Preliminary results of a plantar plate for Lapidus arthrodesis.

The TMT I arthrodesis is an established procedure for the correction of hallux valgus deformity associated with the instability of the TMT-I joint. A risk of transfer metatarsalgia is reported in the literature associated with persistant elevation of MT-I. Detailed information for ideal positioning of the arthrodesis is missing so far. Clinical, radiological and padobarografical results and their correlations were analyzed with special consideration of the elevation position of the MT-I in a TMT-I arthrodesis using the plantar plate osteosynthesis. Postoperative changes in plantar pressure and force distribution occured after TMT-I arthrodesis. A postoperative increase of the load under the medial forefoot and the dependence on the positioning of MT-I in the sagittal plane has been shown. The authors suggest, that increased load of the medial forefoot and constant pressures and forces under the central forefoot may lead to a relative relief of the area, which might explain the postoperative reduction of metatarsalgia.

Influence of varus/valgus positioning of the Nanos® and Metha® short-stemmed prostheses on stress shielding of metaphyseal bone.

The aim of this study was to analyze bone remodeling around the Nanos® (Smith & Nephew) and Metha® (Aesculap AG) implants as a function of varus/valgus stem positioning. In 75 patients with diagnosed coxarthrosis, either Nanos® (n= 51) or Metha® (n= 24) prostheses were implanted. Digital assessment of plain radiographs immediately, 97 days, and 381 days after THA showed no clinically-relevant migration, angulation, or change in offset and center of rotation. The DEXA scans showed significant BMD changes in Gruen zones 1 (-12.8%), 2 (-3.3%), 6 (+6.4%), and 7(-7.8%)(t-test). The pre/postoperative CCD for the Nanos® was 129°/ 135° and for the Metha® 131°/ 127°. Linear regression analysis showed no prediction for BMD by postoperative CCD or stem type. In conclusion, there was no clinically-relevant influence on proximal femur BMD according to varus/valgus implantation of the Nanos® or Metha® prostheses.

[Partial replacement of the knee joint with patient-specific instruments and implants (ConforMIS iUni, iDuo)]. / Patientenspezifische Instrumente und Implantate beim Teilgelenkersatz des Kniegelenkes (ConforMIS iUni, iDuo).

Knee arthroplasty is a successful standard procedure in orthopedic surgery; however, approximately 20 % of patients are dissatisfied with the clinical results as they suffer pain and can no longer achieve the presurgery level of activity. According to the literature the reasons are inexact fitting of the prosthesis or too few anatomically formed implants resulting in less physiological kinematics of the knee joint. Reducing the number of dissatisfied patients and the corresponding number of revisions is an important goal considering the increasing need for artificial joints. In this context, patient-specific knee implants are an obvious alternative to conventional implants. For the first time implants are now matched to the individual bone and not vice versa to achieve the best possible individual situation and geometry and more structures (e.g. ligaments and bone) are preserved or only those structures are replaced which were actually destroyed by arthrosis. According to the authors view, this represents an optimal and pioneering addition to conventional implants. Patient-specific implants and the instruments needed for correct alignment and fitting can be manufactured by virtual 3D reconstruction and 3D printing based on computed tomography (CT) scans. The portfolio covers medial as well as lateral unicondylar implants, medial as well as lateral bicompartmental implants (femorotibial and patellofemoral compartments) and cruciate ligament-preserving as well as cruciate ligament-substituting total knee replacements; however, it must be explicitly emphasized that the literature is sparse and no long-term data are available.

Immediate fullweightbearing after tarsometatarsal arthrodesis for hallux valgus correction--Does it increase the complication rate?

