[Disease-related knowledge acquisition through structured patient information in rheumatoid arthritis (StruPI-RA) : First results of the StruPI-RA study in Germany]. / Krankheitsbezogener Wissenserwerb durch strukturierte Patienteninformation bei Rheumatoider Arthritis (StruPI-RA) : Erste Ergebnisse der StruPI-RA-Studie in Deutschland.

BACKGROUND/OBJECTIVE: The structured patient information for rheumatoid arthritis (StruPi-RA) program was the first standardized outpatient education program in rheumatoid arthritis (RA) in Germany. The main objective of the study was to determine the efficacy of the StruPi-RA program concerning disease-specific knowledge acquisition in patients with early stage RA or after changing the treatment regimen. METHODS: A total of 61 patients were included in a control group design, 32 in the intervention group (IG) and 29 in the control group (CG). Patients of the IG attended 3 modules of 90 min in a structured patient information program (StruPI-RA) including the topics of diagnostics, treatment and living with RA. Patients in the CG only received information material from the German Rheumatism League. The primary target criterion was the disease-related acquisition of knowledge, measured with the patient knowledge questionnaire (PKQ). Data were collected before and after participation in StruPI-RA. RESULTS: The improvement in knowledge in the IG attending the StruPI-RA compared to the CG was significant in time and group comparisons. No influence of disease duration or educational level was observed. The subscale treatment alone showed a significant difference in the group and time comparison. CONCLUSION: Participation in the StruPI-RA program in early RA was associated with a significant increase in disease-specific knowledge compared to the control group of patients. This leads to better decision-making in terms of treatment, a more beneficial doctor-patient communication and better self-management. In the long term an improvement in treatment adherence and quality of life is expected.

Reattachment of the distal tendon of biceps: factors affecting the failure strength of the repair.

Operative fixation is the treatment of choice for a rupture of the distal tendon of biceps. A variety of techniques have been described including transosseous sutures and suture anchors. The poor quality of the bone of the radial tuberosity might affect the load to failure of the tendon repair in early rehabilitation. The aim of this study was to determine the loads to failure of different techniques of fixation and to investigate their association with the bone mineral density of the radial tuberosity. Peripheral quantitative computed tomography was carried out to measure the trabecular and cortical bone mineral density of the radial tuberosity in 40 cadaver specimens. The loads to failure in four different techniques of fixation were determined. The Endobutton-based method showed the highest failure load at 270 N (sd 22) (p < 0.05). The mean failure load of the transosseous suture technique was 210 N (sd 66) and that of the TwinFix-QuickT 5.0 mm was 57 N (sd 22), significantly lower than those of all other repairs (p < 0.05). No significant correlation was seen between bone mineral density and loads to failure. The transosseous technique is an easy and cost-saving procedure for fixation of the distal biceps tendon. TwinFix-QuickT 5.0 mm had significantly lower failure loads, which might affect early rehabilitation, particularly in older patients.

[Arthroscopic suturing of the rotator cuff. Placing of anchor, suturing and tying techniques]. / Die arthroskopische Rotatorenmanschettennaht. Ankerplatzierung, Naht- und Knotentechniken.

Arthroscopic reconstruction of a rotator cuff tear is a demanding technique. Besides assessment and appraisal of the different types of tears, their mobilisation and, especially, secure refixation of the soft tissue are necessary if the operation is to be successful: suture anchors must be optimally placed, and suturing must be reliably achieved while the surgical field is viewed arthroscopically. A correct technique for arthroscopic knot tying after passage of the suture thread through the tendon is also essential for the holding strength of the sutures. The way the suture thread is tied during the arthroscopic procedure needs to be tailored to the individual situation. It is essential that the operator has mastered the technique of tying nonslipping knots, by alternating holding and connecting threads with the use of a knot-pusher. There is a vast number of published arthroscopic knots, and the one selected as suitable also needs to be adapted to the suture material.

A novel surgical technique for transverse sternal bone defects using flexible intramedullary nailing.

Transverse sternal bone defects as a result of surgery or trauma remain an important clinical condition with serious sequelae. Patients sometimes complain of local pain during movement and breathing. Usually, defects are filled with prosthetic materials which remain permanently IN SITU. Small defects can be treated with autogenous bone grafts, whereas large defects are difficult to stabilize with common osteosynthetic techniques. Here, we report a new surgical technique using flexible intramedullary nailing ("Elastic Stable Intramedullary Nailing"--ESIN or "Embrochage Centro-Medullaire Elastique Stable"--ECMES) to stabilize a sternal defect after surgical removal of an osteochondral lesion. The defect was bridged by two elastic titanium nails and an autogenous corticocancellous bone graft. This new surgical technique showed a good clinical and functional outcome.

