Radiologic and long-term clinical outcome from treatment of isolated medial orbital wall blowout fractures.

Blowout fractures in the medial orbital wall may lead to enophthalmos, ocular dysmotility, and diplopia. Ten consecutive patients with unilateral, isolated fractures of the medial orbital wall were retrospectively studied. The radiologic accuracy of the medial orbital wall reconstructions and the long-term clinical outcomes were assessed. All cases were treated through a bicoronal approach and by use of porous polyethylene-titanium implants. The total fracture area and the orbital volume increase from the blowout were measured on computed tomographic scans. Next, we evaluated the reconstruction in the posterior part of the medial wall. This was done by calculating the ratio between the defect area and the implant area located behind the anterior ethmoidal canal. The patients were examined at least 1 year after the operation, and the rates of enophthalmos and diplopia were evaluated. The mean fracture defect area was 2.45 cm2 (range, 0.41-4.16 cm2), and the mean volume increase from the blowout fractures was 1.82 cm3 (range, 0.53-2.76 cm3). The orbital volume was accurately restored in all patients. However, the ratio of implant to defect area behind the anterior ethmoidal canal ranged from 0% to 100% (mean, 47.3%). None of the patients had enophthalmos or diplopia at the long-term follow-up. The results confirm that restoration of orbital volume is important to prevent postoperative enophthalmos in isolated medial orbital blowout fractures. Complete reconstruction of the most posterior part of the medial orbital wall seems to be of lesser importance.

Gelatin-based haemostyptic Spongostan as a possible three-dimensional scaffold for a chondrocyte matrix?: an experimental study with bovine chondrocytes.

The gelatin-based haemostyptic compound Spongostan was tested as a three-dimensional (3D) chondrocyte matrix in an in vitro model for autologous chondrocyte transplantation using cells harvested from bovine knees. In a control experiment of monolayer cultures, the proliferation or de-differentiation of bovine chondrocytes was either not or only marginally influenced by the presence of Spongostan (0.3 mg/ml). In monolayers and 3-D Minusheet culture chambers, the cartilage-specific differentiation markers aggrecan and type-II collagen were ubiquitously present in a cell-associated fashion and in the pericellular matrix. The Minusheet cultures usually showed a markedly higher mRNA expression than monolayer cultures irrespective of whether Spongostan had been present or not during culture. Although the de-differentiation marker type-I collagen was also present, the ratio of type-I to type-II collagen or aggrecan to type-I collagen remained higher in Minusheet 3-D cultures than in monolayer cultures irrespective of whether Spongostan had been included in or excluded from the monolayer cultures. The concentration of GAG in Minusheet cultures reached its maximum after 14 days with a mean of 0.83 +/- 0.8 microg/10(6) cells; mean +/-, SEM, but remained considerably lower than in monolayer cultures with/without Spongostan. Our results suggest that Spongostan is in principle suitable as a 3-D chondrocyte matrix, as demonstrated in Minusheet chambers, in particular for a culture period of 14 days. Clinically, differentiating effects on chondrocytes, simple handling and optimal formability may render Spongostan an attractive 3-D scaffold for autologous chondrocyte transplantation.

Proprioceptive skills and functional outcome after anterior cruciate ligament reconstruction with a bone-tendon-bone graft.

Several studies have shown that patients with anterior cruciate ligament (ACL) reconstruction have an improved proprioceptive function compared to subjects with ACL-deficient knees. The measurement of functional scores and proprioception potentially provides clinicians with more information on the status of the ACL-reconstructed knees. To evaluate proprioception in patients following ACL reconstruction with a bone-tendon-bone (BTB) graft, we used the angle reproduction in the sitting, lying and standing positions and the one-leg hop test. Forty-five patients between 19 and 52 years of age were investigated in a 36-month period after the operation. For functional performance measurement, the International Knee Documentation Committee (IKDC) score was used. Very good and good results were seen in 95% of cases. All patients returned to the same activity level as seen before ACL repair. There was a significant difference in the active angle reproduction test between the ACL-reconstructed knees and normal knees in the active sitting position. Tests with passive angle adjustment in the sitting, lying and active standing positions did not show any differences in proprioceptive skills. Good to very good results in the one-leg hop test we found in 95% of patients. After ACL reconstruction, deficiencies in the active angle reproduction test were very small but, nevertheless, were still observed. Overall, the functional and proprioceptive outcomes demonstrate results to recommend the procedure.

[Radiological and clinical functional examinations 36 months after anterior cruciate ligament repair by a patellar tendon graft]. / Radiologische und klinisch funktionelle Untersuchung 36 Monate nach vorderer Kreuzbandplastik mittels Patellarsehnentransplantat.

