[Classification and treatment of patella fractures]. / Einteilung und Therapie der Patellafraktur.

Patella fractures are rare and account for approximately 1% of all fractures. They are classified regarding their localization (proximal, distal) and appearance. The aim of any treatment is reconstruction of the extensor mechanism and joint surface. If dislocation and cartilage steps are less than 2 mm, conservative treatment may be indicated. Operative treatment is only necessary if a dislocation is more than 2 mm or when the extensor mechanism is unstable. Depending on the shape of the fracture, tension band wiring, interfragmentary screw fixation and combinations are the main techniques. Because patellectomy has functionally the worst result it should be avoided. Sleeve fractures (children) need exact reconstruction of the joint surface. In elderly patients conservative treatment or surgical patella-enclosing wiring techniques for stabilization are the best options due to low bone quality.

Acute injuries in Taekwondo.

Although Taekwondo is becoming an increasingly popular sport, there is a lack of reliable epidemiologic data on Taekwondo injuries. To perform an epidemiologic study on the variety of types of injury in professional and amateur Taekwondo athletes and to find a relation between Taekwondo style, skill level, weight-class and warm-up routine and the occurrence of injuries, we analysed the injury data using a 7-page questionnaire from a total of 356 Taekwondo athletes who were randomly selected. Overall, we registered a total of 2,164 injuries in 356 athletes. Most traumas were contusions and sprains in the lower extremities. Professional Taekwondo athletes have an increased risk of injury in comparison to recreational athletes. Taekwondo style, weight class and tournament frequency have an influence on the athlete's injury profile. Warm-up routines were found to have a positive effect on injury rates. Overall, Taekwondo may be considered a rather benign activity, if injuries during Taekwondo tournaments can be avoided. If not, Taekwondo can result in serious musculoskeletal problems.

Injuries and overuse syndromes in powerlifting.

Powerlifting is a discipline of competitive weightlifting. To date, no investigations have focused on pain encountered during routine training. The aim of the study was to identify such pain, assign it to particular exercises and assess the data regarding injuries as well as the influence of intrinsic and extrinsic factors. Data of 245 competitive and elite powerlifters was collected by questionnaire. Information regarding current workout routines and retrospective injury data was collected. Study subjects were selected from 97 incorporated powerlifting clubs. A percentage of 43.3% of powerlifters complained of problems during routine workouts. Injury rate was calculated as 0.3 injuries per lifter per year (1 000 h of training=1 injury). There was no evidence that intrinsic or extrinsic factors affected this rate. Most commonly injured body regions were the shoulder, lower back and the knee. The use of weight belts increased the injury rate of the lumbar spine. Rate of injury to the upper extremities was significantly increased based on age >40 years (shoulder/p=0.003, elbow/p=0.003, hand+wrist/p=0.024) and female gender (hand+wrist/p=0.045). The daily workout of a large proportion of powerlifters is affected by disorders which do not require an interruption of training. The injury rate is low compared to other sports.

The future of surgical orthopaedics of the knee.

Over the past two decades, orthopaedics has gone through major changes, principally in the surgical treatment options for articular defects of the knee. This paper explores the advantages and shortcomings of the current surgical treatment modalities for cartilaginous defects in the knee. Emphasis is placed on current techniques in knee arthroplasty, including a view on the future of orthopaedic knee surgery.

Anterior dislocation of the shoulder associated with Bankart lesion in a patient with Poland's syndrome: a case report and review of the literature.

Poland's syndrome is a rare congenital entity characterized by unilateral partial or total hypoplasia of the major pectoralis muscle, breast and/or ipsilateral hand abnormalities. It has been reported in association with various structural and functional abnormalities. We report about a 23-year-old male kick-boxer with Poland's syndrome who presented in our department the history of two traumatic anterior shoulder dislocations due to boxing and self-reductions. Physical examination showed an instability of the left shoulder, and the MRI scans demonstrated a Bankart lesion. The patient had been treated with an arthroscopic Bankart repair; reattachment of the detached antero-inferior labrum down to the glenoid and repairing of the inferior gleno-humeral ligament complex. To our knowledge this is a first case report of a patient presenting with traumatic anterior shoulder dislocations due to kick-boxing associated with Poland's syndrome.

