Diagnosis of chondromalacia patellae using CT arthrography.

Using anatomical specimens for experimental investigations, the physical-technical prerequisites for proper demonstration of the femoro-patellar articulation were determined and the following results obtained: hyaline cartilage possesses an attenuation value of 25-35 HU; artificial lesions from 1 mm. deep and 2 mm. wide minimum can be visualized; the use of positive contrast medium is best suited for demonstration of chondral lesions. In clinical practice we found that the various stages of cartilaginous degeneration peculiar to chondromalacia (Fründ I to III) are clearly demonstrated by CT arthrography. In CT the predisposing changes in the morphology of the patella and the femoro-patellar articulation are more precisely defined than in conventional tangential roentgenograms. In 69 cases the CT arthrographic findings could be verified at operation. However, the extent and severity of the lesions was, at times, underestimated.

Evaluation of the cruciate ligaments by CT.

Delineation of the cruciate ligaments in 112 patients using the computed tomography under arthrographic conditions was reported. Special position were used allowing for the demonstration of both cruciate ligaments in their complete lengths. In 6.2% of the examinations a reliable demonstration of the cruciates was not possible for technical reasons. Demonstration of normal cruciate ligaments in CT arthrography was described and normal values were tabulated. Recent cruciate ligament injuries were seldom examined by CT arthrography since the clinical symptoms were mostly unequivocal. The old ruptures of the ACL were divided into 4 different types: Type I: Rupture of the femoral origin that adjoins the PCL. Type II: Attenuation of the intraligamentary ruptured ligament with a preservation of origin and insertion. Type III: Complete rupture with shrinking and retraction of the fragments. Type IV: Osseous involvement of the femoral origin or tibial insertion. In 36 old cruciate ligament ruptures, the sensitivity of this method of investigation was 97%, the specificity 100%. After reconstructive surgery, CT arthrography allows for an objective analysis of the operative results and permits the comparison of different techniques of surgical repair.

[Imaging of the Achilles tendon on the computed tomogram. Normal findings and pathological changes]. / Die Darstellung der Achillessehne im Computertomogramm. Normalbefunde und pathologische Veränderungen.

Ligaments and tendons, including the Achilles tendon, show the highest density among normal soft tissue structures in the body. Traumatic and degenerative changes of the Achilles tendon are often associated with marked thickening and reduction in density associated with increased opacity of the space in front of the Achilles tendon. These changes are easily demonstrated by CT, whereas conventional radiological techniques only show non-specific changes. Twenty-five patients were examined, including nine with pain, seven following rupture of the Achilles tendon and nine post-operative controls; it was found that CT can add information important for the diagnosis and treatment planning of abnormalities of the Achilles tendon.

[Problems of surgical management of old knee joint injuries]. / Probleme der operativen Versorgung veralteter Kniegelenksinstabilitäten.

The problems in reconstructive surgery of old ligamentous injuries arise with the claim for restoration of normal function and anatomy. Based on new findings they are achieved by passive stabilization of the injured ligamentous structures as well as by their active reinforcement by the hamstring muscles. Surgical procedures may be traced back to a sort of integrated system; according to our own experiences these can be performed in any combination when reconstructing rotatory instabilities. Procedures eliminating one plain instability should only be applied with special indication.

[Anatomic principles as a prerequisite for the diagnosis of knee-ligament injuries in skiing]. / Anatomische Grundlagen als Voraussetzung für die Diagnose der Knieband-Verletzungen beim Skifahren

The anatomy of the capsulo-ligamentous structures is most important because of its immense significance for the physiology of the knee joint and its high danger to lesions. On the other hand there exists new knowledge of anatomy which leads to a revision of the importance of the clinical findings. It must be emphasized that the capsule is as essential for the passive stability of the joint as the 4 known main ligaments. Therefore, the instability of varus and valgus must be tested in full extension and in slight flexion of 20 to 30 degrees. To exclude rotatory instability the anterior drawer test of Slocum and Larson (1968) must be routinely performed. If the rotatory drawer sign is positive a lesion of the dorsal capsule and the anterior cruciate ligament is to be suspected.

[Current concepts in the diagnosis of knee injuries]. / Aktuelle Kniegelenksdiagnostik.

The exact diagnosis of affections of the knee is most important, especially of the capsulo-ligamentous lesions. To-day more and more younger patients are suffering from knee-instability. The modern possibilities of operative reconstruction lead to excellent results if the operation is performed at an optimal date. During the last years progress also was achieved concerning the knowledge of the mechanics and the pathophysiology of the knee. New methods of clinical investigation and new clinical findings were possible. Specific tests for the diagnosis of instability of the anterior cruciate ligament have to be emphasized. These tests are specially important if there is only an insufficiency of the anterior cruciate ligament which cannot be proven by the other clinical findings. X-ray examination is necessary to search for a fracture or an avulsion of the bone. In all other problems the exact clinical examination leads to the diagnosis.

