[Etiology and pathogenesis of epiphyseal necrosis in childhood as exemplified with the hip]. / Atiologie und Pathogenese der Epiphysennekrose im Kindesalter am Beispiel der Hüfte.

In many cases the etiology of juvenile necrosis of the femoral head has not been unequivocally explained. Essentially, however, it is due to reduced arterial blood flow, although venous congestion also has to be considered. Epiphyseal necrosis is frequently a result of known underlying diseases. These include, for example, both specific and nonspecific forms of coxitis and rheumatic coxitis, hormonal dysfunctions, metabolic disorders such as mucopolysaccharidosis, blood diseases (e.g. hemophilia, sickle cell anemia), leukosis, and tumors and necrosis following cortisone and cytostatic therapy. The following four factors may directly or indirectly cause arterial vascular damage and thus necrosis: 1) primarily exogenous and 2) primarily endogenous factors, 3) genetic, and 4) skeletal maturation factors. These etiological factors are described in detail and discussed. Epiphyseal deformation occurs in a strict sequence of five phases, which are described. It should be emphasized that while necrotic bone tissue is being gradually resorbed, deposits of new bone matrix are already accumulating on dead trabecula and will subsequently form new bone fibre. In other word, a gradual substitution takes place. Two important clinical facts derive from this. First, epiphyseal crash is not due to the load of the body's weight. Since active resorption takes place, there is no justification for weight-relieving therapy in the basic therapeutic concept for Perthes' disease. Second, in light of our studies, surgical containment therapy appears to be the most suitable form of treatment if performed at the right time, i.e. in the golden period of remodelling, depending on the patient's age, the extent of necrosis and the degree of dislocation. Where stringent criteria are fulfilled we perform a three-dimensional intertrochanteric osteotomy, i.e. an extension-derotation reduction osteotomy.

[Ultrasonography of the spine in infancy]. / Die Wirbelsäulensonographie im Säuglingsalter.

QUESTION: Based on a standardized technic and reliable attachment of the presented structures the suitability of spinal sonography as a screening-method in newborns and infants should be estimated. METHODS: Enabled by the comparison of sonographic transverse and sagittal plains with identical anatomic sections of an infant corpse the anatomic structures of an healthy spine were associated, which was verified in the clinical use later on. RESULTS: Exemplary photographs of a collective of 50 newborns and infants reproduce the presentation of the spine found in the preparation of the corpse. The technical practicability of such an examination in clinical use was confirmed herein and it became clear that the application of this method is limited from the 6.-8. months of living on because of the increasing ossification which involves a reduction of the image quality. The deviations from the spine presentation in normal relations were shown by some ultrasound examples of malformed spines (spinal dysraphism, hemivertebrae). CONCLUSION: Reproducible attachment of the structures obviously seen with ultrasound and the clear demarcation of deformations as well as the simply practicable examination make evident the suitability of spinal sonography in newborns and infants as a noninvasive screening for the exclusion of spine malformations.

[Experiences with cement-free implantation of the Zweymüller/Endler and Zweymüller total hip joint endoprosthesis. Indications, results, complications and modification of periarticular ossification by diphosphonate (ethylidene-1-hydroxy-1,1-diphosphonate)]. / Erfahrungen mit der zementfreien Implantation der Zweymüller/Endler- und Zweymüller-Hüftgelenks-totalendoprothese. Indikation, Ergebnisse, Komplikationen und die Beeinflussung der periartikulären Ossifikationen durch Diphosphonate (EHDP).