[Treatment of proximal humeral fractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fractures]. / Die winkelstabile Osteosynthese am proximalen Humerus mit der PHILOS-Platte. Darstellung von 225 dislozierten Frakturen.

BACKGROUND: Proximal fracture of the humeral head is the third most frequent fracture in humans. Most (70%) of those affected are over 60 years old. It is hoped that advanced locking medullary screws or plates will reduce the risk of secondary dislocation of screws or fracture segments when the bone of the humeral head is osteoporotic. METHODS: From January 2002 to August 2005, 225 displaced humeral head fractures in 223 patients aged on average 66+/-15 years were treated with a new locking proximal humeral plate. RESULTS: In 176 patients in whom follow-up was possible, the average Constant Score after 9 months was 70+/-19 points (raw data), or 81+/-22% in the normalized score. No significant difference was detected between the younger group up to 65 years of age (73% points) and those over 65 years of age (80% points). Axial deviations by more than 30 degrees were noted in 11 (5%), and of 159 displaced tubercles, malreduction by more than 5 mm was noted in 14 (9%). Two infections and two haematomas had to be treated so far. Primary screw perforations were seen in 24 (11%) cases as well as further implant dislocations in 3 (1,7%). Plate dislocations out of the shaft existed in 4 (2,4%) and 14 collapses of the humeral head with secondary screw perforations were recorded. All other complications arose out of technical faults, such as 24 screw perforations (11%) into the glenohumeral joint and 3 (1.7%) cases of secondary implant dislocation from the humeral head and 5 (3%) from the shaft, and 14 (8%) sinterings with glenohumeral screw perforation. So far, in addition to 1 case of pseudarthrosis with a broken plate, 5 (3%) cases of total and 9 (5%) of partial avascular humeral head necrosis have been observed. CONCLUSION: The new implant provides superior stability in the fixation of humeral head fragments and has proved its worth in everyday clinical practice when additional indirect fixation of the tubercle is needed, as it frequently is in elderly patients.

Treatment option in a SLAP-related ganglion cyst resulting in suprascapular nerve entrapment.

INTRODUCTION: Our report shows a rare case of suprascapular nerve palsy due to a SLAP-related ganglion cyst resulting in isolated weakness of the infraspinatus muscle. CASE REPORT: We report on a 31-year old volleyball player with severe shoulder pain. A ganglion cyst was excised in an open procedure and was completely resolved in a postoperative magnetic resonance imaging (MRI). But the patient again had pain and disability 7 months after this procedure. A renewed MRI scan showed a cystic mass in the spinoglenoid notch. An electromyography revealed an isolated lesion of the suprascapular nerve. The patient was treated by shoulder arthroscopy with refixation of a type-II-SLAP-lesion and drainage of the cyst formation. At latest follow-up 29 months after surgery, the patient's pain and shoulder function improved with a constant score of 94 points. A MRI scan documented complete cyst resolution. CONCLUSIONS: Treatment options for ganglion cysts at the spinoglenoid notch are various and can be handled in conservative and operative ways. We believe that the arthroscopic concept with the management of a SLAP lesion as the cause of cyst formation, and the drainage of the ganglion is an effective way with low surgical morbidity that shows good postoperative results.

[Anterior dislocation of the shoulder--a reduction technique that is easy on the patient]. / Neue Technik soil iatrogene Komplikationen vermeiden: Schonende Reposition bei ventraler Schulterluxation.

Modified scapula manipulation represents a simple, highly successful and--both for the physician and the patient--pleasant new reduction technique in cases of anterior dislocation of the shoulder. The advantages of this technique--in particular in comparison with the previously employed methods are well founded. Non-evaluated methods, which are fraught with complications, such as the Hippocrates' method, should no longer be applied.

[Central bone transport system optimizes reconstruction of bone defects. Results of 40 treatments]. / Der zentrale Segmenttransport optimiert die knöcherne Defektrekonstruktion. Ergebnisse von 40 Behandlungen.