[Injuries of the capsular ligament of the ankle joint, so-called "ankle joint distorsion"]. / Kapselband-Verletzungen des Sprunggelenkes. Die sogenannte "Sprunggelenksdistorsion".

The capsular and ligamentous lesion of the ankle is the most frequent injury and very common in sports. Still these injuries are frequently minimized and not treated properly. Late results are instability, subluxation and finally posttraumatic osteoarthritis. Anterio-lateral instability indicates lateral capsular-ligamentous lesions. Antero-lateral instability can be proved chinically by the anterior drawer-test and radiologically by a standardized stress x-ray in lateral position. The fresh lesion has to be treated by primary ligamentous suture or by plaster cast for 6 weeks. The treatment of chronic instability is secondary reconstruction. Severe osteoarthritis can be treated by an ankle replacement (endoprosthesis) or by arthrodesis.

[Prognosis of idiopathic scoliosis]. / Zur Prognose der idiopathischen Skoliose.

The prognosis of the scoliosis is determined by early and exact treatment, which depends on the degree of curvature, age, localization and expected of deviation. Scoliosis up to 30 degrees is treated by physical therapy. Between 30-50 degrees an active treatment with the Milwaukee-brace is recommended. Over 50 degrees surgery is required, because further progression is to be expected. The Harrington procedure should now be used in all centers of scoliosis. Paraplegia is seen in 0,5%. Minor complications and better correction can be expected by surgery carried out in special centers.

[The clinical importance of arthrography after lesions of the meniscus and capsular ligament (author's transl)]. / Die klinische Bedeutung der Arthrographie nach Meniskus- und Kreuzbandläsionen.

Clinical, arthrographic and operative findings of 100 patients were compared and analyzed by a study group with the result, that in questionable lesions of the meniscus, the indication for a double contrast arthrography was markedly reduced when plain films of the knee, an exact case history and a physical examination of the knee joint were performed. Above all, the improved examination technique, with the knowledge of the functional anatomy of the capsular ligament apparatus and the correlation of all stabilizing forces of the knee joint had reduced clinical errors in diagnosis. Clinically clearly analyzed meniscus lesions are therefore no indication for arthrography. In our clinic the indicatin will be reduced to those cases where there are still complaints after meniscectomy. There is a great advantage, if the examinating physician, the radiologist and the orthopedic surgeon cooperate closely together.

[Reticulum cell sarcoma of the pelvis. Diagnostic and therapeutic problems]. / Das Retikulumzellsarkom des Beckens. Diagnostische und therapeutische Probleme.

Diagnostic and operative problems of malignant bone tumors of the pelvis are discussed. Especially mentioned is resection therapy of pelvis tumor including large parts of the pelvis and the hip joint. A case-report is given. In this case replacement of the entire hip joint was successfully performed with a special prosthesis. Stabile fixation of the prosthesis is one of the major problems to be dealth with. Follow-up examination of our patient one year after the operation showed no loosening of the prosthesis and free movement of the hip joint iwth partial loack capacity of the leg.

[Arthroscopic knee surgery]. / Arthroskopische Operationen am Knie.

Endoscopic knee operations have become increasingly accepted during the last years. Meniscectomy is the most important of the endoscopic operations. The technique, developed in Linköping/Sweden, makes it possible to perform partial, subtotal or total meniscectomy according to what is needed to treat the patient appropriately. The technique involves the use of a pump system to distend the joint with saline, a mechanical assistant, a special knife with retractable blades, a grasping and a basket forceps. This very simple and inexpensive equipment makes all kinds of endoscopic meniscus surgery possible. The results of endoscopic meniscectomy have been rewarding. The time for sick leave is very short and the operation can be done on out-patients. Athletes ae back to sport usually within 4 weeks. There have been no complications.

[Juvenile hip pain. 2. Femur head epiphysiolysis, hip dysplasia, tumors]. / Der kindliche Hüftschmerz. Teil 2: Epiphysiolysis capitis femoris, Hüftdysplasie, Tumoren.

