[Patient education before orthopedic elective interventions. "The Lagenthal model of 3-step patient education"]. / Patienten-Aufklärung vor orthopädischen Wahleingriffen. "Das Langenthaler Modell der 3-Stufen-Aufklärung".

There is still quite a controverseY when and how an informed consent should be obtained from a patient in the surgical field. As has been stated of the federal court the patient need to be given that information which is understandable to him and which will not cause him undue anxiety. This information has to be sufficient for the decision whether to proceeD or decline a surgical procedure. The federal courts are therefore asking for the optimal patient consent not necessarily the total and complete revelation during the patient information. For this reason the act of obtaining an informed consent was thought to be turned into a scientific question in identifying the base from optimal quality of giving informed consent respecting at the same time the principal of evidence based medicine. The support presents a sample of an oral and written consent-form given in three stages as it is currently being used in the orthopaedic service of the Langenthal hospital. 100 patients were given this type of a consent and were later on asked for their opinion of acceptance. Most of the patients felt to be sufficiently informed on their procedure after having undergone a three times repeated interview as well as having been given a consent form including hand-drawings concerning their particular procedure. The advantages as well as the disadvantage of this type of consent form are being discussed.

[Migration of Kirschner wires after surgical stabilization of injuries in the area of the shoulder--4 case reports]. / Migration von Kirschner-Drähten nach operativer Stabilisierung von Verletzungen im Bereich der Schulter--Vier Fallberichte.

Internal fixation is recommended for displaced and unstable fractures of the lateral clavicle and fractures involving the proximal humerus. Kirschner wires, although recommended in the orthopedic literature bear the risk of wire breakage and migration. 4 cases with serious and potentially hazardous complications are presented. All reported complications occurred years after the operative treatment without clinical symptoms. Regular postoperative follow-ups and early hardware removal after fracture healing is recommended.

[Treatment of fresh Tossy III acromioclavicular joint dislocation by ligament suture and temporary fixation with the clavicular hooked plate]. / Die Behandlung der frischen AC-Luxation Tossy III durch Bandnaht und temporäre Fixation mit Klavikula-Hakenplatte.

PURPOSE: Retrospective analysis of the functional and radiographic outcome of a new temporary fixation device in the surgical treatment of acromioclavicular joint dislocation stage Tossy III. MATERIAL AND METHODS: Between 1986 and 1993, 19 patients with acute acromioclavicular (AC) dislocation (stage Tossy III) were treated with the clavicle hook-plate as a temporary fixation device combined with suture of the ligaments. Active shoulder mobilization started three days postoperatively. The mean follow-up was 3.9 years (range, 2 to 9.5 years). RESULTS: The mean Constant Score was 94 points (range, 83 to 100 points). All of the patients were able to resume their occupational activities and seventeen (89.5%) could completely resume their prior program of physical fitness. Radiological signs of an AC arthritis were found in 21% of the cases, but only 1 patient had a painful AC-joint. The average distance between the superior aspect of the coracoid process and the inferior aspect of the clavicle in the stress x-ray (5 kp each side) of both AC-joints was preoperatively 20.7 mm (range, 12-50 mm) comparing to 9.5 mm (range, 6-15 mm) for the operated shoulder and to 9 mm (range, 4 to 12 mm) for the nonoperated side in the follow-up. No reluxation was found. Two superficial wound infections (10.5%) were treated successfully with antibiotics without removal of the implant. Neither breakage nor loosening of the clavicle hook-plate were observed. CONCLUSION: Our mid- and longterm results confirm the value of the clavicle hook-plate as an alternative to other temporary fixation devices in the surgical treatment of acromioclavicular dislocation stage Tossy III.

[Arthroscopy: possibilities and limitations in the diagnosis and therapy of meniscus lesions]. / Arthroskopie: Möglichkeiten und Grenzen der Diagnostik und Therapie der Meniskusläsion.

