Dorsal compression of the epidural cord due to free sequestral lumbar prolapse. Diagnostic problems in magnetic resonance imaging and computed tomography.

Due to the anatomical situation, intervertebral disc herniation usually results in compression of the anterior epidural space, with lateral or medial irritation of nerve root or cauda equina. Rare locations are an intra- or extraforaminal position or dislocation dorsally. Three patients with dorsal cauda equina compression caused by a sequestered herniated nucleus pulposus (HNP) are reported. The patients complained mainly of severe back pain. In two patients nondermatome-related leg pain was observed; one patient suffered additionally from incomplete cauda equina syndrome. In all cases magnetic resonance imaging and computed tomography diagnosed neoplastic tissue.

[The effect of various nucleotomy techniques on biomechanical properties of the intervertebral disk]. / Der Einfluss verschiedener Nucleotomietechniken auf die biomechanischen Eigenschaften der Bandscheibe.

AIM OF THE STUDY: The purpose of the present investigation was to determine the significance of the technique of nucleotomy for the biomechanical properties of the intervertebral disc. METHODS: From 29 human cadavers the lumbar-vertebral segment L2/3 was taken. The laminae were removed and the segment was tested by an mechanical testing device. Measurements were taken under physiological loads in flexion/extension, lateral bending and rotation direction. There after nucleotomy was simulated by four different procedures: perforation of the anulus with a diameter of 3 mm, rectangular excision (1 x 1 cm) of the anulus, discotomy with 3 g and 6 g nucleus pulposus. In each step the measurement was repeated. RESULTS: The size of the defect in the anulus fibrosus did not have significant influence on the stiffness of the disc. There was a significant relation between quantity of removed disc material and flexibility of the motion segment. CONCLUSION: The quantity of removed nucleus pulposus plays a crucial role in the segmental mobility whereas the size of the approach in the anulus fibrosus, f.e. endoscopic with a hole diameter of 3 mm or conventionally with a rectangular defect of 1 x 1 cm, did not influence mobility.

Significance of radiographic angle measurements in evaluation of congenital clubfoot.

Numerous formal, positional and angular foot skeleton deviations have been described in radiographic evaluation of congenital clubfoot. To clear up the correlation between clinical and radiological findings, a retrospective study involving 62 cases of congenital clubfoot in 38 patients was carried out, including follow-up observation for 7 years after soft-tissue surgery. Only clubfeet with grade II Harrold and Walker classifications according to the initial findings were included. Clinical follow-up examinations followed the Functional Rating System (FRS) of Laaveg and Ponseti. The postoperative talocalcaneal (TC) angle, measured on a lateral image, averaged 23 degrees as opposed to 32 degrees in healthy feet, i.e. much smaller, although this very significant angle dimension showed only minimum differences between the evaluation groups "very good" to "poor". The TC angle anteroposterior (AP), talonavicular angle (AP and lateral) as well as the calcaneometatarsal V angle revealed considerable deviations, although a correlation of clinical severity grading with the measured angular dimensions was not possible due to measurement imprecision and the range of values occurring within the different severity groups.

[Symptomatic low-energy shockwave therapy in heel pain and radiologically detected plantar heel spur]. / Symptomatische niedrig-energetische Stosswellentherapie bei Fersenschmerzen und radiologisch nachweisbarem plantaren Fersensporn.

QUESTION: The long-term analgetic effect of low-energetic shock-wave therapy in heel spur for two different numbers of applicated impulses is investigated. METHODS: 50 patients with recalcitrant heel pain and a plantar calcaneal spur on the X-ray received in a controlled, prospective and randomized study low-energetic extracorporal shock-wave-therapy. The first group received 3 x 500 impulses and the second group 3 x 100 impulses of 0.08 mJ/mm2 with an experimental device. The follow-up was 1 1/2, 3 and by telephone after 12 months. RESULTS: There was clear improvement and relief of pain in both groups on manual pressure and while walking and an increase of the pain-free walking ability from 10 minutes before the treatment to 2 and 3 hours respectively after 12 months. We saw a significantly better results after the treatment with 3 x 500 impulses. CONCLUSION: The extracorporal shock-wave therapy is an effective treatment in refractory heel pain. An amount of at least 3 x 500 impulses in the low energetic treatment is useful.

[Extracorporeal shockwave therapy in epicondylitis humeri ulnaris or radialis--a prospective, controlled, comparative study]. / Die extrakorporale Stosswellentherapie bei Epicondylitis humeri ulnaris oder radialis--Eine prospektive, kontrollierte, vergleichende Studie.

AIM OF THE STUDY: Has extracorporal shockwave therapy in chronic golfer's elbow comparable results as in tennis elbow? METHOD: 30 patients for extracorporal shockwave therapy who suffered from chronic medial epicondylitis (group I) and 30 patients with persistent tennis elbow (group II) received 500 impulses of 0.08 mJ/mm2 three times at weekly intervals. The final follow-up examination was done after 24 weeks. RESULTS: Significant differences in relief of pain and improvement of function were observed in favour of group II. Good or excellent outcome was found in only 27% for the epicondylitis humeri ulnaris, but in 60% for epicondylitis humeri radialis. CONCLUSION: The indication for extracorporeal shock-wave therapy in medial epicondylitis must be questioned.

[Diagnosis and long-term outcome after surgical therapy of tarsal tunnel syndrome]. / Diagnostik und Langzeitergebnisse nach operativer Therapie des Tarsaltunnelsyndroms.