BACKGROUND: The arthrodesis of the first tarsometatarsal joint has a high correction potential in the treatment of hallux valgus deformity. Compared to distal correction procedures, a pseudarthrosis rate of 12-20% is quoted, however. In a prospective study the results of two different treatment procedures after correction arthrodesis were compared. METHODS: In 17 cases the patients were mobilised with a short arthrodeses shoe with floor contact (NWB group) and in 17 cases in a short arthrodeses shoe with immediate fullweightbearing (FWB group). Clinical and radiological evaluation was done preoperatively, six weeks and one year postoperatively, including visual analogue pain scale and AOFAS score pre- and one year postoperatively. RESULTS: There was no increased complication rate in the group with FWB group. The patients in the FWB group were significantly earlier fit for work. CONCLUSION: Immediate fullweightbearing after TMT I arthrodesis using a plantar plate should be established as a standard posttreatment.

Symptoms of craniomandibular dysfunction in professional orchestra musicians.

BACKGROUND: Up to 80% of professional musicians are affected by playing-related musculoskeletal disorders, but data regarding the frequency of craniomandibular dysfunction (CMD) in professional orchestra musicians is scarce. AIMS: To evaluate the frequency of CMD and its relation to musculoskeletal pain in various body regions. METHODS: A questionnaire-based survey approach assessing CMD symptoms and musculoskeletal pain in professional orchestra players was adopted. Relative prevalence rates and prevalence ratios for different instrument groups were estimated. RESULTS: A total of 408 musicians completed the questionnaire (response rate 57%). Playing-related pain in the teeth or jaw was reported by 19-47% of musicians and TMJ pain by 15-34%, depending on the instrument group. Current pain in the face indicating a painful CMD was reported in 6-10% and related symptoms such as teeth grinding in 25-34%, jaw clenching in 33-42% and jaw locking in 11-18% of musicians. Females were 2.4 times (95% confidence intervals (CI) 1.49-3.84) more likely to report having had orofacial pain within the last month. Musicians reporting orofacial pain within the last month were 4.8 times (95% CI: 2.83-8.02) more likely to report pain in the neck and 2.5-3.8 times (P < 0.05) more likely to report pain in other body regions, including shoulders, right wrist, left fingers and the thoracic and lumbar spine. CONCLUSIONS: Symptoms suggesting CMD were common in this study of professional orchestra musicians and were associated with pain in the neck, shoulder and hands. There is a need to enhance awareness of CMD to optimize early medical diagnosis and treatment.

[Ankle arthrodesis with an posterolateral approach using a polyaxial angle stable Talarlock® plate]. / OSG-Arthrodese über einen posterolateralen Zugang mit der polyaxial-winkelstabilen Talarlock®-Platte.

OBJECTIVE: Safe arthrodesis of the ankle as well as load carrying capacity free of pain. INDICATION: Painful arthritis of the ankle joint occurring idiopathic or posttraumatic, resulting from rheumatoid arthritis or neuromuscular diseases. Extensive bony defects in varus or valgus ankle deformities and after failed prosthesis. Complex hindfoot deformities in neurological disease, paralysis and instabilities. Joint destruction after infection. CONTRAINDICATIONS: Active osteitis, extensive skin ulcers in the approach area, periphery artery occlusive disease. SURGICAL TECHNIQUE: Posterolateral skin incision. Sparing cartilage resection. Penetrating sclerosis zones. Reorientating anatomic positioning of the talus thereby correcting axis deformities. Talarlock(®) plate positioning and tibiotalar arthrodesis. POSTOPERATIVE MANAGEMENT: Full weight bearing in an arthodesis boot for 6 weeks. After bone grafting partial weight bearing (20 kg) in an arthrodesis boot for 8 weeks. Full weight bearing after 10weeks. RESULTS: Ten patients were operated on using this procedure. The follow-up time was 1 year. There were no complications requiring further surgical procedures. Ankle fusion and a good clinical outcome could be achieved in all cases.

[Pedobarographic results of Girdlestone-Taylor tendon transfer in flexible small toe deformity]. / Ergebnisse der pedobarographischen Untersuchung nach Girdlestone-Taylor-Sehnentransfer bei flexibler Kleinzehdeformität.

