[Trauma surgery - a lasting motivation]. / Unfallchirurgie - eine bleibende Motivation.

Retirement is a caesura already determined on the day of assumption of office. With an abundance of tasks and a long period of enthusiasm the turning point slips out of memory or is simply repressed. We should have the good sense to think about alternatives in advance after running a hospital for so many years. There is an abundance of tasks within and outside the profession. The continuation of long established collegial alliances all over the world presents an excellent opportunity to maintain surgical skills as well as to retain motivation in trauma care and to obtain a broader view of human society.

Intraoperative localization of calcification in the supraspinatus via a percutaneous marking suture after preoperative ultrasound.

In a prospective study, we evaluated the efficiency of a technique for localizing calcification via a marking suture. In 27 patients, we measured the distance between the center of the calcification and the long head of the biceps preoperatively. Intraoperatively, we determined the distance detected by ultrasound on the articular side of the cuff under arthroscopic visualization. In this position, a spinal needle was inserted through the supraspinatus tendon. A PDS suture was passed through the spinal needle into the joint. The spinal needle was then removed. The entrance point of the PDS suture into the supraspinatus tendon was localized in the subacromial space after resection of bursal tissue. We perforated the cuff with a spinal needle in this area to definitively detect the calcification. The calcification was pressed out of the cuff with a probe. With this technique, calcification could be removed arthroscopically in all patients. This operative technique led to a reduced operative time, with a mean of 19 minutes.

Regression and correlation analysis of preoperative versus intraoperative assessment of axes during navigated total knee arthroplasty.

OBJECTIVE: Modern computer assisted surgery (CAS) systems allow accurate positioning of the implants in navigated Total Knee Arthroplasty (TKA). However, when an operation is performed with a navigation system, it is important to know if the anatomical situation of the knee is reflected equally in both the preoperative image (e.g., CT) and the intraoperative navigation setup. In this study, we compared the preoperative anatomical situation to the virtual intraoperative situation of the navigation setup. MATERIAL AND METHODS: We analyzed 24 navigated operations. Intraoperatively, the condylar twist angle (CTA) was documented with the navigation system by measuring the angle between the transepicondylar axis (TEA) and posterior condyle axis (PCA). This data was compared with the preoperative data from the CT scan. RESULTS: Statistical analysis revealed that there was no correlation between the pre- and intraoperative data (r = 0.095). CONCLUSIONS: Statistically, there is no possibility of collecting the same angles and axes when using the two different methods (CT and navigation) on the same knee. It is not possible to copy the preoperative anatomical situation exactly with the virtual intraoperative data. Reasons for this include systematic errors, as well as inter- and intraobserver errors in both methods.

Locked posterior dislocation of the shoulder: treatment using rotational osteotomy of the humerus.

This study reports the use of rotational osteotomy in 10 patients with locked posterior dislocation of the shoulder. The average interval between injury and diagnosis was 155 days (range, 21-400 days). Patients were aged 40-78 years old, with an average age of 53 years. Articular impaction fracture of the humeral head involved 20-40% of the articular surface as determined by CT analysis. There were no postoperative complications except a transient axillary nerve palsy. Patients were started on immediate passive motion followed by an active program at 2-3 weeks. Using the Rowe/Zarins scale, six patients had good-excellent results, two fair results, and two poor results. The poor results were seen in cases where articular cartilage damage was advanced. Rotational osteotomy is an effective procedure at restoring glenohumeral congruity and early functional activity in the patient with locked posterior shoulder dislocation given the following criteria: (a) healthy articular cartilage, (b) a humeral head defect involving less than 40% of the articular surface, and (c) a patient who is able to participate in an active rehabilitation program.

An evaluation of retrieved UHMWPE hip joint cups.

In this study it is demonstrated that the combined chemical and mechanical influences of the implant situation cause property changes of ultra-high-molecular-weight polyethylene (UHMWPE) hip joint cups. Nearly 250 loosened hip cups, retrieved 3 weeks to 14 years after implantation, were investigated. The clinical long-term behavior of various shaped polyethylene hip sockets are statistically analyzed. The main damage features were defined and described. Density measurements show a density increase with implantation time and a dependence of these changes from implant position and loading conditions. The rate of extractable constituents also increases with course of time. An increased in vivo conditioned oxidation of the UHMWPE can be demonstrated by infrared (IR) spectrometry. The density increase can be explained by post-crystallization, which is the result of oxidative chain scission. This leads to a reduction of the average molecular weight of the PE and to an increased extractability of constituents. Since these changes have been recognized as the reasons for aging and failing of UHMWPE, the methods of material characterization used in this study for retrieved implants will help to develop suitable in vitro testing and simulating methods. Characteristic damage features of hip cups allow direct relationships with construction characteristics and their improvement.

