[Prioritization or unlimited resources in orthopedics and trauma surgery?] / Priorisierung oder unbegrenzte Ressourcen in Orthopädie und Unfallchirurgie?

The development of the healthcare system in Germany is increasingly approaching human and economic limits. A social consensus and a political concept at which point priorities are promoted and for which services the money should be primarily spent, do not exist on the whole. As soon as it becomes clear that resources are limited and that is now, prioritization has to be introduced to avoid the alternative threat of rationing of treatment benefits. The goal of prioritization is to rationally and optimally use the existing but limited resources. Medical progress and the relationship to the demographic development are the variables in the future. The individual care of the patient, patients' needs and dependence on access to treatment are the foundations of ethical actions. They must be at the center of attention for doctors and nurses because, after all they are the patient's advocates in the complex healthcare system. At the same time, unjustified claims for entitlement must be rejected just as a preservation of vested rights. Efficiency and economic considerations in diagnostics and treatment are not mutually exclusive. The physician acts as a mediator between the claims of the patient to be treated, the individual realization and the existing resources in the healthcare system.

[Significance of the fibula in tibial fractures and pseudarthroses]. / Uber die Bedeutung der Fibula bei Unterschenkelfrakturen und -pseudarthrosen.

The importance of the shaft of the fibula in lower leg fractures is the greater, the more unfavourable the situation of the tibia together with the surrounding soft tissue. We consider the operative stabilisation of the fibula to be a good procedure in cases of distal lower leg fractures, comminuted fractures of the tibial shaft and intramedullary nailing of the tibia, to increase overall stability of the whole lower leg system. The fibula is of still greater importance in cases of non-unions with loss of bone, with or without infection. The reconstruction of the tibial bone defect can be achieved via the stable fibula by means of several modifications of the fibula-pro-tibia operation. It can be demonstrated by various examples that the fibula and its stability should be considered more often in the therapeutic management of lower leg fractures and non-unions of the tibia.

[Stable osteosynthesis following ilial resection in intraosseous Ewing sarcoma]. / Stabile Osteosynthese nach Beckenschaufelresektion bei intraossärem Ewing-Sarkom.

A case of a young man with Ewing's sarcoma of the os ilium is demonstrated. The tumor is removed by resection of the os ilium and the adjacent musculature. The bony stability is reconstructed by means of a double autogenous free fibula graft in combination with a broad plate, braced between os sacrum and the roof of the acetabulum. Full weight bearing is possible, at present there is no evidence of a local recidive or of metastases.

[Bore wire osteosynthesis in distal radius fractures]. / Die Bohrdrahtosteosynthese bei distalen Radiusfrakturen.

In the presence of an area of extensive dorsal comminution percutaneous pinning is indicated in a typical distal radius fracture (Colles). It enlarges the stability and thus helps avoiding a secondary dislocation of the fracture. Indication and technique of this procedure are discussed following a series of 66 patients. Typical mistakes are as follows: insufficient reduction, poor diverging of the K-wires and improper anchoring in the opposite cortex. Avoiding of these possible faults leads to good final results. Flexion fractures and extensive shattering of the bone are contraindications for percutaneous pinning of these fractures.

[Indications status and surgical treatment of spinal fractures. Attempt at a survey and determination of present status]. / Indikationsstellung und operative Behandlung bei Wirbelfrakturen. Versuch einer Bestandsaufnahme und Standortbestimmung.

Indications for operative treatment of spinal fractures sometimes are difficult to work out. Undoubtedly deteriorating neurological deficits require decompression always combined with stabilization. Due to new classifications a severe instability of the fracture, an axis deviation more than 25 degrees and polytraumatized patients show up being an indication for operative treatment. A proper preoperative planning with use of X-rays and CT Scan as well as the knowledge of the kind and site of instability is mandatory. In cervical spine fractures anterior fusion seems to be the best method. In thoracic spine fractures dorsally attached plates give enough stability. In the thoraco-lumbar spine region and in the lumbar spine itself the internal fixator with dorsal instrumentation together with a transpedicular bone graft is preferred by the authors. Among 384 fractures of the spine 62 have been operated. Both kinds of treatment do not compete; they are complementary instead.

[Management and results of conservative treatment of patients with injuries of the thoracic and lumbar vertebrae]. / Management und Ergebnisse der konservativen Behandlung von Patienten mit Brust-und Lendenwirbelsäulenverletzungen.

Conservative treatment of injuries of the thoracic and lumbar spine is indicated in stable fractures without or with an axis angle up to 25 degrees and in children fractures. Stable injuries are compression-wedge-fractures and burst fractures. Severe compression fractures with dorsal ligamentous injuries are regarded being conditional stable. Conservative treatment can be divided into 3 periods: lying period, rising period and stand-walk-sit period. Physiotherapy together with proper nursing is to avoid pulmonary and circulatory complications as well as to support motility of the intestinal tract. After stabilization of the general condition of the patient physiotherapy should furthermore lead to: relaxation of the hypertonic musculature, facilitating and preservation of muscle activities to secure the injured parts of the spine, training and assignment of global, diagonal muscle chains following physiological motions. From 1982-1986 389 patients with fractures of the spine were treated in the Tübingen Accident Hospital (Berufsgenossenschaftliche Unfallklinik Tübingen). An early functional treatment following Bürkle de la Camp was performed in 84%. The follow up examination showed no further displacement in 84%. In 1/3 of the cases a free movement was regarded in the sagittal plane. 2/3 of the cases showed restriction of movement in only one segment. The good functional result is underlined by the subjective impression of the patient themselves: 2/3 were satisfied with the result.