AIM: The aim of the study was to analyze the biomechanical effects of flexible claw toe correction by tendon transfer with the Girdlestone-Taylor approach using dynamic pedobarography. MATERIAL AND METHODS: In the study 12 patients were examined preoperatively and 12 months postoperatively. The results obtained by pedobarography 12 months postoperatively were compared with those of a healthy control group of matched age and body mass index (BMI). For clinical evaluation the American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue pain scale (VAS) were evaluated. RESULTS: The results showed a significant increase in the average AOFAS score from 72 (range 63-79) preoperatively to 92 (84-96) points 12 months postoperatively. The pedobarography revealed significantly increased values in the force-time integral and the maximum force for the second and third toes 12 months postoperatively. Compared with preoperative measurement values a significantly increased peak pressure could be assessed for the third toe only. It is assumed that the combination of functional arthrodesis of the proximal interphalangeal (PIP) joint and the strain shift by tendon transfer causes this increase in peak pressure. CONCLUSION: Atter Girdlestone-Taylor tendon transfer reestablishment of floor contact of flexible claw toes could be demonstrated by dynamic pedobarography.

Comparative study of Lapidus bunionectomy using different osteosynthesis methods.

The treatment of hallux valgus in patients with pathology of the first tarsometatarsal (TMT I) joint by fusion is an established procedure. Multiple osteosynthesis methods for the fixation of the TMT I joint are available. In comparison to the distal procedures the Lapidus bunionectomy is associated with a pseudarthrosis rate of up to 12% [9-11]. We present results after TMT-I arthrodesis using an interfragmentary screw and a plantar plate compared with an interfragmentary screw and a dorsomedial locking plate. Clinical and radiological examinations were performed preoperatively, six weeks and one year postoperatively. The AOFAS (American Orthopaedic Foot and Ankle Society) score and Visual Analogue Pain Scale (VAS) were evaluated preoperatively and 12 months after surgery. We observed a significantly increased rate of undesirable effects in mediodorsal plate positioning.

Is it feasible to rely on intraoperative X ray in correcting hallux valgus?

BACKGROUND: The aim of the study was to prove whether the intraoperatively taken fluoroscopy pictures compared to the X rays taken 8 weeks and 3 months postoperatively picture the achieved correction reliably. METHOD: In a prospective study, the pre- and postoperative standing foot X rays as well as the intraoperatively taken fluoroscopy pictures of 31 patients were analysed. The intermetatarsal angle (IMA) and the hallux valgus angle (HVA) were measured. In all cases, a tarso-metatarsal joint I arthrodesis combined with a distal soft tissue release was performed. The mean age was 54 (17-73) years. RESULTS: There was no significant difference between the measured angles in intraoperative fluoroscopy and standing X rays postoperatively taken. CONCLUSIONS: Despite the consideration that fluoroscopic pictures lack the loading criteria, we found reliable results in IMA and HVA.

[Medium-term results of the Mayo™ short-stem hip prosthesis after avascular necrosis of the femoral head]. / Mittelfristige Ergebnisse der Mayo™-Kurzschaftprothese bei Hüftkopfnekrose.