[Hypophosphatemic diabetes and knee pain: does treatment with total knee arthroplasty promise success?]. / Phosphatdiabetes und Knieschmerz: Ist die Versorgung mit einer Knietotalendoprothese erfolgversprechend?

Hypophosphatemic diabetes, a rare metabolic disease, presents in children, young adults as well as in elderly patients. In this report we describe the case of a 43-year-old woman with known hypophosphatemic diabetes who complained of severe knee pain after several osteotomies of the lower extremities. The patient was treated with bilateral total knee arthroplasty. The immediate post-operative outcome was good but showed deterioration at 12-month follow-up with decreased range of motion due to ligament stiffness. Knee arthroplasty in patients with hypophosphatemic diabetes remains a challenge for the orthopaedic surgeon. Arthroplasty can be recommended in severe knee pain; however, pre-operative interventions should be considered to prevent post-operative complications.

[Stress fracture of the calcaneus--a rare case]. / Ermüdungsfraktur am Kalkaneus--ein seltenes Ereignis.

Non-specific foot pain can have a variety of causes. Stress fractures mostly appear in over- or disuse of the lower extremities. Diagnosis can be made, albeit delayed, following an interval of 2-4 weeks using positive X-ray findings which can be supported by further diagnostic steps. In case of doubt, magnetic resonance tomography can provide a diagnosis and help determine therapeutic intervention; in most cases conservative treatment is performed. The majority of stress fractures heal fully within 6-8 weeks under conservative therapy. Additional therapy of fatigue fracture symptoms may be provided by analgesics and physiotherapeutic methods. Risk factors, particularly in young women, need to be detected. Although their efficacy is controversial, shock-absorbing insoles can reduce stress.

Imageless navigation of hip resurfacing arthroplasty increases the implant accuracy.

Surface arthroplasty of the hip is increasingly popular. Optimising the position of the femoral component is essential to avoid early implant failures such as femoral neck fractures. Sixty hip surface replacements were retrospectively analysed. In 30 patients imageless navigation was used, and 30 patients were operated upon using conventional jigs. Accuracy, implant position, operating time, and complications have been recorded. The navigation device improved the implant position with high accuracy. Implant-shaft angles <130 degrees and uncovered cancellous bone of the superior femoral neck could be safely avoided. After a significant learning curve, navigation took 15 minutes longer than conventional implantation. No complications were found in either group. Computer-assisted navigation allowed accurate implantation of the femoral component avoiding pitfalls of hip surface replacement. From our point of view the optimal placement of the femoral component outweighs the disadvantage of a longer operating time.

Stability changes after cryosurgery in long tubular bones in correlation to histological results: an animal trial.

STUDY QUESTION: Pathologic bone fractures in cryosurgery of bone tumors have been described in literature. This study utilizing a sheep model should prove the possible reduction of potential fracture while using a new miniature cryoprobe minimizing tissue damage and providing accurate control of the ablation process. Furthermore, postoperative histological changes should be investigated and the results correlated with the stability trials. METHODS: In 24 sheep, ablation of the femur and the tibial bone on one side was carried out. Ablation of the right femur was limited to an area of 2 cm(2) with single cortical bone, whereas at the left tibia the whole proximal tibial plateau was included. The other side served as a control entity without cryoablation. After a period of 2, 4, and 6 months postoperative investigation of bending resistance of the femoral bone and of compression resistance of the tibial bone as well as histological findings were done in eight animals each. RESULTS: After 2 months there was a significant difference (P < 0.05) regarding compression resistance between the treated and the contralateral tibia, whereas the bending resistance in the treated femur was slightly lower than on the contralateral side. After 4 and 6 months the cryo-treated part showed a tendency towards weakness. Histological findings showed bone necrosis with slight beginning repair after 2 months. Four and six months later, bone necrosis still existed with increasing development of woven bone and conversion into lamellar bone. DISCUSSION: A thorough control of the freezing process and the low iatrogenous weakening of the bone due to placing the probe when modern miniature cryoprobes are used can minimize the risk of pathological postoperative fractures. However, at least 2 months after operation there is histological proof of bone healing with appropriate reduction of bone stability, which should be considered for the clinical application of this new technique.