The menisci consist of fibrocartilage and are an important supporting structure of the knee joint. They are poorly vascularized and have to withstand a high mechanical strain and load; therefore, lesions are common, especially on the medial side. Meniscal lesions are among the most frequent surgical procedures in orthopedic surgery. Meniscal lesions are diagnosed by a careful clinical examination in 80% of all cases in spite of modern imaging techniques such as magnetic resonance imaging (MRI). In the last 15 years, arthroscopic meniscectomy has become the 'golden standard' of therapy. Arthroscopy provides a powerful tool to precisely locate and classify the type of meniscus injury and to perform arthroscopic meniscectomy at the same time. This means less morbidity, reduced hospitalization time and earlier return to work and hence reduced costs. The endoscopic technique allows to exactly remove the damaged parts of the meniscus with precision instruments (partial meniscectomy). Former open techniques only allowed the complete removal of the meniscus. The arthroscopic techniques used nowadays allow a preservation of the functionally important edge of the meniscus, which is responsible for the stability and the biomechanics of the knee joint and can thus prevent an early onset of arthrosis. In rare cases of peripheral meniscal tears in young patients, arthroscopic refixation is an advantageous treatment option. Partial arthroscopic meniscectomy and arthroscopic meniscus refixation are challenging therapeutic procedures that require a trained and experienced orthopedic surgeon. Today diagnostic arthroscopy is more and more abandoned in favour of noninvasive and reliable MRI techniques. MRI is also useful in cases of previous knee surgery and clinically unclear findings, but should not be used on a routine basis. In differential diagnosis, the orthopedic surgeon always has to evaluate the MRI findings as to their impact. Today, arthroscopic knee surgery is a reliable, technically sophisticated and standardized technique to treat meniscal damages of all patients. There is a relatively low rate of complications, provided that the indication for the procedure is critically applied and restricted to patients with sufficient clinical and MRI findings.

[Autologous blood transfusion: results with routine use of autologous blood transfusion, normovolemic hemodilution and postoperative retransfusion of drainage blood salvaged with the Solcotrans system]. / Autologe Bluttransfusion: Erfahrung mit routinemässiger Anwendung von Eigenblutspende (EBS), normovolämischer Hämodilution (NHD) und postoperativer Retransfusion von Drainageblut (PORT) mit Solcotrans.

BACKGROUND: Although the medical advantages of autologous blood transfusion are undisputed today, it has been established only in a few hospitals. At our hospital we have employed infusion of previously stored autologous blood and normovolemic hemodilution routinely in all patients undergoing major orthopedic surgery since June 1, 1986. QUESTION: In this study the efficacy of additionally infusing salvaged drainage blood postoperatively in reducing the need for homologous blood transfusion was examined. METHOD: From June 1, 1990 through December 30, 1993 the effectiveness of autotransfusion techniques with the additional use of postoperative infusion of salvaged blood was studied in 318 patients. RESULTS: Preexisting anemia with hemoglobin value of less than 11 g/dl proved to be the only contra-indication for autologous blood transfusions and was found in 8 (2.5%) of our patients. These patients were not eligible for the autologous blood program. The 310 remaining patients were all given their previously stored autologous blood with hemodilution. In addition, 261 of these patients (84%) were also given salvaged drainage blood postoperatively using the solcotrans system or solcotrans-plus-orthopedic system. Of the total 310 patients, 218 (70.3%) did well without homologous blood. This was also true for 206 (78.9%) of the patients treated with all 3 autotransfusion procedures. No complications implicating the autotransfusion techniques were encountered. In addition, the method described and as employed in our hospital led to a cost reduction of about 40% compared to homologous transfusions. DISCUSSION AND CONCLUSION: The efficiency of autologous blood transfusions and hemodilution in reducing the need for homologous blood at our hospital, as previously described, could be increased by 22% using the solcotrans system. The advanced age of our patients (average 73 years) and the number of preexisting, in part considerable, medical problems permit the conclusion that these autotransfusion techniques are quite well tolerated. The contraindications could be reduced to a few exceptions. The logistics necessary to carry out these procedures are simple and can be achieved with a bit of will and effort in all hospitals including those of middle and small size.

[Surgical treatment of lateral clavicular fracture with the "clavicular hooked plate"]. / Operative Behandlung der lateralen Clavicula-Fraktur mit der "Clavicula-Hakenplatte".

We know different surgical techniques for the treatment of lateral clavicle fractures (type 2 of the Neer-classification). Often an exercise stable osteosynthesis and early functional aftercare can be realized only with a jointconnecting transfixation (acromioclavicular joint). With a new osteosynthesis implant it is possible to solve the problems of this fracture with a save and relatively simple operation. The suggested implant guarantees an exercise-stable osteosynthesis that allows immediate functional aftercare. With this technique we can reduce the complication rate and reach full working capacity earlier. Within an observation period of about five years we used this implant on 21 patients and the clinical and radiological follow-up shows good to very good results in the medium and long-terms.

[Autologous blood transfusion in elective orthopedic surgery]. / Autologe Bluttransfusion bei orthopädischen Wahloperationen.

Despite extensive testing, blood transfusions still involve a minor risk of transmitting infections. Autologous blood transfusions (ABT) are safe in this respect. Within 31 months 145 of 149 patients were enrolled in this hospital's ABT program, the majority with planned total hip replacement. The mean age of the patients was 68.5 years. 72 patients donated 3 and 52 patients 2 units of blood, while 21 patients donated 1 unit. In 70 of the 145 patients (48%) the blood losses were covered by autologous blood. Of the 72 patients who donated 3 units, 50 (69%) did not depend on homologous blood. We observed only minor side effects in patients enrolled in the program. The establishment of an ABT program does not require complicated logistics, and almost every patient awaiting elective surgery is eligible for ABT.