In the last six years the authors have implanted 340 hip joint prostheses of the Zweymüller/Endler or Zweymüller type in 285 patients from the lateral transgluteal approach. Approximately one-third of these patients (111) had previously undergone surgery on the hip joint in question. Intraoperative complications included four cases of elongation of the leg due to implantation of an over-long prosthesis shaft. Four of the shafts implanted were too small and in two cases subsequently loosened. In two patients a divulsion of the trochanter major occurred and there were two cases of cracking of the calcar femoris with involvement of the trochanter minor. There were also two cases of shaft divulsion at the level of the prosthesis tip. Postoperative complications included periarticular ossifications in 41 cases. There were 11 cases of phlebothrombosis and six of pneumonia. Superficial hematomas developed in the wound region in four cases. In addition, there were two cases of shaft and one of acetabular loosening, as well as three prosthesis dislocations. Between October and December 1987, a total of 232 of these patients were examined and the results rated according to Merl d'Aubigne's classification: 166 (71%) were classified as very good or good, 49 (21%) as satisfactory, and 17 (7%) as unsatisfactory. The most common postoperative complication was periarticular ossification, seen in 41 cases. Even though this is not a serious complication and the periarticular ossifications did not necessarily result in severe limitation of movement, a major functional loss as compared to the preoperative findings was seen in the patients with severe ossification (IIIrd degree) at the examination 12 months postoperatively. By giving EHDP, since November 1984, it has proved possible to reduce the incidence of periarticular ossifications from 28 to 12%. In the last 24 months even better results have been achieved by administration of EHDP unter function-scintigraphic control. According to the author's results the Zweymüller/Endler and Zweymüller systems satisfy the requirements for a cement-free total hip replacement since, on the one hand, intraoperative and postoperative complications are slight and, on the other, a good functional result is achieved. The Zweymüller prosthesis has proved particularly suitable for hip joints operated on previously.

[Experiences with Wagner's hip joint cup endoprosthesis. Indication, results complications]. / Erfahrungen mit der Hüftgelenksschalenendo-prothese nach Wagner. Indikation, Ergebnisse, Komplikationen.

In the last 5 years the authors have installed Wagner hip joint cup prostheses in 260 patients. Of these, 211 were implanted with an iliofemoral approach after Smith-Petersen, severing the pelvitrochanterian musculature, and 49 with a lateral approach after Watson-Jones, modified after Harris, with temporary ablation of the trochanter major. Altogether, 160 of the patients thus treated were followed up 3, 6, 18, 24, 30 and 36 months after surgery. The most common postoperative complication, found in 36% of those examined, was periarticular calcification, which was rated as severe in 5%, moderate in 15% and slight in 16%. Even though the periarticular ossifications did not necessarily lead to severe restrictions of movement, the patients with severe and moderate calcifications who were examined after 3 years were found to have a reduction of function of approx. 24% in flexion and extension, approx. 50% in abduction and adduction and approx. 57% in internal and external rotation compared with preoperative findings. In contrast, patients with no significant periarticular ossifications were found to have a definite improvement in motility 3 years after surgery as compared to their preoperative conditions. Further important complications were 2 infections, 3 fractures of the neck of the femur, 3 slipped prostheses and 23 cases of loosening of the prosthesis. The number of loosened prostheses (9% of those examined) represents a marked increase as compared to the loosening rate with conventional total hip replacements.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis, differential diagnosis and therapy of lymphedema]. / Diagnose, differential- diagnose und therapie des lymphödems.

Swellings in the legs, caused by lymphedema, are encountered quite frequently in everyday orthopedic practice. The swellings are hard, pale in color and usually painful. Swellings of this kind occasionally atrain a completely disproportionate size and are the referred to as elephantiasis. Lymphedemas fall into two categories: 1. Congenital lymphedemas. These comprise lymphedemas occuring as a result of aplasias or dysplasias of lymph vessels. 2. Acquired lymphedemas: In such cases the edema may be due to mechanical causes, or it may be the result of a disturbance of lymph drainage, e.g., due to the destruction of lymph vessels by metastases, following extirpation of lymph nodes and radiation therapy; or it may be the result of inflammatory processes, e.g., following erysipelas, in filariasis or after a wound infection. Four stages of lymphedema are also distinguished: Stage I - latent lymphedema Stage II - reversible lymphedema Stage III - irreversible lymphedema Stage IV - Elephantiasis. Apart from clinical diagnosis the most comprehensive and reliable diagnostic procedure is lymphangiography. A simple and well-tried method of diagnosing lymphedema is to inject lymphotropic dye subcutaneously. The technique is outlined. The differential diagnosis of lymphedema is described. With regard to treatment, reference is made to surgical possibilities. However, these do not always augur success and the complication rate is high. Massive lymphedemas, therefore, are usually treated conservatively, by Van der Molen's tube method, with intermittent cuff pressure (pressure-curve therapy) and manual lymph drainage. The various treatment methods are described and some of the disadvantage and risks involved are pointed out.

