[Conservative treatment strategies for gonarthritis. New trends and established therapy concepts]. / Konservative Behandlungsstrategien bei Gonarthrose. Neue Trends und bewährte Therapiekonzepte.

This article gives a current overview of non-operative procedures in cases of osteoarthritis of the knee, e.g. with special medications, local physiotherapy and gymnastic therapy including ergotherapy and aids for activities of daily living (ADL).

Safety and efficacy findings from a non-interventional study of a new hyaluronic acid/sorbitol formulation (GO-ON® matrix) for intra-articular injection to relieve pain and disability in osteoarthritis patients.

This non-interventional study was intended to examine the efficacy and tolerability of intra-articular injections with the GO-ON® matrix, a new viscosupplement product made of non-animal sodium hyaluronate combined with the oxygen free radical scavenger sorbitol, when used in routine clinical practice. A total of 1 147 patients (43.5% male, 53,5% female, 3% missing) aged on average 63.3 years with osteoarthritis were enrolled in 398 centers and treated with the product. The most commonly treated joint was the knee (92.9%) with a Kellgren-Lawrence classification of Grade I (6.7%), Grade II (31.4%), Grade III (48.0%), and Grade IV (13.9%).Most patients (58-66%, imputing for missing data) received 1 injection, 29-40% received 3 injections. Using a Likert scale to asses pain, the mean change in pain due to osteoarthritis was a reduction of 56.5% from baseline (2.61±0.80) to 6 months (1.07±0.86). At baseline, 56.2% of patients reported severe/very severe pain versus 5.9% after 6 months. Accordingly, 6.8% of patients reported no pain/mild pain at baseline vs. 67.1% after 6 months. At baseline, 28.9% reported no pain/mild pain vs. to 66.4% after 6 months. At baseline, 29.1% of patients reported severe/very severe functional impairment vs. 3.9% 6 months after the first injection. The 3 and 6 month results were comparable.Adverse reactions were rare and confined to musculoskeletal and connective tissue disorders. No infections were reported in any treated joints. The results confirm that the GO-ON matrix® treatment is effective and well tolerated in the treatment of symptoms due to osteoarthritis.

[Postoperative rehabilitation after minimally invasive total hip arthroplasty]. / Rehabilitation nach minimal-invasiver Hüftendoprothesenimplantation.

Currently more than 150,000 total hip arthroplasties (THA) are performed in Germany each year. Despite limited financial resources approximately 50% of these patients participate in a standardized inpatient rehabilitation program. This report reflects own experiences with patients after a minimally invasive approach for THA compared to others with conventional procedures, in context with findings from the literature. Rehabilitation and convalescence in patients with a minimally invasive approach for THA seem to have advantages especially in the first weeks after surgery, with manageable complications and socioeconomic improvements compared to conventional approaches.

[Treatment of osteoarthritis with cristalline glucosamine sulfate. Results of the IDEAL-study]. / Die Gonarthrosetherapie mit kristallinem Glucosaminhemisulfat. Ergebnisse der IDEAL-studie.

AIMS AND METHODS: The treament of patients with mild to moderate osteoarthritis of the knee with cristalline glucosamine sulfate (CGS; dona) under real life conditions was documented for 6 months in a multicenter, prospective, non-controlled, noninterventional trial. In addition to efficacy evaluated with Lequesne's index, changes in use of analgesics and the incidence of related adverse events were to be assessed during the intake CGS. Furthermore, quality of life was to be documented using a patient-diary. About 80% of the patients were treated with 1,500 mg p.o. (min. 750, max. 3,000 mg) CGS per day. Data of 698 patients, mean age 58 years (58% female), could be evaluated. RESULTS: The mean Lequesne-Index decreased from the beginning of the study to the end from 7.2 (moderate) to 4.2 (mild). The sub-scores assessing pain, mobility, and daily work changed accordingly. The fraction of patients with complaints associated with the use of analgesics changed from 12% at the beginning of the study to 3% at the end, the amount of analgesics being taken decreased to one third of that taken at the beginning. According to the global assessment of the physicians 80% of patients felt better or much better with regard to their knee complaints at the end of the study. The patients' own assessment was even better. Quality of life increased considerably. Only 1.6% of all patients reported adverse events but none was severe. CONCLUSIONS: In the study it could be demonstrated once more that treatment with CGS is well tolerated and leads to an improvement in complaints related to osteoarthritis accompanied by an increase in quality of life. Furthermore the use of analgesics could be reduced and patients reported a progressive improvement of symptoms over the observation period. CGS can be considered an effective and well tolerated medication.

[Konzept Perioperative management for endoprosthetic hip joint replacement. The functional interdisciplinary therapy (FIT) concept]. / Perioperatives Management beim endoprothetischen Hüftgelenkersatz. Das funktionelle interdisziplinäre Therapie-(FIT-) Konzept.

During the last decade there have been significant changes in the perioperative management of total hip replacement patients. This process begins in the preoperative phase. Many patients are much better informed and standardized preoperative patient programs improve patient outcome and optimize the clinical pathways. The techniques in perioperative pain management have also significantly improved. The surgeon should not only rely on the anesthesiologist but should also use the options available during surgery. Postoperative weight bearing is handled in a much more progressive way than previously. In a standard primary hip replacement pain-adapted full weight bearing is possible if there are no patient-specific problems. There has also been a shift in the postoperative capability of performing athletic or recreational activities. In general patients can perform those activities that were performed before the surgery, which also includes, for example downhill skiing.