AIM: Short-stemmed prostheses are increasingly regarded as implants of first choice in coxarthrosis, especially in young patients. Despite promising short-term results, long-term follow-up studies are still lacking. Short-stemmed femoral implants are characterised by a metaphyseal osseointegration and strain distribution. Therefore a reduced stress shielding of the proximal femur is hypothesized and in some studies already proven. There is histological evidence that osteonecrosis (ON) of the femoral head may involve not only the intracapital region but also the femoral neck and metaphyseal area. This could lead to a higher rate of aseptic loosening of short-stemmed implants. The aim of this retrospective study was to analyze the midterm results of the Mayo™ short-stem prosthesis after ON with particular attention on osseointegration. METHOD: From 2002-2004, in 21 patients (2 females, 19 males; mean age 45 years; mean BMI = 27) with secondary coxarthrosis after ON implantation of 26 Mayo™ Conservative Hips was performed. Postoperatively, all patients were mobilised with full weight-bearing. Using the specially developed Wristing® software, longitudinal stem migration and varus-valgus femoral stem alignment were examined digitally in anteroposterior X-rays taken immediately after surgery and in standing AP radiographs after 8.2 months and on average after 7.9 years (16 patients). The incidence of periprosthetic radiolucent lines was captured in the anteroposterior X-rays and assigned to the Gruen zones and a DEXA scan was performed. The X-rays of a matched control group with implantation of a Mayo™ short-stem prosthesis in primary coxarthrosis were analyzed by the same method. In all patients the Harris hip score (HHS) was obtained pre- and postoperatively. RESULTS: There was no significant migration or valgus tilt of the Mayo™ prosthesis in the study and control groups during postoperative follow-up (paired t-test, p = 0.13 and 0.69, respectively). In six of 26 Mayo™-Stems 12 radiolucent lines (RL) of the Mayo™ prosthesis were observed. The control group showed at ten of 30 Mayo™ stems 17 radiolucent lines. The difference between the groups was not statistically different (chi-square test for the total number of RL: χ² = 0.001, p = 1.0 and χ² = 0.06, p = 0.79 for the number of Mayo™ stems with RL). The DEXA scan showed a slightly higher bone mineral density (BMD) in Gruen zones 3 and 5 compared with a control group: study group. In the study group the postoperative HHS was 93.5 (SD 5.6) compared to 94.2 (SD 6.9) in the control group (t-test, p = 0.63). CONCLUSION: In the mid-term course no increased migration or tilt could be proven for Mayo™ short-stem THA in patients with osteonecrosis of the femoral head. Due to the absence of differences in the occurrence of radiolucent lines and the same results in the DEXA scan an unimpaired osseointegration of the Mayo™ stem is assumed. Therefore it is concluded that the Mayo™ Conservative Hip can be regarded as an alternative for operative treatment of ON of the femoral head.

[Results of single stage vs. two-stage total knee arthroplasty]. / Ergebnisse einzeitiger vs. zweizeitiger bilateraler Knietotalendoprothetik.

BACKGROUND: The total knee arthroplasty (TKA) is a successful procedure. In cases of bilateral knee osteoarthritis, advantages of single stage TKA vs. two-stage TKA as well as the gap between the procedures in case of two-stage TKA are discussed controversially. The aim of the present study is to compare the clinical and radiographic results of single stage bilateral TKA and two-stage bilateral TKA. In cases of two-stage TKA the dependency on the gap between surgeries was determined. MATERIAL AND METHODS: In this retrospective study 43 patients with single stage TKA and 35 patients after two-stage TKA with a maximum of 12 months between surgeries were included. Follow-up was in mean 31 ± 15 months. For clinical and radiological evaluation the Knee Society score (KSS) and Stolzalpen knee score were used. Quality of life was measured by the SF-36 score. The pain was determined using a visual analogue scale (VAS). Radiological evaluation was done by use of Knee Society roentgenographic evaluation and scoring system. RESULTS: The overall hospital stay for patients with two-stage TKA (26 ± 5 days) was twice as long as for patients with single stage TKA (14 ± 4 days). Patients with single stage bilateral TKA had a significantly higher KSS level (186 ± 19 points) than patients after two-stage bilateral TKA (179 ± 22 points). Within the two-stage group the best range of motion was achieved by patients with a gap of 4 to 6 months between surgeries and a decreased point value was measured in patients with a gap of 10 to 12 months between TKAs. Using the VAS patients with simultaneous bilateral TKA had significantly increased pain levels during passive motion. Within the two-stage group there were no differences in VAS. The results of Stolzalpen knee score were comparable in both groups. The analysis of radiological measurements showed a significantly higher number of radiolucent lines (1 mm) in patients with single stage TKA without any clinical relevance or progress in follow-up. Patients with single stage bilateral TKA had a higher complication rate than patients with a two-stage procedure. In the single stage group 6 patients had to be revised because of fracture, dislocation, peroneal nerve palsy, patella lateralisation or loosening. In the two-stage group only one patient had to be revised due to a quadriceps tendon rupture caused by a fall at day one after surgery. CONCLUSION: Analysis of clinical and radiological results shows only marginal differences between the two groups. In two-stage procedures functional results were best when the second surgery was done 4 to 6 months after the first procedure. Single stage TKA had a significantly higher complication rate. However, patient and surgeon should make the decision for single or two-stage bilateral TKA individually.