[Computer-assisted joint replacement surgery. Financial and clinical impact for a specialised orthopaedic hospital]. / Navigation in der Endoprothetik. Die Kosten-Nutzen-Analyse einer orthopädischen Fachklinik.

AIM: Incorrect alignment is a known risk factor for early loosening of implants. Computer-assisted joint replacement surgery (CAS) improves the positioning of the used implants. So far there is no study comparing the improvement of radiological implant position and the extra costs for the CAS. METHOD: We therefore analysed 200 (100 navigated procedures versus 100 conventional operations) total knee replacements and 60 (30 navigated procedures versus 30 conventional operations) hip resurfacing procedures. Evaluation criteria were radiological alignment and costs produced by using computer-assisted navigation tools. RESULTS: In our series of total knee and hip resurfacing arthroplasties the number of outliers could be significantly reduced by using CAS. Patients receiving a navigated total knee replacement had a significantly lower blood loss and need for blood transfusion. The financial calculation for CAS for our specialised orthopaedic hospital showed that every CAS operation produced 442 euro extra costs per operation. So far these extra costs are not reimbursed. CONCLUSIONS: By using CAS the implant positioning is significantly improved. Total knee replacements have a lower blood loss. Due to the prolonged operation time, the leasing costs and the single use navigation tools of every navigated operation produced costs for our hospital of 442 euro. As there is so far no reimbursement of these costs, long-term survival studies are needed to reveal the superiority of the navigation method and to show an impact on the medical budget.

[Neonatal traumatic epiphyseolysis of the humeral head. A rare occurrence]. / Geburtstraumatische Epiphysenlösung am Humeruskopf. Ein seltenes Ereignis.

Neonatal traumatic epiphyseolysis of the humeral head is rare, and only a few cases are reported in the literature. We present a case of a 13-day-old female newborn with malposition and relaxation of the left upper limb. The clinical examination showed distinct range of motion particularly for abduction. Magnetic resonance imaging (MRI) indicated epiphyseolysis of the humeral head. Closed reposition followed by immobilisation was done. The following MRI showed correct axis with adaption of the humeral head. Later, malposition of the axis with angulation in the ventromedial position was seen. This status was not followed by renewed repositioning. The x-ray examination 5 months later and MRI 9 months later showed a centered position of the epiphysis. In conclusion, neonatal traumatic epiphyseolysis of the proximal humeral head occurs rarely but should be considered, particularly with unclear relaxation of the limb.

Upright MRI of the shoulder demonstrates labrum dynamics.

Conservative treatment of anterior shoulder luxation includes immobilization in internal rotation. This has been increasingly debated, but imaging techniques in supine position do not reflect the influence of gravity. To examine glenoid labrum dynamics, the shoulders of 15 healthy subjects were imaged in standing position at different (0, 15, 30) degrees of external rotation using the Upright MRI. The functional length of the anterior labrum was measured. Due to an increasing tension of the anterior capsule, functional labrum length increased the more, the more the humerus was externally rotated. The results underline the usefulness of the Upright MRI and support the concept of immobilization in the position of external rotation.

[Injuries to the upper limbs in competitive wrestlers]. / Verletzungen der oberen Extremitäten bei Ringern im Hochleistungssport.