[Notes on the indication of corrective osteotomy in Perthes' disease (author's transl)]. / Zur Indikation der Varisierungsosteotomie beim Morbus Perthes. (Ein morphologischer Vergleich zweier Behandlungsverfahren).

The results of surgical (corrective osteotomy) and conservative therapy (Thomas splint treatment) are compared in 88 patients suffering from Perthes' disease. It is attempted to show whether the age of the patients, the stage of disease, centric or excentric head of femur, Cattherall's stage or any risk factors influence the results. Statistics show that only young children profit from surgical treatment whereas it offers no advantage to children over six years of age. Among the young children only those with excentric head of femur, show significantly better results as opposed to conservative splint treatment. Surgery is otherwise only indicated when it is seen as an alternative to prolonged splint treatment.

[May Perthes' disease be due to venous block? Experimental investigations on growing pigs]. / Gibt es einen Morbus Perthes durch venöse Stase? Experimentelle Untersuchungen am wachsenden Schwein.

In 13 growing pigs (mini-pigs) all veins draining the head of femur were ligated intra-abdominally. In 2 i.v. injection of 12% Varigloban into the common iliac vein was added, in another 2 the same drug was injected into the head of femur. No real changes could be seen in X-rays, macro- and microscopically. Slides showed only more or less pronounced fibrosis. Scintigrams showed a reduction of radio-active storage in the head of femur by about 12%. The results and conclusions for human pathology are discussed.

[Age dependent possibilities for healing in cartilage injuries (experimental investigations with animals) (author's transl)]. / Altersabhängige Heilungsmöglichkeiten von Knorpelwunden (Tierexperimentelle Untersuchungen)

Regenerative and degenerative changes of cartilage were studied in animals by micromorphological methods and autoradiography. Cartilage lesions of defined size were set in the femoral condyle of rabbits of variing age by means of an electrical drill developed by us. We used juvenile animals, 3 months old, and senile animals 4 years old. The lesions were studied by lightmicroscopy, electronmicroscopy and scanning electron microscopy. In young animals we were able to demonstrate prevailing reparative changes after injury and the potency for genuine regeneration originating from cartilage. Isolated chondral lesions develop reactive tissue originating mainly from superficial parts of the cartilage. When subchondral bone is exposed we see granulation tissue filling up the defect and change by metaplasia. The replacing tissue originating from superficial cartilage as well as from subchondral bone is able to fill the defect within 3 months. In the replacing tissue originating from cartilage we find fibroblasts and fibrocytes with many mitoses. Consecutively the cells are rounding increasingly. Finally chondrocytes are developing. At the same time as these reparative changes occur we see degenerative changes with decreased mucopolysaccharide synthesis, cell necroses with consecutive decrease in number of cells and singular small cluster. In old animals we could not demonstrate any reparative or regenerative changes after injuries; the artificial defect in cartilage persists. Instead, degenerative changes with signs of arthrosis are developing rapidly: chondroitin sulfate synthesis is decreased, there is ample cluster formation, cell necrosis, decrease in number of cells, and incorporation of paraplasmatic substances in cartilage. We could not demonstrate any mitoses. The causes for the inability of cartilage of aged individuals for reparative changes are discussed.

[Complications after total hip replacement (author's transl)]. / Komplikationen der Totalendoprothese

Alloarthroplastic replacement of the hip comprises certain risks. Therefore good apparative and instrumental equipment and biological understanding of the post operative phase are necessary. Our rate of operative complications was 1.3% of all cases. In this number fat embolism after implantation of acrylic cement is of special interest. Reference is made of animal experiments on the pathogenesis of this phenomenon. Early complications comprise luxation of the prosthesis, bleeding and hematoma formation, iliotibial-nerve syndrome, phlebothrombosis, embolism, early infection. Late complications comprise infection and loosening of the prosthesis. In a total of 1200 implantations we had early complications in 1.8% and late complications in 0.9%. Reference is made of clinical and X-ray signs of loosening of the implant. Arthrography proved to be the most dependable method. We found periarticular calcifications in 30% of all cases. Fractures of the prosthesis were extremely rare: in few cases we found fractures of the polyestercup. In all cases the aggressive granuloma will leed to rarefication of bone sooner or later going along with loosening of the implant.