[One-stage aseptic revision of loosened metatarsophalangeal prosthesis]. / Einzeitiger aseptischer Wechsel gelockerter Grosszehengrundgelenkendoprothesen.

The high loosening rate of the Moje prosthesis in the treatment of hallux rigidus caused disappointing medium term results. Arthrodesis using an iliac crest bone graft is the standard salvage procedure. We present short-term results after one-stage revision of the metatarsophalangeal joint using the TOEFIT-PLUS™ prosthesis for implant revision. Clinical and radiological examinations were performed on three metatarsophalangeal joints after explantation of the Moje prosthesis and one-stage revision using the TOEFIT-PLUS™ prosthesis for implant revision. The AOFAS score and VAS were checked preoperatively and 6 and 12 months after surgery.Good to very good short-term results after one-stage revision of the metatarsophalangeal joint using the TOEFIT-PLUS™ prosthesis for implant revision could be demonstrated in this study. One-stage revision of the arthroplasty of the metatarsophalangeal joint can increase the range of motion and avoid arthrodesis entailing iliac crest bone graft morbidity.

Cellular compatibility of highly degradable bioactive ceramics for coating of metal implants.

Resorbable ceramics can promote the bony integration of implants. Their rate of degradation should ideally be synchronized with bone regeneration. This study examined the effect of rapidly resorbable calcium phosphate ceramics 602020, GB14, 305020 on adherence, proliferation and morphology of human bone-derived cells (HBDC) in comparison to ß-TCP. The in vitro cytotoxicity was determined by the microculture tetrazolium (MTT) assay. HBDC were grown on the materials for 3, 7, 11, 15 and 19 days and counted. Cell morphology, cell attachment, cell spreading and the cytoskeletal organization of HBDC cultivated on the substrates were investigated using laser scanning microscopy and environmental scanning electron microscopy. All substrates supported sufficient cellular growth for 19 days and showed no cytotoxicity. On each material an identical cell colonisation of well communicating, polygonal, vital cells with strong focal contacts was verified. HBDC showed numerous well defined stress fibres which give proof of well spread and strongly anchored cells. Porous surfaces encouraged the attachment and spreading of HBDC. Further investigations regarding long term biomaterial/cell interactions in vitro and in vivo are required to confirm the utility of the new biomaterials.

[Dynamic gait analysis of blocked distal tibiofibular joint following syndesmotic complex lesions]. / Dynamische Ganganalyse bei blockiertem distalem Tibiofibulargelenk nach Syndesmosenkomplexverletzungen.