AIM: The aim of this study was to examine radiological and functional outcome measurements after anterior cruciate ligament (ACL) reconstruction with a bone-tendon-bone (BTB) graft. Investigations included assessment of bony integration conditions regarding the use of bioabsorbable cross pins or a lateral screw for femoral graft fixation. A description of radiological parameters in contrast with IKDC findings is also given. METHOD: After ACL injuries, 45 patients underwent an ACL repair. For tibial tunnel placement the tibial guide was used in full knee extension. A size-specific femoral aimer was placed by using the transtibial technique in the "over the top" position and the tunnel was reamed with the acorn reamer to 30 mm depth. In 15 patients the BTB graft was fixed with a titanium blunt nose screw from the lateral aspect. The cross-pin technique with bioabsorbable RIGIDFIX implants was used in 30 patients. All patients underwent a follow-up study 36 month postoperatively. Geometric tests of digitised X-rays were performed. For clinical and functional outcome studies of ACL repairs the IKDC score is widely accepted. The score was modified into numeric parameters for 15 selected groups of the IKDC score. All 15 categories were rated from 1 to 4 points (Category A = 4, B = 3, C = 2, D = 1). Clinical and radiological results were statistically analysed. RESULTS: According to the literature, tunnel placement tibial was physiological in 91% and femoral in 93% of the cases. The femoral tunnel was completely invisible in all patients. No necrosis or pathological findings in former pin holes were seen. In 24 patients the medial compartment space was smaller, but less than 50 % compared to intraoperative X-rays. Even if the mean of tibial tunnel widening was 2.65 mm it was statistically not connected to the results of the IKDC score or X-ray findings of the femoral tunnel. Results in the IKDC groups and categories were seen to be in accord with overall very good and good outcomes. The modified IKDC score showed a mean of 55 points with a range from 46 as lowest (1 patient) and 60 in 4 patients (9%) as highest numeric score. CONCLUSION: Lateral femoral fixation with screws or bioabsorbable cross-pins shows a biological bony incorporation of a BTB graft. Tibial tunnel widening was seen but without any functional effects. Overall radiological and functional outcomes based on the IKDC score demonstrate results in favour of ACL reconstruction with BTB grafts. Due to the narrowing of the medial compartment space, more radiological outcome studies with a special emphasis on degenerative aspects have to be done.

Press fit fixation of cementless cups: how much stability do we need indeed?

INTRODUCTION: Using screws for a better primary and secondary fixation has been discussed in the literature of the recent years, although the principle of press fit has been explained as the principle of a push-button. The authors wanted to compare their own results in patients using X-rays from the postoperative course to decide if it is really safer to use screws or not. MATERIALS AND METHODS: Two hundred and twenty one consecutive, not selected patients were treated with total hip arthroplasty using a cementless cup type Duraloc. They were followed up over a time of 5 years for radiological changes of the bony acetabulum around the cup ("acetabular zones" according to De Lee and Charnley). One hundred and ten cups were additionally fixed with one to three screws at the upper part in region C1, 101 cups were implanted without the use of screws. RESULTS: Periprosthetic changes visible on the radiographs (immediate postoperative gaps, subsequent sclerosis and radiolucent lines) were assessed according to the time of their appearance. A gap in zone C2 was seen more often immediately after operation within the group without screws (17.8% vs. 7.3%) and disappeared within the following 25 months. Within the group with screws significantly more often a gap was found in zone C1 and C3 compared to the group without screws (7.3% vs. 1.9%). In the group with screws a sclerosis of the bone in zone C1 developed in 32.7% mostly within the first 5 months. It was followed by a radiolucent line in zone C3 in 28.2% mainly within 5-25 months postoperatively and in zone C1 in 20.9% within 16 months. Significantly less seldom were these phenomena seen at the cups without screw fixation. There was no correlation between lateral or medial positioning and deviations from the ideal inclination to the bony changes around the cups. No signs of loosening occurred in either group. CONCLUSION: Less radiological changes around the cup if no screws were used and no disadvantages within this group led to the conclusion that an additional screw fixation in principle is not necessary in press-fit cups.

Solitary fibrous tumor in the thigh: review of the literature.

Solitary fibrous tumors (SFT) of extremities, especially the thighs are very rare. Despite SFTs are generally benign, well-circumscribed soft tissue tumors new cases should be presented and followed up carefully to monitor their biological behavior. In general for tumor classification a biopsy is state of the art. Histological including immunohistochemical patterns for SFTs are defined. MRI and ultrasound are not sufficient for differential diagnosis. Once property identified and defined by size and location, resection with intact tumor capsule may result in full recovery of the patient. Reviewing the literature there are no validated reasons for a wider resection. The current patient was a 41-year-old male. Four years after an arthroscopy of the left knee the patient has been suffering an ongoing swelling of the lateral thigh. Because MRI scan data suggested a synovial sarcoma a biopsy was performed. The tumor was classified as a benign SFT. The diagnosis based on histological findings and the presence of the positive immunohistochemical markers Vimentin, CD34, and CD99. The complete tumor resection with intact capsule was achieved in a final operation. Clinical and in MRI after 54-month outcome period there were no local recurrences.