Great variety of tackling and defence in wrestling in standing position and on the floor cannot be compared to other kind of sports. High demand to motoric characteristics and tournament specific movability is required. However wrestling in Germany belongs to a fringe sport there is an increase of professionality. This leads to a sufficient and high-demanded supervision. Aim of this retrospective study was to evaluate sport injuries using a questionnaire and to figure out a correlation between kind and frequency of sport injuries of different body regions. 163 questionnaires out of 200 had been evaluated. In the region of the upper limb injuries had been found in 23%. The injury rate was higher in the athletes wrestling in the 2nd league. Wrestling is a technically and tactically ambitious sport. Injuries should be evaluated very careful to minimize the risk changing tactics and training methods.

Long-term results after operative treatment of osteochondritis dissecans of the knee joint-30 year results.

Osteochondritis dissecans (OD) mostly appears at the knee joint on the weight-bearing part of the medial femoral condyle. A multi-factorial event is most likely responsible for the triggering of OD. The aim of this retrospective study was to carry out long-term assessment of the results of operative treatment. Between 1959 and 1976, 148 patients were treated for OD by an open technique. For this purpose, a total number of 38 patients were analysed after approximately 30 years. Twenty-six patients were evaluated clinically by means of standardised questionnaires and also radiologically; 12 patients were analysed only by questionnaire. In order to verify the clinical findings and the subjective assessment, radiographs were done and analysed according the Kannus score. The Brückl score was used to evaluate the results of the OD. Twenty-four knee joints were analysed by radiographs. Sixty percent of the operated joints showed poor results in the analysis according to Kannus. Only four patients showed an excellent result by using the clinical scoring system. Nevertheless, we were able to prove a markedly higher rate of osteoarthrosis. The causal explanation for this lies in the patient selection. Most of the patients were above average age, and the OD was discovered quite late, and thus the disease had already progressed to a higher degree. In 74% of all cases, an extirpation of the osteochondral fragment was performed, whereas today there are several operative options. In our view, therefore, the need arises to conduct further follow-up examinations with comparative time spans, as well as to conduct a parallel analysis of corresponding control groups in order to evaluate the aetiology of the increased rate of osteoarthrosis.

Spondylodiscitis caused by Mycobacterium xenopi.

The infection with non-tuberculous mycobacterium correlates highly with immunodeficiency. Mycobacterium xenopi (M. xenopi) is most commonly isolated in the respiratory tract, as a cause of endogenous spondylodiscitis it occurs but rarely. Only seven such cases have been reported in literature. In this paper, we present the case of an about 28-year-old HIV-positive patient with a long history of back pain. MRI of the spinal column and Positron Emission Tomography with (18)F-fluorodeoxyglucose as a tracer (F18-FDG-PET) confirmed the suspected spondylodiscitis. After performing a CT-controlled abscess drainage the patient's condition improved. Because of the severe destruction of the spinal segment concerned and because of the epidural abscess formation a vertebrectomy of T10 and surgical debridement of the paravertebral soft tissue via thoracotomy became urgently necessary. The spine was stabilized by interposing a cage and an anterolateral monobar system. M. xenopi could be proven by PCR out of the intraoperative specimen. After operation and antituberculotic therapy there was a fast convalescence. Diagnostics, therapy, and clinical outcome are discussed.

Dynamic ultrasound for the golfer shoulder.

Although golf is a popular sport amongst different age groups, it can result in injury, usually from overuse and from poor technique. The shoulder is a commonly affected site, with the lead shoulder (e.g., the left shoulder in the right-handed golfer) most vulnerable to injury. In our present study, we used ultrasound to analyze if a hyperlaxity of the lead shoulder was present. In total, 33 asymptomatic golf-players were investigated by questionnaire, clinical examination and static, as well as dynamic ultrasonography. Neither clinically nor through ultrasound hyperlaxity of the shoulder was found. However, in golfers with shoulder pain, hyperlaxity followed by secondary impingement should be considered as a possible cause.

[Volume changes of intervertebral disc and vertebral body after dorsal fusion]. / Bandscheiben- und Wirbelkörpervolumenänderungen nach dorsaler Instrumentierung.