AIM: Dynamic gait analysis of blocked distal tibiofibular joint (TFJ) has not performed yet. This prospective study investigated patients treated for ankle fractures with combined syndesmotic complex lesions after surgery including tibiofibular positioning screw using CT data detecting fibular maltorsion and dynamic gait analysis. METHOD: Prepublished data of 61 patients after surgical block of TFJ were analysed for torsional deformity of the distal fibula with an especially developed novel CT method. 10 of these patients were selected for dynamic pedography (emed-SF4, Novel GmbH, Munich). The measurements were accomplished one and six weeks (with blocked TFJ) and four months (with deblocked TFJ) postoperatively. RESULTS: The gait pattern of 10 pedographically investigated patients showed increased loads of the hindfoot as well as a load shift to the lateral midfoot. Four months postoperative significant differences of the plantar pressure pattern concerning the parameters force, pressure, impulse and contact time were not observed. The analysis of the foot progression angle (fpa) of the non operated feet demonstrated external rotation of 9,5 degrees in average. In comparison to the healthy side with tibiofibular positioning screw the operated feet were significantly internal rotated during the first two measurements. Patients with fibular torsional differences > 15 degrees showed not only with tibiofibular positioning screw but also after its removal a persistent difference of fpa in average of 5,6 degrees without external rotating retraction. CONCLUSIONS: The temporary blockage of TFJ results into an altered pattern of dynamic plantar pressure distribution. A constant foot progression angle in relative internal rotation is registered. After removal of the positioning screw the recovered ligamentous structures allow retraction to the anatomic position. But, concerning fibular torsional differences > 15 degrees osseous fixation leads to alterated fpa presented as diminished external rotation of the foot of the formerly fractured ankle with consecutive dysfunction of the physiologic kinematic of movement and eventual provocation of posttraumatic arthritis. AIM: Dynamic gait analysis of a blocked distal tibiofibular joint (TFJ) has not been performed yet. This prospective study investigated patients treated for ankle fractures with combined syndesmotic complex lesions after surgery including a tibiofibular positioning screw using CT data for detecting fibular maltorsion and dynamic gait analysis. METHOD: Prepublished data of 61 patients after surgical block of TFJ were analysed for torsional deformity of the distal fibula with an especially developed novel CT method. Ten of these patients were selected for dynamic pedography (emed-SF4, Novel GmbH, Munich). The measurements were accomplished one and six weeks (with blocked TFJ) and four months (with deblocked TFJ) postoperatively. RESULTS: The gait patterns of 10 pedographically investigated patients showed increased loads of the hindfoot as well as a load shift to the lateral midfoot. Four months postoperative significant differences of the plantar pressure pattern concerning the parameters force, pressure, impulse and contact time were not observed. The analysis of the foot progression angle (fpa) of the non-operated feet demonstrated external rotation of 9,5 degrees in average. In comparison to the healthy side the operated feet with tibiofibular positioning screw were significantly internally rotated during the first two measurements. Patients with fibular torsional differences > 15 degrees showed not only with the tibiofibular positioning screw but also after its removal a persistent difference of fpa in average of 5.6 degrees without external rotating retraction. CONCLUSIONS: The temporary blockage of the TFJ results into an altered pattern of dynamic plantar pressure distribution. A constant foot progression angle in relative internal rotation is registered. After removal of the positioning screw the recovered ligamentous structures allow retraction to the anatomic position. But, concerning fibular torsional differences > 15 degrees osseous fixation leads to alterated fpa presented as diminished external rotation of the foot of the formerly fractured ankle with consecutive dysfunction of the physiologic kinematic of movement and eventual provocation of posttraumatic arthritis.

[Unspecific back pain - basic principles and possibilities for intervention from a psychological point of view]. / Unspezifische Rückenschmerzen - Grundlagen und Interventionsmöglichkeiten aus psychologischer Sicht.