BACKGROUND: This article describes the results, experiences, and advantages of a bone transport system with one single rope or a fully implantable distraction nail for the treatment of bone defects that totally avoids soft tissue cross traction. METHODS: 40 patients with bone defects were treated by central bone transport systems. 30 post-traumatic defects (12 aseptic, 18 post-septic) and 10 defects after resection of bone tumors (2 benign, 8 malignant). Thirty defects were located at the tibia and ten at the femur; the mean defect size was 10.1 cm; 36 central rope systems and 4 motorized distraction nails were used. The follow-up examination took place after an average of 2.4 years. RESULTS: All defects were totally bridged. The mean distraction time was 131 (57-208) days and the mean time of external fixation 283 (126-326) days. The time of partial load bearing was 466 (302-594) days and the healing index was 47 (33.1-60.4) d/cm. In 34 patients autologous bone grafting at the docking site was performed, and in 30 patients the external fixator was replaced by internal stabilization. The mean leg length discrepancy compared to the contralateral side was 4+/-3 mm, and the leg axis deviation from the center of the knee joint was 1.5+/-7.0 degrees . There were 1.8 complications per patient on average (15 pin tract infections with replacement, 2 premature consolidations). CONCLUSIONS: In contrast to conventional methods reduced pin tract infections offer better conditions for internal fixation. Control of length and axis can be optimized, immobilization of the patients is reduced, and the comfort of treatment is significantly improved.

[Complete rupture of the proximal semimembranosus tendon. Minimally invasive surgical repair by use of a suture anchor in a rare but often underestimated injury]. / Komplette Ruptur der proximalen Semimembranosussehne. Minimal-invasive Refixation mittels Nahtanker bei einer seltenen und in ihrer Schwere häufig unterschätzten Verletzung.

Complete rupture of the proximal semimembranosus tendon is a rare injury associated with significant functional loss. Conservative treatment has proven inadequate in returning patients to their previous activity level. However, diagnosis is often delayed because of underestimation of the severity of this injury. Satisfactory results can be achieved with both early and late surgical tendon repair in the majority of cases. However, repair delayed by more than 4 weeks post trauma usually requires extended mobilisation of the injured muscle and neurolysis of the sciatic nerve. Therefore, we recommend surgical repair as early as possible. We report on the successful minimally invasive surgical repair of a complete rupture of the proximal semimembranosus tendon by use of a suture anchor 18 days after injury.

Microcirculation associated with degenerative rotator cuff lesions. In vivo assessment with orthogonal polarization spectral imaging during arthroscopy of the shoulder.

BACKGROUND: Diminished vascular supply is associated with degenerative rotator cuff lesions. Orthogonal polarization spectral imaging allows noninvasive assessment of microcirculation without application of fluorescent contrast medium. The aim of our study was to visualize and quantify in vivo the microcirculation of the rotator cuff during arthroscopic surgery and to compare the results with the number of microvessels identified in vitro by immunostaining of biopsy specimens taken from the scanned areas. METHODS: Eleven patients with clinical signs of a degenerative rotator cuff lesion were studied. Prior to arthroscopic subacromial decompression, the superficial part of the supraspinatus tendon at the edge of the lesion as well as the unaffected tendon insertion was examined. Microvascular parameters established for the description of tissue perfusion with use of conventional intravital fluorescence microscopy (functional capillary density and capillary diameter) were assessed in vivo. Biopsy specimens were taken from the scanned areas, and the microvessels were localized by immunostaining for the endothelial surface marker CD31. RESULTS: In the region of the unaffected tendon insertion, the mean baseline functional capillary density (and standard deviation) was 106 +/- 13 cm/cm(2) and the mean capillary diameter was 10 +/- 0.7 microm. In contrast, at the edge of the lesion, the functional capillary density was significantly reduced to 20 +/- 14 cm/cm(2), whereas the diameter of the vessels that were present did not differ. The total number of vessels stained in vitro was also significantly reduced at the edge of the lesion compared with the number of vessels in the tendon insertion zone. CONCLUSIONS: Quantitative in vivo analysis of human microcirculation during arthroscopy demonstrated that the functional capillary density at the edge of a degenerative rotator cuff lesion was significantly reduced compared with that in the control tissue. The capacity to assess microcirculatory flow in vivo may help to identify specific repair strategies based on knowledge of individual perfusion patterns.

[Scapho-lunate ligament reconstruction with Mitek suture anchors. Initial clinical results]. / SL-Bandrekonstruktion mit Mitek-Fadenankerdübeln. Erste klinische Ergebnisse.