AIM: Even today, different opinions can be found concerning realignment loss of the adjoining intervertebral disc after fracture followed by dorsal fusion. There is still disagreement on intervertebral disc excision and the subsequent necessity of intercorporal fusion. METHOD: In this context, fractures of the thoracolumbar transition and its operative repair via instrumented bisegmental dorsal fusion at T11 - L1 and T12 - L2, respectively, have been examined. Immediately after the accident and after removal of the implant, sagittal MR images (T1-, TE-, T2-weighted) with a standard 4 mm slice thickness were made. Eighteen patients with fractures of the thoracolumbar transition (A3 and B1 according to the AO classification) could be included in this study. All fractures were of traumatic genesis. The implant was removed after an average of ten months. RESULTS: Allowing for planimetric measuring errors, our analysis generated a 14 % volume decrease of the upper and a 15 % volume decrease of the lower intervertebral disc. A volume change of 3 % in the bridged or fractured vertebral body was found to be without any verifiable significance. Tendentially, a slight volume loss of both adjacent intervertebral discs could be observed. CONCLUSION: In our opinion, the realignment loss after a mean ten months cannot be explained by the volume changes of the discs alone. The creeping of the intervertebral disc into the adjacent vertebral body accounts for the post-traumatic malalignment.

[Students evaluation of a sports-orthopaedic and sports-traumatological course in theory and practice]. / Evaluierung eines sportorthopädisch-sporttraumatologischen Studentenkurses in Seminar- und Praxisform.

Sports traumatology and sports orthopaedics are two closely interconnected fields usually more or less non-existent in a medical curriculum. Optional courses are difficult to coordinate because of the densely packed course schedule of a medical student, although the overall interest in it shows a continually upward trend. The course that is being offered since the winter semester 2004 / 2005 has been conceived as a seminar with lectures on a variety of subjects but it contains a practical part as well, e. g. for improving examination techniques. The offered course is particularly aimed at students of higher clinical semesters. The evaluation was carried out using questionnaires that were designed especially for this purpose. Subject to evaluation were not only general topics, but also the course instructors who had participated in the theoretical and practical implementation of the course. Suggestions for improvement or other comments were encouraged and taken into consideration. A total of 116 medical students (m = 68, f = 48) who have taken the course since the winter semester 2004 / 2005 have answered the questionnaire for the present evaluation. The interdisciplinary topics, covered the theoretical as well as the practical ones, were considered as interesting and important by 90 % of the students, organization and commitment on the part of the instructors were largely commended. Additional training in sports orthopaedics and sports traumatology enjoys great popularity on the part of medical students, in spite of their densely packed course schedule. Especially its multidisciplinary orientation provides students with a general overview in sports orthopaedics and sports traumatology and raises further interest in both fields of study.

[A vascular pedicled duplicated fibula transplant for treatment of lumbar instability following tuberculous spondylodiscitis]. / Ein gefässgestieltes gedoppeltes Fibulatransplantat zur Behandlung der lumbalen Instabilität nach tuberkulöser Spondylodiszitis.

Operative treatment of tuberculous spondylodiscitis is still an important part of the treatment for lumbar spine instability. We report on a patient who suffered an extensive relapse with microbiological confirmation of tuberculous spondylodiscitis following operative spinal treatment for unspecific spondylodiscitis. X-Ray examination showed development of pronounced lumbar instability, which was first treated with the aid of an external fixateur and later by means of a doubled fibular bone graft with a vascularised stem with no dorsal instrumentation, which led to bony consolidation.

[Dynamic ultrasound examination of the shoulder of golf players]. / Dynamisch-sonographische Untersuchung der Schulter beim Golfspieler.

Although golf is becoming popular it can result in injury, usually from overuse and from poor technique. The shoulder is a commonly affected site, with the lead shoulder (or the left shoulder in the right-handed golfer) vulnerable to injury. With this study we tried to figure out any hyperlaxity of the lead shoulder using ultrasonography. 33 golf-players were investigated by questionnaire, clinical examination and dynamic ultrasonography. Neither clinically nor by using ultrasonography hyperlaxity of the shoulder was found. Nevertheless hyperlaxity followed by secondary impingement should be considered.