[Autologous blood transfusion in surgical interventions]. / Die autologe Bluttransfusion bei chirurgischen Eingriffen.

By the autologous blood-transfusion we understand the dose of own blood in contrary to strange blood. The advantageous of the method are well-known. But nevertheless the own-transfusion is rarely realized. By the immune infirmity AIDS this method is of pressing importance at the present time. In orthopaedics and the traumatology of the movement mechanism especially selected operations and delayed emergency-operations are qualified for the autologous blood-transfusion. Regarding a ten years positive experience we introduce a simple and safe method which is also commonly used in the regional hospital in Langenthal since summer 1986. It is a combination of a pre-operative own-blood-transfusion and the "isovolumic" actual blood-dilution. 158 patients have been analysed which have been treated by this method. The most frequently operation has been the total hip replacement 85% of the analysed persons could be operated without any strange blood and totally 426 times autologous blood donation could be received within 26 months. That safe and simple method can be managed in the hospital by an engaged but moderate display and it is recommended especially for average and small hospitals.

[Treatment of distal forearm splinter fractures using the Wagner apparatus]. / Behandlung der distalen Vorderarm-Trümmerfraktur mit dem Wagner-Apparat.

Normally, the distal forearm fracture is treated conservatively. The classic conservative therapy mostly obtains good results. Certain fracture-types cannot expect a good result for a long time by the treatment of conservative measures. So, they should be recommended to an operative therapy. In addition to the classical osteosynthesis the external fixator is currently used. The principle of the joint-reconciling fixator can be realized in many ways. Of common use is the small fixator of the AO and also the tube fixator is described in the literature. A real alternative to both treatments is the small extension machine of Wagner. This method has nearly been forgotten in the clinical training. We are talking in a few pages about our experiences and the advantages of that measures.

[Examination of the injured knee joint]. / Untersuchung des verletzten Kniegelenkes.

Examination of the knee joint and the assessment of capsular ligament lesions require profound anatomical and biomechanical knowledge. Particular importance attaches to detailed information about the mechanism of the accident and to stability testing; these allow the establishment of diagnosis in the majority of cases. The diagnosis should take account of the anatomical structures damaged, thus defining both the location and the functional significance of the lesion, which are also important for therapeutic strategy. Arthroscopy makes it possible to solve almost all diagnostic problems and also to apply adequate therapeutic measures. This has necessarily had a considerable influence on strategies for the management of patients with knee injuries. Therapeutic considerations should include the critical evaluation of indications for surgery.

Olecranization of the patella in posterior instability of the knee.

A case report is given in which temporary fixation of the patella to the tibia with a Steinmann pin was used in a patient with gross knee instability due to deficient cruciate ligaments. The pin was left in place for seven months, and at last follow-up--14 months postoperatively--marked improvement in knee stability was noted. The procedure is applicable as a means of maintaining reduction in posterior cruciate repairs and reconstructions.

[Idiopathic coxa antetorta (antetorsion syndrome)]. / Die idiopathische Coxa antetorta (Antetorsionssyndrom).

Idiopathic anteversion of the femoral neck must be primarily considered as a variant of physiological development. Surgery should be discussed in extreme cases only. Indication for surgery is partly offset or becomes disputable by the ensuing complications, the questionable prophylaxis of arthrosis and the observed spontaneous regression. It is quite a problem for the doctor to take adequate care of the children and to calm the parents; he must under all circumstances try to postpone surgery up to the 10th year of life by regular outpatient follow-ups. Strengthening of the abductors of the hip is the only meaningful causal-conservative treatment measure. Surgery should be discussed during the 10th year of life while applying the most severe criteria; it should remain an exception and should be performed under optimal conditions only.

[Arthroscopic evaluation of cartilage lesions in the knee joint]. / Kie arthroskopische Beurteilung der Knorpelschäden am Kniegelenk.

Arthroscopy constitutes an important supplementary method for investigating and diagnosing affections of the knee joint. Despite the low risk and little trouble it causes to the patient it should only be used if radiological and repeated clinical examinations do not permit any evaluation of the disease. Arthroscopy is the method of choice in case of cartilage damage because from the appearance of the altered cartilage conclusions may be drawn about the occurrence and kind of the trauma. This examination method is valuable not only in diagnosis, it is also used to follow up the result of surgical interventions. Small pieces of cartilage that cannot be fixed may be removed by means of the arthroscope, so that examination and therapy can be done in one single operation. In most cases, cartilage damage is caused by laxity of ligaments.