in 27 cases. The overall group included 24 non-smokers and 8 smokers. CONCLUSION: If indicated, the herein demonstrated procedure with an augmentive plate fixation while leaving the nail in situ is simple and safe. Although the intramedullary canal is potentially affected through the initial nailing, the healing of femoral non-unions was observed in the majority of cases in spite of the additional extramedullary approach for plating and bone grafting.

[Fracture of the distal ulna accompanying fracture of the distal radius. Minimally invasive treatment with elastic stable intramedullary nailing (ESIN)]. / Distale Ulnafraktur als Begleitverletzung des körperfernen Speichenbruchs. Minimal-invasive Versorgung mittels elastisch-stabiler intramedullärer Nagelung (ESIN).

The distal radius is one of the commonest sites of fracture, and this injury is sometimes associated with fracture of the distal ulna. In recent years, surgical treatment of distal radius fractures has consisted increasingly in internal fixation with locking plates followed by early functional postoperative treatment. The associated injury to the distal ulna has so far not received much attention in the literature. Various techniques have veen described for its treatment: Kirscher wire fixation, tension band wiring, and internal fixation with screws and plates. Following positive results with elastic stable intramedullary nailing (ESIN) in the treatment of shaft fractures in children this technique was also applied in in fractures in adults (forearm, clavicle). Use of this technique for stabilisation of distal ulnar fractures has not previously been reported. In the course of a prospective longitudinal study (EBM level II), in 26 patients with an average age of 73.6 (42-88 years), bone healing in anatomical position was achieved in all cases within 6-12 weeks after closed reduction and anterograde ESIN with subsequent treatment that did not involve immobilization. No length differences of more than 2 mm and no functionally relevant deviations of the ulnar axis were observed. Apart from 3 cases of nail perforation at the distal end of the ulna, which had no clinical manifestations, there were no complications. ESIN offers a minimally invasive option for the treatment of unstable fractures of the distal ulna associated with distal radius fractures; it allows functional aftertreatment and can be regarded at least as an alternative to open reduction with internal fixation.

[Long-term results after acetabular fractures with respect to heterotopic ossifications]. / Langzeitergebnisse nach Azetabulumfrakturen unter Berücksichtigung von heterotopen Ossifikationen.

BACKGROUND: Arthrosis, necrosis of the femoral head and heterotopic ossification (HO) tend to decline the outcome of acetabular fractures despite of good fracture reduction. In this study functional outcome and degree of HO were analyzed due to fracture type and surgical approach. The aim of this study is to delineate wether minimization of soft tissue damage increases the functional outcome. PATIENTS AND METHODS: 55 patients with surgically treated acetabular fractures (mean age: 40.4 (20-81) years, male 43, female 12) where retrospectively evaluated with a mean follow-up of 7.7 (4.4-12.3) years. Fractures were classified according to the Orthopaedic Trauma Association (OTA), functional outcome was scored by D'Aubigné-Postel and the degree of HO was defined by Brooker's classification. RESULTS: Following the OTA the distribution of fractures was: A-24 (44 %), B-23 (42 %) and C-8 (15 %). Mean D'Aubigné Index (max. 18 points) was 15.2, distributed to fracture type: A-15.9, B-15.0 and C-13.6. 32 % of all heterotopic ossifications were classified as Brooker 0, 10 % as Brooker 1, 29 % as Brooker 2 and Brooker 3 each, whereas Brooker 4 ossifications were not observed. 2/3 of the severe ossifications were observed using extended approaches or in case of type C fractures. The iliofemoral approach showed the tendency of fewer ossifications compared to extended approaches. CONCLUSION: Decrease of soft tissue damage during acetabular surgery plays an important role to improve outcome. Due to the higher risk of wrong implant position and insufficient reduction using a soft tissue sparing approach, we recommend a CT scan postoperatively to evaluate reduction and osteosynthesis.

[Callotaxis--osteogenesis by stretching--a conservative possibility for restoring leg length after post-traumatic primary tibial shortening?]. / Kallotaxis--Osteoneogenese durch Dehnung--eine schonende Möglichkeit der Beinlängenwiederherstellung nach posttraumatischer primärer Unterschenkelverkürzung?

From 1993 to the beginning of 1996 28 patients (20 male/8 female) with open fractures of the lower leg (classification of Gustilo Type II, Type III) were treated by a primary shortening with a maximum of 5.7 cm (+/- 0.6 cm) after first debridement. After this management 23 patients showed a good soft-tissue cover; 5 patients needed a supplementary musculus latissimus dorsi-transfer to cover the bone. After an average of 22 days (+/- 4.2 days) and the radiologic sign of new callus 8 patients were treated by callotaxis in the fracture gap; 20 patients underwent lengthening by callotaxis of a separate osteotomy after an average of 24 days (+/- 3.6 days). After the mean of 52 weeks (+/- 1 weeks) all patients demonstrated good healing of the fracture and osteotomy. No one showed clinical or radiological signs of osteitis.

[Supination trauma. A classic case]. / Das Supinationstrauma. Ein Klassiker.

Sprains in the lateral ligaments of the ankle produce the most common ligamentous injuries of the human body. The mechanism of injury is complex, while supination represents the main component of foot movement. Classifying lateral ankle ligament injuries, many authors use a system of three degrees, which includes mild, moderate and severe sprains. Despite this scientific categories, in our opinion is the differentiation between elongation and complete ruptures of practical relevance. Under a biomechanical point of view, ligamentous trauma of the lateral ligaments lead to acute antero-lateral rotational instability (ALRI). Following the retrospective clinical study of Zwipp with 1,235 patients, in 70% of complete disruptions, the anterior talo-naviculare and fibulocalcanear ligaments are involved together. Syndesmotic injuries have been reported at a rate up to 10% of ankle sprains with deltoid ligaments at 2.5%. Rarely, the classic ankle sprain leads to injuries which affect the foot on a so called "supination fracture line". A rate of 7.4% is reported for these accompanying injuries. Therefore, clinical examination of ankle sprains should not only address on the distal tip of the fibula. Critical bony and ligamentous structures like the fifth metatarsal base, the calcaneo-cuboideal ligament, the ligaments of the anterior calcaneal process, the talus and syndesmotic ligaments have to be screened for pain and swelling. In our opinion, careful clinical examination and plain radiographs in two plains are sufficient for diagnosing ankle sprains and functional therapy.