The early symptom in hip joint diseases in children is pain. Pain is localized in the groin and thight, but mostly in the knee. Other important signs are limping and reduced internal rotation. If a hip disease is suspected it is necessary to take X-rays in two planes. If diagnosis is early and special therapy started immediately, the results are usually excellent without deformation of the hip. Otherwise early osteoarthritis can develop. This is important because osteoarthritis in the hip joint is in 75% of the cases due to hip joint diseases in childhood. The problems of diagnosis and treatment of the most common hip joint diseases in children (transient synovitis, rheumatoid arthritis, osteomyelitis, Legg-Perthes disease, slipped capital femoral epiphysis, dysplasia, tumors) are discussed.

[Meniscus ganglia. Diagnosis and differential diagnosis]. / Meniskusganglien Diagnose und Differentialdiagnose.

3% of isolated meniscectomies were performed on patients with cysts of the meniscus. The etiology is not yet fully elucidated. The problems in clinical and radiological diagnosis are discussed using the examples of two operatively verified cases. In computerized tomography the density values of these lesions range from 20 to 35 Hounsfield units thus allowing specific diagnosis. Localization and extent of the cyst can be shown exactly by computerized tomography.

[An unusual observation of total hip replacement with meta on metal gliding bearings]. / Ungewöhnliche Beobachtung nach Hüft-TEP mit Metall/Metall-Gleitpaarung.

QUESTION: The conically clamping inlay of solid metal for the Hofer-Imhof threaded socket makes possible the use of a metal-metal-bearing by completely dispensing with polyethylen but keeping the four-elements-construction of THR. In order to perceive long-term problems and complications patients of our hospital who took part in a closed multi-center-study which was established prospectively were checked again. METHOD: Clinical and X-ray examination of 27 patients after 19 months on an average (12-23 months). RESULTS: Harris-score increased from 38 points before the operation to 89 points three months after the operation and 91 points in the present check-up. Three months after the operation 22 patients were free of pain, at present only 12. X-Rays did not show any signs of loosening within the prostheses. But increasing ectopic ossifications of Brooker were found: ten times Class I, once Class II and six times Class III. CONCLUSION: Using equal form of after treatment the increasing break out of pain as well as the growing symptom of ectopic ossifications in the hip area after the implantation of the Hofer-Imhof threaded socket with solid metal inlay is presumably caused by the use of the metal-metal-bearing as well as by the direct lining of the Co-Cr-inlay in the titan-socket and by possible changes in corrosion.

[Cartilage injuries of the femoro-patellar joint in the computerized tomogram]. / Knorpelschäden des Femoro-Patellar-Gelenks im Computer-Tomogramm.

The conventional arthrographic methods for demonstration of the femoro-patellar joint are not sufficiently reliable. Through the use of CT-arthrography a cross-sectional image free of superimposition and possessing a high density resolution is available thus facilitating a direct demonstration of the joint cartilage. Traumatic and degenerative lesions of the cartilage can be clearly shown by CT-arthrography. Damage of cartilage in patients with chondromalacia patellae can be differentiated in its different stages. The shape of the patella and its relation to femoral condyles can be evaluated more accurate than by conventional axial x-rays.

[Arthroplasty of the upper ankle joint. Possibilities and limitations]. / Arthroplastik des oberen Sprunggelenks.

It is out of the question that alloarthroplasty of the upper angle joint must today belong to the therapeutic repertoire of the orthopedic surgeon. The anatomical situation of the upper ankle joint brings considerable problems for the total replacement and then also for the surface replacement. At the time being models are already available, which, seen on the whole, have already brought quite reliable results. Requirement for the success of the operation is the technically perfect insertion of the surface replacement or of the total joint and furthermore the insertion of the replacement under appropriate conditions, whereby the operation in an aseptive room ("Reinraum") has proven itself effective also on the upper ankle joint.

[Periarticular ossification following severe brain injury]. / Periartikuläre Ossifikationen nach schwerem Schädel-Hirn-Trauma.

A particular ossification should be considered besides primary neurological causes, if there are functional restrictions of the joint movements after severe head trauma. New bone formation has been seen extending from the periarticular tissue. The problems of the new bone formation in both hip-joints are shown in a patient with traumatic apallic syndrome. After exact indication and with careful and atraumatic operative technique functional restitution of the joints can be achieved without danger of recurrence.

[Neurofibroma and neurofibrosarcoma in Recklinghausen's neurofibromatosis]. / Neurofibron und Neurofibrosarkom bei der Neurofibromatose von Recklinghausen.

The neurofibromatosis von Recklinghausen is a systemic disease, which can cause various different changes in the body. The case report of a female patient shows all the typical signs of neurofibromatosis von Recklinghausen. These signs are café-au-lait spots, congenital tibia pseudarthrosis, abdominal plexiform neurofibromatosis and peripherical neurofibromas with sarcomatous degeneration.