INTRODUCTION: Back pain is one of the most common and expensive health problems in Germany. Apart from somatic parameters, psychological factors are thought to influence the aetiology and, especially, the chronification of back pain. A literature search has been performed to establish which psychological procedures are used in the diagnosis, prevention and therapy for back pain, and how effective they are. METHOD: The connection between back pain and psychological factors was investigated in English and German technical articles identified in a literature search in Medline (2000-2006) and in psyndex (2000-2006). 714 hits were identified for the key words "back pain and prevention", 61 hits for "back pain and psychological factors", 732 hits for "back pain and risk factors" and 4 hits for "back pain and chronification of pain". 75 technical articles or studies were selected from these hits and used as a basis for the evaluation of the above questions. The search was completed by a manual search in the literature lists of published articles, perusing monographs, searching the internet and evaluating congress and meeting reports (2000-2008). RESULTS: The results of various studies show that cognitive, emotional and behavioural aspects and the processes of respondent and operant learning are of great importance in processing and overcoming pain. Biopsychosocial procedures appear to be superior to biomedical procedures. There has been good research on the (psychological) risk factors which contribute to the chronification of pain. It seems to be sensible to use screening procedures, such as the "Orebro Musculoskeletal Pain Questionnaire (OMPQ)" for the identification of patients at increased risk of chronification. For patients with chronic symptoms, there are evidence-based psychological programme components; these are usually successful, especially as part of multimodal programmes. As yet, there have only been initial studies on the use of psychological intervention for prevention, particularly in occupational settings. DISCUSSION: In the high risk group of patients already suffering from back pain, relapses and chronification can best be prevented by multimodal programmes. A decisive condition for the success of these physiotherapeutic, ergotherapeutic, sports therapeutic and psychotherapeutic interventions is apparently that there should be a standardised procedure in accordance with the theoretical principles of behavioural therapy, complied with by all those involved in the process. However, the principle objective of all measures should be the avoidance of the transition from acute to chronic back pain and the protracted and expensive clinical course this can lead to. Psychological intervention appears to work here as well. Further studies are needed to clarify whether the psychological program components are effective in isolation or whether they must be embedded in a multimodal (preventive) concept. It must also be investigated which target groups benefit most from which type of preventive (psychological) intervention. Provision of specific information is an alternative preventive approach. This health psychological or educative procedure corresponds to demedicalisation of this condition. Although media campaigns have been successfully performed in Australia, it is as yet unclear whether these can be transferred to Germany and which structural changes these would require in our health care system.

[Violence and aggression in care-related jobs--a literature overview]. / Gewalt und Aggression in Pflege- und Betreuungsberufen--Ein Literaturüberblick.

For many people working in the care sector, aggression and violence are part of their everyday working life. In order to obtain an overview of the occurrence of violence and aggression in care-related jobs, the current literature on this topic has been analysed. Most published studies are in English and refer to psychiatric facilities. There are fewer analyses of facilities that provide care for the elderly, and facilities that look after people with disabilities have been analysed even less frequently. The German as well as the English literature provides no clues as to the valid prevalence rates in the various fields of the health sector. It is particularly difficult to comment on the prevalence rates because different tools have been used to collect the information. In addition, the definitions of violence and aggression used differ from study to study. In the present article, we introduce fourteen tools that have been developed to record aggressive behaviour towards others. The choice of the tools should be based on the choice of the target group. There are hints indicating that the Staff Observation Aggression Scale-Revised (SOAS-R) is the most suitable tool to record aggressive behaviour prospectively across all fields in the health care sector.

[Reimplantation of a hip prosthesis in patients with an infected resection arthroplasty]. / Die Reimplantation eines künstlichen Hüftgelenkes bei septischer Girdlestone-Situation.