The scapholunate dissociation is an often misjudged lesion of carpal ligaments as clinical and radiological signs often don't allow a clear interpretation. Apart from chronical courses with increasing arthrosis the consequences are limited and more difficult operations. The application of Mitek suture anchors is a new and simple supplement to large-scale operative reconstructions of ligaments or partial arthrodesis. Of nine reconstructions of the scapholunate interosseous ligament using this anchor method so far only one relaps occurred.

Allogeneic cultured keratinocytes vs. cadaveric skin to cover wide-mesh autogenous split-thickness skin grafts.

Improved shock therapy has extended the limits of survival in patients with massive burns, and nowadays skin coverage has become the major problem in burn management. The use of mesh skin grafts is still the simplest technique to expand the amount of available donor skin. However, very wide-mesh skin grafts take a very long time to heal, often resulting in unaesthetic scar formation. On the other hand, allogeneic cultured keratinocytes have been reported as a natural source of growth factors and thus could be useful to improve wound healing of these wide-mesh grafts. A clinical study was performed to compare the use of cryopreserved allogeneic cultured keratinocytes vs. the traditional cadaveric skin as a double layer over widely expanded autogenous skin grafts. This procedure was performed in 18 pairs of full-thickness burn wounds (with similar depth and location) in 11 severely burned patients. Early clinical evaluation was made at 2, 3, and 4 to 5 weeks. Parameters such as epithelialization, granulation tissue formation, infection, and scar formation were evaluated. Biopsies were taken to compare the histological characteristics of the epidermis, the epidermal-dermal junction, and the dermis. Late evaluations were performed at 6 and 12 months regarding color, softness, thickness, and subjective feeling of the scar tissue. Aside from a faster (p < 0.05) epithelialization in the keratinocyte group at 2 weeks, there were no statistically different results in any of the early evaluated parameters, neither clinically nor histologically. At long-term follow-up, clinical results and scar characteristics were not significantly different in the two compared groups. It is concluded from the results of this study that, during the early phase, epithelialization was faster with allogeneic cultured keratinocytes compared with cadaveric skin. However, taking into account the substantial difference in costs, the described use of cryopreserved allogeneic cultured keratinocytes as a double layer on meshed autogenous split-thickness skin grafts can hardly be advocated.

[Fully implantable intramedullary distraction nail in shortening deformity and bone defects. Spectrum of indications]. / Der voll implantierbare Distraktionsmarknagel bei Verkürzungen, Deformitäten und Knochendefekten. Indikationsspektrum.

Since the first clinical experiences with the fully implantable programmable distraction nail nearly ten years ago, the system has been improved in Munich and meanwhile used in 26 patients. During the first 10 cases there has been highest interest in the reliability of the system, while in the following the expansion of indications was more important. At the thigh a good indication beside shortening is the combination of shortening and axis deviation, even if the center of deviation is located near to the knee joint in the supracondylar area. According to preoperative planing the deformity correction can be done acutely while the lengthening procedure follows postoperatively automatically at night-time. If the stabilization with an intramedullary nail is possible, large bone defects can be treated by bone transport using this system also. The fully implantable intramedullary nail has proved its variable functions in cases of large bone defects combined with shortening of the femur. The system is able to perform the bone transport at first and the lengthening procedure automatically without any further operation thereafter.

[Indications and technique of bone cutting]. / Indikation und Technik der Knochendurchtrennung.

For cutting bones different tools and techniques are available. The question which method is most advantageous depends on the basic surgical concept, the location of the bone cut and the choice of the subsequent implant. The biological activity of the anatomical site of the cut determines how much the tissue needs to be protected, taking into consideration the vascularity of the bone and avoiding heat transfer. The surgical approach depends on the implant and should be used also for the bone cut. Specific indications are given for the oscillating saw, the Gigli saw, the osteotome, drill holes and the medullary saw.

[Primary shortening--secondary lengthening. A new treatment concept for reconstruction of extensive soft tissue and bone injuries after 3rd degree open fracture and amputation of the lower leg]. / Primäre Verkürzung--sekundäre Verlängerung. Ein neues Behandlungskonzept zur Rekonstruktion ausgedehnter Weichteil- und Knochenverletzungen nach drittgradig offener Fraktur und Amputation am Unterschenkel.

