[Tuberculous rice body synovitis of the shoulder joint]. / Tuberkulöse Reiskornsynovitis des Schultergelenks.

The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.

[Immobilisation of the shoulder in external rotation after traumatic first-time dislocation--what is reasonable? A retrospective survey]. / Die Ruhigstellung der Schulter in Aussenrotation nach traumatischer Erstluxation--Was kann man seinen Patienten zumuten? Eine retrospektive Patientenbefragung.

BACKGROUND: Immobilisation in external rotation has become a new option in the therapy of the traumatically dislocated shoulder. Brace comfort and patient's satisfaction with this kind of conservative treatment are evaluated in a retrospective survey. METHODS: 34 patients with a traumatic first-time anterior shoulder dislocation were immobilised in an external rotation brace for three weeks. Afterwards they were asked to complete a questionnaire regarding brace comfort and how they managed their daily life with one arm immobilised in external rotation. RESULTS: 29 questionnaires could be evaluated. 26 patients (90%) were satisfied with the new therapy. 24 patients (83%) would prefer the conservative treatment in an external rotation brace in case of another dislocation under similar circumstances. The impact of the brace therapy on daily live was reasonable. 79% of the patients (23) wore the brace more than 20 hours daily (average 22 hours, min.15, max. 24 hours). CONCLUSION: Despite the uncomfortable arm position during immobilisation the therapy in an external rotation brace showed a high acceptance. In addition to previous results regarding reposition of the labroligamentous complex it appears to be proven a suitable therapy for first-time traumatic anterior shoulder dislocation.

[Reduction of glenoid rim fractures after primary shoulder dislocation in external rotation]. / Indirekte Reposition und Retention der Bankart-Fraktur in Aussenrotation.

The treatment of anterior glenoid rim fractures depends on the size of the fracture and the articular surface involved. The operative treatment is open or arthroscopic refixation. In cases with small fragments and a stable shoulder nonoperative treatment is recommended. In patients with a primary shoulder dislocation immobilization in external rotation has been showed to improve the position of the displaced labrum on the glenoid rim. However, whether external rotation can reduce displaced glenoid rim fractures is not known. With the use of CT the repositioning of a glenoid rim fracture in a single patient in external rotation is evaluated.A 26-year-old patient with an anterior glenoid rim fracture after a primary shoulder dislocation was referred to our shoulder service. After initial reduction a CT scan in internal and external rotation of the involved shoulder was performed. In the external rotation CT the glenoid rim fracture was reduced in anatomic position. The patient was immobilized in a 30 degrees external rotation brace for 4 weeks. Six weeks after trauma the internal rotation CT showed the fracture healed in the anatomic position. At the 1-year follow-up the Constant Score and the Rowe Score were 100 points each. In patients with anterior glenoid rim fractures immobilization of the shoulder in external rotation seems to allow a reduction of the fracture. A study with a large number of patients is under way to evaluate long-term results.

[Immobilization in external rotation after primary shoulder dislocation]. / Ruhigstellung in Aussenrotation bei primärer Schulterluxation.

INTRODUCTION: The standard method of treating acute primary dislocation of the glenohumeral joint is immobilization of the arm in adduction and internal rotation with a sling. The recurrence rate for anterior instability after nonoperative treatment in young active patients is extremely high (up to 90%) and well reported. A new method of immobilization with the arm in external rotation improves the position of the displaced labrum on the glenoid rim. With the use of control MRI before and after immobilization in external rotation, a study on this new repositioning of the labrum is evaluated. METHODS: Ten patients (mean age 30.4 years) with primary anterior dislocation of the shoulder and Bankart lesion as shown on MRI but with no hyperlaxity of the contralateral side were immobilized in 10-20 degrees of external rotation for 3 weeks. Scans with MRI were taken in internal and external shoulder rotation post trauma and in internal rotation after 6 weeks. All patients were reevaluated after 6 and 12 months. RESULTS: Dislocation and separation of the labrum were both significantly less with the arm in external rotation due to the tension of the anterior capsule and the tendon of the subscapularis muscle. In the MRI taken in internal rotation 6 weeks post trauma, all Bankart lesions were fixed in reposition after three weeks of immobilization in external rotation. At 12-month follow-up, the average Constant Score was 96.1 points (range 63-100), and the Rowe Score was 91.5 points (range 25-100). One patient had traumatic redislocation after 8 months. CONCLUSION: After primary shoulder dislocation, immobilizing the arm in 10-20 degrees external rotation provided stable fixation of the Bankart lesion in an anatomic position. First long-term indications from an ongoing prospective study of recurrence rates after immobilization in external rotation are promising.

[Initial results of shoulder MRI in external rotation after primary shoulder dislocation and after immobilization in external rotation]. / Initiale Ergebnisse der Schulter-MRT in Aussenrotation bei primärer Schulterluxation und nach Ruhigstellung in Aussenrotation.