[Can the number of thromboembolisms incidents in total hips replacement be further reduced?]. / Ist die Zahl thrombembolischer Ereignisse in der Hüftendoprothetik weiter verringerbar?

QUESTION: Is it possible to reduce the rate of thrombembolic events during total hip arthroplasty (THA) by the intraoperative use of a mechanical device for thrombembolic prophylaxis (A-V Impulse System). METHOD: The efficacy of additional mechanical thrombembolic prophylaxis was investigated in a prospective randomised trial on 104 patients who underwent cementless THA. All patients received low dose heparin. In 52 patients the additional application of the A-V Impulse System was introduced intraoperatively for the next 24 h. A perfusion scintigram of the lung was performed before and 7 days after the operation in both groups to detect embolic patterns. RESULTS: Perfusion deficits typical for thromboembolic events were detected postoperatively in 8 patients (15.4 %) of the controls and 5 patients (9.6 %) of the A-V Impulse System group. CONCLUSIONS: With the perfusion lung scan we saw postoperatively a total of 13 patients (12.5 %, n=104) with an asymptomatic microthromboembolism of the lungs. Hence it is necessary to increase the protection against thromboembolism. Although statistically not significant (p=0.374), there is a tendency that the additional use of the mechanical thrombotic prophylaxis can reduce thromboembolic events in THA. The impact of the intraoperative introduction of the A-V Impulse System is not really clear. However, for a higher velocity of blood flow during the operation it makes sense to start the procedure intraoperatively.

The long-term results of resection arthroplasties of the first metatarsophalangeal joint in rheumatoid arthritis.

We performed a retrospective study in 188 patients (254 feet) with rheumatoid arthritis and compared the late results of Keller's procedure with those of Hueter-Mayo's technique after 7.9 years. More than 60% of the Keller group and 30% of the Hueter-Mayo group were suffering from persistent metatarsalgia due to increased forefoot pressure as well as experiencing pain around the great toe. Plantar callosities, recurrent hallux valgus deformity, lack of plantar flexion and weakened push-off were more frequent after Keller's procedure.

[Complications and therapy after arthroscopic interventions of the knee joint]. / Komplikationen und deren Therapie nach arthroskopischen Eingriffen am Kniegelenk.

Complications following arthroscopic knee surgery are known from the literature to be relatively rare. It hence is all the more important for the rehabilitation staff to know the possible risks for complications. Usually it is quite sufficient to perform a good clinical examination in case of complications in order to be able to carry out the necessary therapeutic measures in regular contact with the surgeons involved. Among the most dangerous complications requiring immediate therapy are the extraarticular vascular complication, the knee joint infection, and the intraarticular bleeding complication. Responsible teamwork among surgeons and rehabilitation staff will be the key to a successful treatment outcome.

[Critical evaluation of indications for the holmium:YAG laser and the neodymium:YAG laser in orthopedic surgery based on an in vitro study]. / Kritische Betrachtung der Indikationen des Holmium: YAG- und des Neodym:YAG-Lasers in der orthopädischen Chirurgie anhand einer In-vitro-Studie.

This is an in vitro study of the biophysical effects of holmium:YAG and neodymium-YAG lasers that was prompted by the poor clinical results obtained with lumbar percutaneous laser discus decompression (PLDD). In the absence of adequate cooling, ablation of tissue with the holmium:YAG laser causes thermal damage to the surrounding tissues. Utilizing the immediate colour-independent laser coupling effect, the holmium:YAG laser removes soft and hard tissue immediately. The low tissue penetrating power (max. 0.32 mm), together with the use of irrigation, avoids thermal problems, and this laser type with its high pulse energy and frequency is to be recommended for arthroscopic surgery. In contrast, the effects of the neodymium:YAG laser are highly dependent on tissue colour. Using this laser on light-coloured tissue only diffuse warming but no ablation of soft tissue was often seen. The depth of tissue penetration seen in our study was 0.58 mm, but is greatly dependent on the duration of application, and is much larger with long application times. In conclusion, we believe that the neodymium:YAG laser is more suitable for percutaneous intradiscal procedures than the holmium:YAG laser. For arthroscopic surgery, the holmium:YAG laser will be the better choice. The effect of each type of laser depends not only on its physical properties, but also on tissue properties (light or dark-coloured, thermal conductivity) and duration of application.