The main problem in major limb replantation--especially of the lower extremity--is an extensive bone- and soft-tissue loss. The traditional replantation concept tries to preserve the initial limb length; only a small shortening is accepted. To avoid a more extensive shortening, often insufficient debridement at the time of replantation is carried out. After successful revascularisation, bone and soft-tissue defects will be reconstructed according to the principles of staged reconstruction. Especially segmental nerve defects of more than one major peripheral nerve and severe skin and muscle loss necessitate extensive secondary grafting procedures. This often leads to a prolonged hospitalisation and a high complication rate. In 1951, Lorenz Böhler described the deliberate extremity shortening as a method of therapy in segmental combined bone-soft-tissue defects of the extremities. No additional surgical procedure were necessary to treat the soft tissue defect. A functional but shortened extremity was the result. With Ilizarov's principle of callus distraction he proved in an extensive experimental and clinical study the possibility to lengthen extremities without functional damage up to 20 cm. A new reconstruction concept--"concept of primary shortening with secondary limb lengthening"--for the treatment of amputation and/or amputation-like injuries was created by combining both principles mentioned above. At the time of replantation (reconstruction), deliberate shortening is carried out in order to reduce soft-tissue and/or bone defect or to enable primary nerve repair. Moreover, the aggressive debridement leads to a reduction of the local complication risk (wound healing disturbance, infection) and the potential systemic complications (crush-syndrome, ischemia-reperfusion-syndrome) after revascularisation of a large tissue bloc. Six to twelve months after replantation, secondary limb lengthening is started using an external or internal (= programmable intramedullary nail) distraction device. Since 1985, twelve patients (six macroamputations and six third-degree open fractures of the lower leg) have been treated using the "concept of primary shortening with secondary limb lengthening". Indications, operative technique, and results are shown and discussed, comparing this new concept to the traditional "concept of staged length-reconstruction" with extensive free tissue reconstruction and secondary nerve grafting.

[Possibilities of osteotomy. Osteotomy and corticotomy techniques]. / Möglichkeiten der Knochendurchtrennung. Osteotomie- und Kortikotomietechniken.

Corrective measures on the bone undertaken after the fusion of epiphyses are only possible through an initial break in its continuity. This paper deals with the different methods of osteotomy available to the orthopaedic or trauma surgeon. After introducing the terminology of the so-called "osteotomy", the vascularity of the bone, special features of the various osteotomy site, the different indications, and particular details of the operative procedures are discussed. Special emphasis is placed on minimally invasive techniques and osteotomies in the framework of callus distraction. In addition to established procedures a new sawing technique for the Küntscher's closed osteotomy is described.

Colorimetric analysis as a means of quality control for dental ceramic materials.

In this in-vitro study colorimetric analysis using the CIELAB-system was applied to two all-ceramic materials in shades A1 and A2. The material for the 96 specimens was taken from three production batches and examined spectrophotometrically after firing. For both materials the firing-process led to only small colour differences (average DE-value < 2.2). Between the three batches of each material, significantly higher, visually perceivable colour differences were detected. The results revealed that the Castor system is capable of producing high-precision colour measurements. The use of spectrophotometric devices is recommended as a means of quality control in order to decrease colour tolerances between different batches of the same material.

[Intramedullary nailing in callus distraction]. / Marknagelung im Rahmen der Kallusdistraktion.

Intramedullary nailing is an established fixation method in fracture treatment as well as in deformity-correction procedures on tubular bones. The interlocking nail has increased the potential for employing the intramedullary nail in the treatment of fractures in metaphysial regions. Recent developments are biased towards the use of small-diameter unreamed nails, preferably made of titanium. Callus distraction, the controlled continuous shifting of corticotomized bone, leads to new bone formation and has been known since the beginning of this century. This method, however, gained wide acceptance and popularity through the work of Ilizarov. This paper describes a fusion of the two methods into a very promising management concept for substantial bone defects resulting from trauma or resection of bone tumors, as well as for the correction of congenital or acquired uni- or bilateral differences in length of the extremities. Various systems such as the combination of callus distraction by external fixation over an intramedullary nail and a fully implantable system are presented.

[Perspectives in callus distraction]. / Perspektiven der Kallusdistraktion.

Callus distraction is an enrichment of the surgical orthopaedic way of reconstructing bone defects, but it is also an effective method of lengthening limbs. The biological facts correspond to our knowledge about fracture healing. Concerning apparatures, further development is needed. In certain cases the ring fixator is the method of choice, but in most indications it is not necessary. Every effort should be made to adapt modern technologies, including fully implantable systems, to the "biological method" of callus distraction, whenever possible.