In differential diagnosis of foot pain the tarsal tunnel syndrome has to be considered. Only few publications concerning clinical signs, diagnostic means, especially electrophysiological methods and postoperative long term results can be found in literature. In this study 21 of 32 patients who had a decompression operation of the posterior tibial nerve between 1972 and 1995 were reexamined at an average follow-up time of 12 years. Electrodiagnostic evaluation and clinical results by time of follow-up were compared to preoperative findings. Using the criteria described by Kaplan 10 postoperative results were rated as very good, 6 as good and 5 as poor. Sensible neurography has proven the most sensitive electrodiagnostic method. In the majority of cases the tarsal tunnel syndrome is still a clinical diagnosis.

[Ultrasound image of the lumbar spine and the lumbosacral transition. Ultrasound anatomy and possibilities for ultrasonically-controlled facet joint infiltration]. / Die Sonographie der Lendenwirbelsäule und des lumbosakralen Uberganges. Sonoanatomie und Möglichkeiten der sonographisch gesteuerten Facettengelenksinfiltration.

QUESTION: Is sonography helpful in facet joint infiltration of the lumbar spine? METHOD: The sonoanatomy of the lumbar spine and the of lumbosacral junction was examined and described in a skeleton and in 10 volunteers. One representative cross section and 3 longitudinal sections were defined. According to these results (no neurological symptoms) the possibilities of ultrasound guided infiltration of the facet joints was examined in 78 patients (36 female, 42 male, average age 55 y., 38-78 y.) with chronic low back pain and increase of pain by hyperextension. 5 ml Carbostesin partially in combination with steroids were applied to each joint. In all cases the tip of the syringe could be placed on the joint. RESULTS: There were no complications, especially no infection or neurological symptoms. Application of local anaesthetics into the spinal canal could be excluded in all cases. The sonoanatomy of the lumbar spine and of the lumbosacral junction can be reproduced. Sonography allows an accurate infiltration of the facet joints of the lumbar spine. Applications into the spinal canal can be avoided. CONCLUSIONS: This method is a secure and economic (extra time 2-4 min.) alternative to clinically guided infiltration. Flouroscopy guided infiltration is needed only in anatomical variations or if strictly intraarticular application is necessary.

[Radiological changes after implantation of 2 different cementless hip prostheses]. / Radiologische Veränderungen nach Implantation zweier unterschiedlicher zementfreier Hüftschaftsysteme.

PURPOSE: Of the study was to evaluate radiological alterations of the femoral bone after implantation of two different prostheses. METHODS: 81 patients with 87 hips underwent total hip arthroplasty by using the Zweymüller-stem fixating in the medullary canal, and 175 patients with 182 ABG-stems with a proximally fixating, anatomical design were followed up clinically and radiologically. RESULTS: Adaptive bone remodelling in Zweymüller-stems showed in some patients thickening of the cortex of the femur and proximal bone-stock loss; reactive lines were seen in the proximal areas surrounding the prosthesis. Radiographs of patients with ABG-stems showed these lines in the distal, smooth part of the prosthesis and cancellous densification occurred in the area of load transfer distal to the trochanteric region. CONCLUSION: Typical x-ray findings due to various stem designs were identified and can be transferred to other cementless prostheses and should be considered if there is a suspicion of aseptic loosening.

[Long-term results of triple arthrodesis in neurogenic foot deformities]. / Langzeitergebnisse nach Triple Arthrodese bei neurogenen Fussdeformitäten.

The number of good results after triple arthrodesis due to neuromuscular foot disorders in literature varies between 24% and 94%. 46 patients with 64 triple arthrodesis due to neuromuscular foot disorders were reexamined 18 years (15 to 25 years) after the operation. In 36 cases arthrodesis was performed by k-wire and pin fixation and in 28 cases by k-wire and screw-fixation. For preoperative and follow-up grading the McGuire score was used which increased on the average due to the operation from 58 to 89 points. Good and excellent results were found in 91% of the patients. Triple arthrodesis in patients with neuromuscular foot disorders is recommended. It leads to functional good results with a small amount of complications.

[Diagnosis and therapy of erosive intervertebral osteochondrosis]. / Diagnostik und Therapie der Erosiven Osteochondrosis Intervertebralis.

Pathogenically the erosive intervertebral osteochondrosis is the destructive form of the intervertebral osteochondrosis. This paper aims to define this acute variant by means of diagnostic criteria. In differential diagnosis a spondylodiscitis, an ankylosing spondylitis, a destructive spondylo-arthropathy and a morbus Scheuermann must be considered. Fifteen patients with erosive osteochondrosis were treated at the Department of Orthopaedic Surgery of the University of Mainz between 1990 and 1994. The diagnosis on admission into hospital was incorrect in all cases. Plain X-rays showed a decrease in height in the affected intervertebral room and bony erosions of the adjacent vertebral endplates. Distinction to spondylodiscitis was possible in MRT. In contrast to erosive osteochondrosis in spondylodiscitis edema cannot only be seen in the adjoining vertebrae but also in the affected disc. In later paravertebral inflammatory abscess often can be found. After conservative treatment four patients were free of complaints. 11 patients were operated on due to neurologic symptoms or increasing kyphosis of the lumbar spine. At average follow-up of 16 months intervertebral fusion was found in all operated patients. Lack of publicity and severance to spondylodiscitis seem to be major problems in diagnosing erosive osteochondrosis.

[Indications for surgical treatment of clavicular fractures]. / Indikation zur operativen Behandlung von Klavikulafrakturen.

Most fractures of the clavicle can be successfully treated by conservative management. In few cases however primary or secondary operative stabilisation is necessary. Good results can only be obtained considering clearly defined indications and correct surgical techniques. Reconstruction-plates and Small-dynamic-compression-plates have proved best to provide internal fixation. In a period of 6 years 262 patients with fractures of the clavicula were treated in the Unfallchirurgischen Klinik Hofheim, eleven of which by operative means. We report on those 11 patients that have undergone surgical treatment. Indications, operation techniques and results will be presented and discussed in comparison to recent literature.