AIM: Resection arthroplasty is an accepted surgical option to treat severe late periprosthetic infections. However, it is known that one has to consider that a persistence of infection is very often combined with a permanent fistula in approximately 10 % of the patients. In particular, the occurrence of a fistula and pain caused by the persistent infection is followed by a considerable reduction of the quality of life of these patients. We have analysed the effort and complications of treatment and the change of pain and function of these patients. METHOD: In this study 11 patients (average age 68 years) with a Girdlestone situation and persistent infection with an average duration of 33 months were successfully treated by a multiple stage surgical therapy plan which included a radical surgical revision of the infection, stepwise leg lengthening and subsequent reimplantation. In all cases surgical revision of the infection was supported by both systemic and local (antibiotic-loaded cement spacer) antibiotic therapy. The choice of implants followed the general recommendations for revision hip arthroplasty. RESULTS: The mean follow-up after reimplantation was 16 months (min 4, max 24). We observed an average improvement of the Harris hip score from 27.7 points at the beginning of the therapy to 72.5 points at the end of the follow-up. None of the patients had suffered from a reinfection at the end of the follow-up. We observed no surgically related mortality. Surgical complications including spacer dislocations and implant dislocation were seen. The leg length discrepancy could be decreased from an average of 6.8 cm to 1 cm without the occurrence of a neurological deficit. CONCLUSION: The reimplantation of a hip prosthesis in cases of infected Girdlestone situations is complex, it can, however, offer the prospect of a marked increase in function and less pain for these patients.

[Influence of the surgical approach on postoperative rehabilitation after TKA]. / Der Einfluss des Zugangsweges auf die frühe postoperative Rehabilitationsphase nach Knieprothesenimplantation.

BACKGROUND: Minimising the soft tissue trauma and early rehabilitation are among the major aims using the MIS technique in joint replacement. AIM: The aim of this prospective randomised study is to compare the results after TKA using an MIS approach versus a standard approach. METHOD: We compared 30 TKA using a mini-midvastus approach (MIS group) with 30 conventionelly performed TKA using a midvastus approach (control group). In all cases the same implants (NexGen LPS) were used. The Knee Society score (KSS), an activity score, the visual analogue scale, myoglobin and creatinine kinase as well as the blood loss were measured up to 12 weeks postoperatively. Implant positioning was evaluated using the Knee Society Roentgenographic evaluation and scoring system. RESULTS: Advantages of the MIS group were measured in KSS and activity score up to 12 weeks postoperatively. The increase of myoglobin and creatinine kinase was lower in the MIS group up to 24 hours or 72 hours, respectively. No differences were found comparing the implant positioning and blood loss. CONCLUSION: The MIS technique in TKA with minimisation of the soft tissue trauma leads to better clinical and functional results in the early postoperative time and does not modify the implant positioning.

[Comparison of anterior lumbar fusion rates after circumferential fusion using beta-tricalcium phosphate (Cerasorb) versus autologous iliac crest spongiosa]. / Vergleich der anterioren lumbalen Fusionsrate nach dorsoventraler Fusion unter Einsatz von beta-Trikalziumphosphat (Cerasorb) versus autologer Beckenkammspongiosa.

AIM: The aim of this prospective clinical trial was to analyse the ventral fusion rate following circumferential fusion for degenerative spine disease using a radiolucent carbon fibre cage (Brantigan, Fa. DePuy-Acromed) loaded with either autogeneous bone graft (iliac crest) or with the tricalcium phosphate Cerasorb with PRP (Curasan AG, Kleinostheim, Deutschland). METHODS: In 26 patients (15 female, 11 male, average age: 57.7 years) a circumferential fusion of the lumbar spine was performed (titanium posterior instrumentation and Brantigan, Fa. DePuy-Acromed). Autogeneous bone graft (iliac crest) and Cerasorb-PRP as cage filling substance were randomly assigned to each level in all patients. Anterior fusion was evaluated in a total number of 69 Brantigan cages by radiographs after 3, 6, 9 and 12 months and by CT 1 year after surgery. RESULTS: The evaluation of radiographs resulted in a fusion rate 49 %. This was significantly different from the fusion rate accessed by CT scanning (28 %). None of the Brantigan cages (n = 33) filled with Cerasorb with PRP showed an anterior fusion in the CT while fusion was proven in 19 of 36 (49 %) Brantigan cages loaded with cancellous bone from the iliac crest. CONCLUSION: The use a of cancellous bone from the iliac crest as filling substance for Brantigan cages in circumferential fusion of the lumbar spine leads to a significantly higher anterior fusion rate than Cerasorb with PRP.