[Indications, technic and results of autogenic bone transplantations]. / Indikation, Technik und Ergebnisse der autogenen Knochentransplantation.

The results of autogenous bone grafts to reconstruct defects created by fractures, pseudarthrosis, osteotomies and tumor-like lesions were analyzed in 397 cases. In the different fields of indication the grafts were repaired in approximately the same time and incidence. Stabile conditions at the site of defect are of utmost importance. Mostly the grafts were taken from the iliac crest and there the 0.3% incidence of postoperative hematoma is low. For a solid repair of the defect the grafts should not only fill the gap but also bridge the defect from fragment to fragment.

[Fatigue fracture of the femoral neck in a recreational runner. A case report]. / Der Ermüdungsbruch des Schenkelhalses beim Hobbyläufer. Ein Fallbericht.

A report about a hobby runner's femoral neck fatigue fracture is presented. Femoral neck fatigue fractures are rare injuries. Young soldiers occasionally are involved. The under-evaluation of pains in the inguinal region delies the diagnosis. The femoral neck breaks under cyclic load. Therefore the operative treatment is necessary though the injury could be treated conservatively during early stage.

[Isolated injury of the subscapular muscle tendon]. / Die isolierte Verletzung der Sehne des M. subscapularis.

Avulsion of the subscapularis tendon is caused by a combined abduction and external rotation trauma of the upper limb. Weakness of internal rotation and a positive apprehension test are clinical signs of the injury. A fracture of the lesser tuberosity in the x-ray film or a disruption of the subscapularis tendon documented in dynamic sonography of the shoulder clarify the diagnosis. Operative treatment is indicated of prevent weakness of internal rotation as well as anterior instability. This recommendation is supported by four cases with full range of motion and good anterior stability after surgery.

[Compound osteosynthesis in spontaneous femoral fractures]. / Verbundosteosynthese bei Spontanfrakturen am Femur.

Compound osteosyntheses are in fact mostly intended to effect temporary (i.e. for a limited time) stabilization of pathological fractures, especially of spontaneous fractures in the case of metastasizing tumours. However, in view of the fact that progression of such tumours metastasizing into the skeleton cannot be predicted with reasonable accuracy, it is better to bridge over the spontaneous fracture not only by means of a compound of bone cement and metal plate, but also to see to it--as far as ever possible--that bony healing is induced via grafting of autogenous bone material. If this is not done, prolonged stress on the metal/cement compound may result in fatigue rupture.

[Subcutaneous tendon ruptures of the upper arm]. / Die subkutanen Sehnenrupturen des Oberarms.

25 subcutaneous tendon ruptures of the upper arm were operatively treated between 1982 and 1985. The long biceps tendon was ruptured fifteen times, the distal biceps tendon eight times and the triceps tendon twice. Operative procedures and the functional results are described. The follow-up investigation was undertaken on an average of 14 months after operation. Mechanism of injury and variations of histological findings in the different tendons are compared. The functional results are good. The operative treatment of subcutaneous tendon ruptures of the upper arm is therefore recommended.

[Reconstructive interventions following femoral fractures]. / Rekonstruktive Eingriffe nach Femurfrakturen.

The complex and simple fractures seen in polytrauma patients after initial treatment sometimes show signs of poor setting and non-union with possible unfavourable functional consequences making reconstructive surgery necessary. In this report characteristic posttrauma problems and reconstructive surgery of the proximal femur, the femoral shaft and the distal femur are discussed. Possibilities other than prothesis or joint fusion, especially in the hip or knee joint, should be considered.

[Treatment of the open tibial fracture with the fixateur externe with special reference to osteosynthesis of the fibula]. / Die Behandlung der offenen Unterschenkelfraktur mit dem Fixateur externe unter besonderer Berücksichtigung der Osteosynthese der Fibula.

In the treatment of open fractures of the lower limb and of fractures combined with severe damage of soft tissues, external fixation is favoured. Additional soft tissue damages in the compartments of the lower limb are avoided by using an external fixation in form of a clamp. In defect fractures, shattered fractures and in all fractures in the distal third the stability of clamp fixation is enhanced by plating of the fibula. Furthermore by osteosynthesis the reconstruction of the correct length of the lower limb can be performed. 36 fractures healed definitively in an average of 17.1 weeks by this procedure. Secondary procedures were: 8 cases with decompression of compartments, 11 cancellous bone grafts, 13 fixateur externes were removed because of the infection of the Schanz'screws, and healing was achieved by using a plaster cast. The therapeutical procedure was changed in 5 patients to a plate osteosynthesis and in 8 patients to an intramedullary nail.