[Influence of the treatment of fractures on the development of pseudoarthroses of the humerus shaft (author's transl)]. / Einflüsse der Frakturbehandlung auf die Entstehung von Oberarmschaftpseudarthrosen.

The evaluation of 98 pseudoarthroses of the shaft of the humerus showed that 42 of these occurred after conservative and 56 after surgical treatment of the original fracture. It appears that pseudoarthroses are caused in conservative treatment chiefly by the traction methods. Among the surgical methods, intramedullary nailing does not seem to bring about sufficient stabilization with a satisfactory measure of safety, whereas in the case of plate osteosynthesis, errors in respect of operation technique are mainly responsible for causing pseudoarthroses. All 98 pseudoarthroses returned to normal condition after proper plate osteosynthesis and, if necessary additional deposition of cancellous bone graft.

[Primary valgisation osteotomy in femoral neck fractures]. / Die primäre Valgisationsosteotomie bei Schenkelhalsfrakturen.

Technique and results after primary valgisation osteotomy in 41 patients with femoral neck fractures are described. 2 non unions and 9 avascular femoral head necroses were observed. The primary valgisation most probably does not influence the rate of necrosis. When performed by accurate technique it lowers the incidence of non union of the femoral neck. Postoperative leg lengthening is always evident. The most current avoidable mistake is an external rotational deformity. The procedure requires proper preoperative planning.

[Non unions of the humerus shaft (author's transl)]. / Die Oberarmschaftpseudarthrose.

The clinical evaluation of 121 cases of non union of the humerus shaft shows that 46 of these occurred after conservative and 75 after operative treatment. The main failures could be found after conservative treatment by traction methods. Operative treatment by intramedullary splinting did not achieve sufficient stability. The high rate of non unions after plate osteosynthesis is caused by basic technical faults in nearly all cases. The number of postoperative nerve palsy is remarkable. All cases could be healed by means of proper plate osteosynthesis after decortication combined with cancellous bone grafting in 12 atrophic non unions. The high rate of non unions of the humerus shaft gives occasion to reflect upon the correct indications for fracture treatment. From our point of view a more conservative attitude should be required.

[Special problem in the replacement operation in cemented prostheses]. / Das besondere Problem der Austauschoperation bei zementierten Prothesen.

The replacement of a loose total hip prosthesis requires a great amount of surgical skill and experience. Severe bony defects in the acetabulum should be filled by homogeneous bone grafts. Implantation of a Schneiderring together with the graft gives sufficient stability. The new shaft should be cemented very carefully, avoiding cavities between bone, cement and stem. The shaft of the femur should be reinforced by a long bridging plate.

[Clinical manifestations of diffuse idiopathic skeletal hyperostosis (DISH)]. / Manifestationsformen der diffusen idiopathischen Skeletthyperostose (M. Forestier) in der HNO-Heilkunde.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH, Forestier disease) is in most cases a harmless, asymptomatic disease characterized by a massive, noninflammatory ossification with intensive formation of osteophytes affecting ligaments, tendons, and fasciae, especially of the spinal column. If the disease becomes symptomatic at all, the leading complaints will usually be dysphagia in the sense of a lump in the throat and difficulty in swallowing. However, in rare cases the osteophytes may influence the laryngeal function ranging from hoarseness and immobility of the vocal cord to life-threatening inspiratory stridor. Such laryngeal manifestations are almost unknown. PATIENTS AND METHOD: We report on three patients, two female and one male, suffering not only from chronic dysphagia but also from increasing inspiratory stridor and difficult breathing. RESULTS: Especially one case illustrates how difficult it can be to establish the etiological relationship between a cancer-like ulcer in the postcricoid region and a bilateral inactivity of the vocal cord on the one hand and DISH on the other hand. Only the resistance of the ulceration to any therapy as well as rare case reports in the literature confirmed our suspicion that the ulcer and disturbance of laryngeal function were caused by chronic pressure exerted by the huge vertebral osteophytes. In all three patients surgical resection of the osteophytes resulted in complete relief of complaints. CONCLUSION: Uni- or bilateral immobility of the arytenoids, possibly associated with chronic inflammatory hyperplasia of the tissue of the arytenoids and the postcricoid region, may be a symptom of an unusual manifestation of DISH.

[Treatment of necrosis of the femur condyle with a medial gliding knee prosthesis]. / Die Behandlung der Femurkondylennekrose mit der medialen Knieschlittenprothese.

Spontaneous osteonecrosis of the femoral condyles occurs rather seldom particularly in elderly patients. Whereas some authors recommend valgusosteotomy and bone drilling, implantation of a unilateral knee prosthesis should be performed in the presence of large defects. It is reported a series of 11 patients suffering from osteonecrosis of the femoral condyle. All patients were treated by a unilateral knee prosthesis with good results except one case. The filling of the defect with cancellous bone prior to the implantation of the condylar part of the prosthesis is mandatory.