PURPOSE: A change in the strategy for treating primary anterior traumatic dislocation of the shoulder has occurred. To date, brief fixation of internal rotation via a Gilchrist bandage has been used. Depending on the patient's age, a redislocation is seen in up to 90 % of cases. This is due to healing of the internally rotated labrum-ligament tear in an incorrect position. In the case of external rotation of the humerus, better repositioning of the labrum ligament complex is achieved. Using MRI of the shoulder in external rotation, the extent of the improved labrum-ligament adjustment can be documented, and the indication of immobilization of the shoulder in external rotation can be derived. The aim of this investigation is to describe the degree of position changing of the labrum-ligament tear in internal und external rotation. MATERIALS AND METHODS: 10 patients (9 male, 1 female, mean age 30.4 years, range 15 - 43 years) with a primary anterior dislocation of the shoulder without hyper laxity of the contra lateral side and labrum-ligament lesion substantiated by MRI were investigated using a standard shoulder MRI protocol (PD-TSE axial fs, PD-TSE coronar fs, T2-TSE sagittal, T1-TSE coronar) by an axial PD-TSE sequence in internal and external rotation. The dislocation and separation of the anterior labrum-ligament complex were measured. The shoulders were immobilized in 10 degrees external rotation for 3 weeks. After 6 weeks a shoulder MRI in internal rotation was performed. RESULTS: In all patients there was a significantly better position of the labrum-ligament complex of the inferior rim in external rotation, because of the tension of the ventral capsule and the subscapular muscle. In the initial investigation, the separation of the labrum-ligament complex in internal rotation was 0.44 +/- 0.27 mm and the dislocation was 0.45 +/- 0.33 mm. In external rotation the separation was 0.01 +/- 0.19 mm and the dislocation was - 0.08 +/- 0.28 mm. After 6 weeks of immobilization in 10 degrees external rotation, the separation of the labrum was - 0.10 +/- 0.14 mm and the dislocation was - 0.23 +/- 0.21 mm. CONCLUSION: In anterior labrum-ligament tears, the axial MRI of the shoulder in external rotation demonstrates a more physiologic position of the glenoid. This may indicate an immobilization of the shoulder in external rotation, which results in a more anatomical healing of the glenoidal tear. Thus, in the case of labrum-ligament tears, MRI in external rotation is becoming indispensable.

[Severe complications after percutaneous transaxillary refixation of a glenoid rim fracture]. / Schwerwiegende Komplikation nach perkutan-transaxillärer Verschraubung einer Glenoidfraktur.

The common treatment for glenoid rim fractures has been open reduction and internal fixation by a deltopectoral approach. Minimally invasive procedures with percutaneous transaxillary manipulation have a high risk for neurovascular damage. In a single case we demonstrate the possible complications associated with percutaneous refixation of a glenoid rim fracture. A 34-year-old patient with an anterior glenoid rim fracture was referred to our shoulder service after percutaneous transaxillary fixation of the fracture of the glenoid. He presented a dislocated fracture with joint infection and damage of the axillary nerve and artery. During revision surgery, joint infection with Staphylococcus aureus, dislocation of the fracture, aneurysm of the axillary artery, and a lesion in continuity of the axillary nerve were diagnosed. The fragment was excised and the capsule reattached to the remaining glenoid rim. The aneurysm was resected with an end-to-end anastomosis. The outcome was a noninfected and stable shoulder with a limited range of motion. In patients with a glenoid rim fracture with more then 21% of the glenoid fossa involved, refixation of the fracture is recommended. Open reduction and internal fixation is the gold standard. In some cases arthroscopic repair is possible. Percutaneous transaxillary manipulation is not recommended.

[Sigmoid colon perforation with local peritonitis caused by indirect trauma--case report and review of the literature]. / Sigmaperforation mit lokaler Peritonitis durch indirektes Trauma--Fallbericht und Literaturübersicht.

Injuries to the sigmoid occur either as acute or protracted events. In the first case, enteral contents discharge into the abdominal cavity and a generalized, fecal, life-threatening peritonitis with a bad prognosis develops. In the protracted form, the rupture is covered by peritoneum and adherent organs before perforation. The ensuing abscess formation may lead to perforation into contiguous visceral organs or the cutis. Frequently an intestinal or cutaneous fistula results. The trigger for a sigmoid perforation can be a spontaneous rupture in an already vulnerable intestine. Common precursory diseases are diverticulitis, colitis, carcinomas, and necroses. Also, elevated intestinal pressure invoked by increased bearing down or coproliths may cause disruption. Diagnostic procedures such as rectoscopy and rectal contrast instillation are frequent idiopathic causes of traumatic injuries to the sigmoid. Perforating injuries of the abdominal cavity by stabbing, gunshot, or impalement may affect the sigmoid and open its lumen. Foreign bodies often lead to traumatic injuries of the rectosigmoid junction. In contrast, indirect trauma as a cause of sigmoid perforation, which is described in the following case, is very rare. A 62-year-old woman,who had a cholecystectomy and adhesive strangulation of intestine in her history, was admitted to our clinic after falling down stairs and landing on her bottom. She suffered a sigmoid rupture and peritonitis. Laparotomy and suturing of the sigmoid defect were performed.

Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients.

BACKGROUND: The treatment of open fractures of the tibial shaft is often complicated by delayed union and nonunion. The objective of this study was to evaluate the safety and efficacy of the use of recombinant human bone morphogenetic protein-2 (rhBMP-2; dibotermin alfa) to accelerate healing of open tibial shaft fractures and to reduce the need for secondary intervention. METHODS: In a prospective, randomized, controlled, single-blind study, 450 patients with an open tibial fracture were randomized to receive either the standard of care (intramedullary nail fixation and routine soft-tissue management [the control group]), the standard of care and an implant containing 0.75 mg/mL of rhBMP-2 (total dose of 6 mg), or the standard of care and an implant containing 1.50 mg/mL of rhBMP-2 (total dose of 12 mg). The rhBMP-2 implant (rhBMP-2 applied to an absorbable collagen sponge) was placed over the fracture at the time of definitive wound closure. Randomization was stratified by the severity of the open wound. The primary outcome measure was the proportion of patients requiring secondary intervention because of delayed union or nonunion within twelve months postoperatively. RESULTS: Four hundred and twenty-one (94%) of the patients were available for the twelve-month follow-up. The 1.50-mg/mL rhBMP-2 group had a 44% reduction in the risk of failure (i.e., secondary intervention because of delayed union; relative risk = 0.56; 95% confidence interval = 0.40 to 0.78; pairwise p = 0.0005), significantly fewer invasive interventions (e.g., bone-grafting and nail exchange; p = 0.0264), and significantly faster fracture-healing (p = 0.0022) than did the control patients. Significantly more patients treated with 1.50 mg/mL of rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Compared with the control patients, those treated with 1.50 mg/mL of rhBMP-2 also had significantly fewer hardware failures (p = 0.0174), fewer infections (in association with Gustilo-Anderson type-III injuries; p = 0.0219), and faster wound-healing (83% compared with 65% had wound-healing at six weeks; p =0.0010). CONCLUSIONS: The rhBMP-2 implant was safe and, when 1.50 mg/mL was used, significantly superior to the standard of care in reducing the frequency of secondary interventions and the overall invasiveness of the procedures, accelerating fracture and wound-healing, and reducing the infection rate in patients with an open fracture of the tibia.

[Biomaterials in the skeletal system]. / Neue Biomaterialien am Skelettsystem.

The increasing number of biomaterials for the skeletal system requires mote and move their distinct clinical application. To guarantee useful therapeutic results the characteristics of the biomaterials have to be matched with the characteristics of the implantation site. Recently developed biodegradable polymers with a slow degradation process and longer stability are being increasingly clinically applied with a low complication rate. The development of new remodelable bone cements for bone-defect filling revives the idea of cement-metallic implant constructs. Finally, recombinant human bone growth factors are currently under controlled clinical examination with first promising results. Long-term results allowing common clinical use of these factors are still to be expected.

[Transport-fixator for reconstructive surgery of the extensor apparatus of the knee joint]. / Verletzungen des Kniestreckapparats. Rekonstruktion mittels Transportfixateur.

Operative repair in ruptures of the extensor mechanism of the knee joint mostly requires additional external or internal fixation by plaster, transfer of tendons or encircling wires. Reconstruction of initially undiagnosed ruptures has to solve the problems of fixed proximal or distal migration of the patella and tendenous shortening. This can be performed with a tibiopatellar external fixator which allows gradually reduction of the patella in an anatomical position before operative reconstruction by suturing or reinsertion. During this period as well as a post-operative protection this fixator enables patients to maintain motion of the knee joint and full weightbearing. This technique can avoid poor functional results caused by long periods of immobilisation and is helpful in patients with marked displacement of the patella and inability to manually reduce the patella distally when delayed repair is necessitated.

[Scapulo-thoracic dissociation. A missed injury?]. / Skapulothorakale Dissoziation. Ein "missed injury"?

The scapulothoracic dissociation (SD) is a complex injury of the shoulder girdle, mostly associated with polytraumatized critically ill patients. This case report of 3 patients shows the variety of possible injuries combined with SD. Diagnosis and therapy in such a rare trauma, which is most likely seen in specialized trauma centres are being described. The 3 patients are presented from trauma to management, with remarks to various possibilities in treatment. Reports of other groups include multicenter studies with small numbers of patients, making it different to look for homogenity or defining standards, whereas current guidelines are being mentioned, including remarks on the management of these mostly polytraumatized and vitally endangered patients.