[Differential diagnosis of shoulder dislocation with special reference to posterior dislocation]. / Die differenzierte Diagnostik der Schulterluxation mit besonderer Berücksichtigung der hinteren Luxation.

Evaluation of a dislocated shoulder must classify the direction of dislocation and describe additional injuries as well as the recurrence rate. This is required in all types of dislocations by recording the case history in detail, and by examining the shoulder clinically as well as radiographically in two planes. Ultrasound and arthro-computer tomography are valid methods to demonstrate injuries of bony and ligamentous structures. They may therefore influence surgical treatment. In posterior dislocation of the shoulder quite often early diagnosis is missed. If this injury is suspected, careful clinical and radiographical evaluation is most important.

[The treatment of distal radius fractures using the external fixator]. / Die Behandlung der distalen Radiusfraktur mit dem Fixateur externe.

This is a report on the stabilisation of fractures of the distal end of the radius type C2 and C3 and open fractures by external fixator. Between 1982 and 1989 38 patients with 43 fractures were treated. A follow-up was done 8 to 80 months after operation including 35 patients. 14 patients were polytraumatised. Especially in this group of patients, the advantages of this procedure can be seen. This advantages are a small stress for the patient, involving only a short time of assembling of the external fixator besides a high stability of the system. Our results show, as well as the results of the literature, that the external fixator has its place in a differentiated therapeutic concept of intraarticular fractures, open fractures and fractures with a defect of the distal radius.

[Modified transpeduncular spongiosa-plasty with osteotomy of the transverse process]. / Die modifizierte transpedunkuläre Spongiosaplastik mit Querfortsatzosteotomie.

Bone grafting of the vertebral body is an essential part in stabilisation of the spine. A modified transpeduncular approach to the vertebral body is described. Using this approach a bone graft can be placed more exactly in a shorter time.

[Problems of differentiating sacral fractures and fissure formations in the sacrum]. / Zur Problematik der Differenzierung von Kreuzbeinfrakturen und Spaltbildungen im Kreuzbein. Zwei Fallbeispiele.

It is shown on the basis of two observations that computed tomography represents a valuable additional means to clarify the diagnosis of congenital and traumatic changes in the pelvis, especially the sacrum and vertebral column. The article explains the differential diagnosis between congenital fissures of the pelvic arch and fractures by means of computed tomography. This is illustrated with the help of x-ray morphologic criteria.

[2d- and 3d-degree open fractures of the long tubular bones--therapeutic management and treatment results]. / Zweit- bis drittgradig offene Frakturen langer Röhrenknochen--therapeutisches Management und Behandlungsergebnisse.

In compound fractures, after debridement and stabilisation, primary open wound treatment with synthetic skin substitute is the method of choice. A follow-up examination of 171 second- and third-degree compound fractures between April 1974 and June 1981 showed an infection rate of 18,7% and an osteitis rate of 14,6%. In 23 cases conservative surgery was performed, in 17 cases primary amputation was necessary. In 85% of all cases bone healing was achieved after an average of 5,4 months.

[Differentiated therapy of distal radius fracture]. / Die differenzierte Therapie der distalen Radiusfraktur.

The fracture of the distal radius loco typico is one of the most frequently occurring fractures. This article presents types of fractures, in particular Colles', Smith's, Barton's and multiple-fragment's fractures. Conservative and operative treatment is described, as well as problems related to the different procedures. Besides fracture retention by plaster splint or cast, Besides fracture retention by plaster splint or cast, transcutaneous osteosynthesis by Kirschner wire, lag screws, osteosynthesis by buttress plate and the use of the external fixator are described as examples of operative therapeutics.

[Ludloff's osteotomy in hallux valgus surgery]. / Die Osteotomie nach Ludloff bei der Hallux-valgus-Operation.

The oblique osteotomy of metatarsale I according to Ludloff allows good and various corrections in hallux valgus deformities. Various modifications of the osteotomy are described. In case of simultaneous osteoarthritis of the metatarsophalangeal joint the additional resection according to Keller-Brandes is recommended.

[Indications and technique of arthrodesis of the knee joint (author's transl)]. / Indikation und Tecknik der Kniegelenksarthrodese.

The indications of an arthrodesis of the knee joint have changed and seem to be rare in a century of total arthroplasty. However, even nowadays the arthrodesis of the knee joint is still carried out with good results in: postinfectious gonarthrosis, irreparable posttraumatic instability, Charcots knee, Neoplastic destructions in special cases, for patients with a severe painful and deforming arthrosis of any reason, which are too young for an arthroplasty and in a century of arthroplasty for all patients after failure of arthroplasty. Within a period of 11 years from 1969-1980, 105 patients underwent an arthrodesis of the knee joint at BG Unfallklinik Tübingen. Indications and technique are given, the value of an individual postoperative care is pointed out.