[Conservative strategies for treating low back pain]. / Konservative Behandlungspalette des Rückenschmerzes.

This article discusses the importance of a careful patient history and a detailed clinical assessment to differentiate etiologic factors concerning the cause and continuation of low back pain. The indications and efficacy of various physiotherapeutic and balneological strategies are presented, with emphasis on the economic necessity of a targeted plan of care.

[Rehabilitation following total hip and knee replacement]. / Rehabilitation nach endoprothetischem Ersatz von Hüfte und Knie.

For the more than 330.000 patients/year with primary total hip replacement (THR) or total knee replacement (TKR) in Germany alone, postoperative rehabilitation either on an inpatient or follow-up outpatient basis is largely accepted as standard, despite limited financial resources. The present article discusses the necessary diagnostic and therapeutic measures in the immediate postoperative phase in the hospital or clinic, the so-called post-inpatient phase in a rehabilitation clinic or centre, as well as the subsequent outpatient phase with consistent and regular specialist follow-up.

[Simple and valid ICD9-/10- and IKPM coding using an electronic data-assisted coding system "do it"--experiences after one years use]. / Einfache und valide ICD9-/-10- und IKPM-Kodierung mit Hilfe des EDV-gestützten Verschlüsselungssystems "do it"--Erfahrungen nach einjähriger Anwendung.

UNLABELLED: Question by introducing "Fallpauschalen" and "Sonderentgelte" in German health system the coding of diagnoses and therapies gains a new momentum. Therefore, a new computer based coding-system for ICD- and ICPM- digits is presented. The physician gets enabled for simple and valid classification within his documentation routine. METHODS: Development of a hierarchic menue system, whose first part represents the anatomic region. The second part is reserved for the most common diagnosis rsp. therapies within its special anatomic region. By further sub-menues all other ICD numbers in the orthopedic and traumatologic field may be coded (selection related by frequency). This coding-system has been in clinical use since jan. 1st. 1995. RESULTS: Control of the efficiency of this coding-systems by 1316 patients with 1551 operations within one year. By using ICD-10, the representation of orthopedic-traumatologic diagnosis inhanced by factor 1.8 versus ICD-9. According to ICPM, 3560 therapies were coded, making it 2-3 actions per operation. "Fallpauschalen" were found in 21.9%, in 27.7% there were "Sonderentgelte". Within one year the coding error rate was reduced from 25% to 5%. CONCLUSIONS: Because of its easy handling the coding system "do it" represents a good alternative to conventional coding rsp. clear text analysis.

The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments.

STUDY DESIGN: A retrospective study was performed of 182 revisions on failed back surgery syndrome from the years 1965 to 1990. OBJECTIVE: To analyze the reasons for failure of primary discectomy, the outcome of the revisions, and factors that influenced those outcomes. SUMMARY OF BACKGROUND DATA: The reported reintervention rates after lumbar discectomy range from 5% to 33% depending on the type of surgical procedure. The authors' former investigations reported a revision rate of 10.8% in evaluating 1500 lumbar discectomies. METHODS: Because the documentation was standardized, detailed data of all patients were available. To gain further information concerning the long-term results a questionnaire was used. Computer processing and statistical tests were performed. RESULTS: One hundred eighty-two revisions were performed on 136 patients. Forty-four patients (34%) were revised multiple times. Generally, recurrent or uninfluenced sciatic pain and neurologic deficiency or lumbar instability led to reintervention. Recurrent lumbar disc herniation mainly was found at the first reintervention. In multiple revision patients the rate of epidural fibrosis and instability increased to greater than 60%. In 80% of the patients the results were satisfactory in short-term evaluation, decreasing to 22% in long-term follow up (2-27 years). CONCLUSIONS: Laminectomy performed in primary surgery could be detected as the only factor leading to a higher rate of revisions. A trend toward poor results after recurrent disc surgery seems to be fateful because of the development of epidural fibrosis and instability. In severe discotomy syndrome, a spinal fusion seems to be more successful than multiple fibrinolyses.

[Endoprosthetic joint replacement in Morquio-Brailsford syndrome]. / Endoprothetischer Gelenkersatz beim Morquio-Brailsford-Syndrom.

Morquio-Brailsford's disease belongs to the mucopolysaccharidoses, it shows growth-retarding with dysproportional dwarfism. Due to bone deformations and joint dysplasias very early severe arthritic changes arise with serious functional disabilities, especially in the loaded lower extremities; this may lead to early alloplastic joint replacement surgery. By means of two patients with respective bilateral THR and singular total knee replacement intraoperative complications and postoperative follow up (up to 12 years) are represented casuistically. Unfavourable anatomic properties (dysplasia, size of joints) were the main technical surgery problem; the use of individually manufactured implants might be recommended in some of these cases. The achieved subjective and objective functional results of our cases were-compared to the preoperative situation-altogether quite satisfactory.

Demonstration of interleukin-1beta and interleukin-6 in cells of synovial fluids by flow cytometry.

Cytokine levels are increased in the synovial fluid of affected joints from patients with inflammatory joint diseases. The aim of our study was therefore to determine if and to what extent immmunologically defined subpopulations of mononuclear cells (MNC) in the synovial fluid are responsible for the increased levels of interleukin-1beta (IL-1beta) and interleukin-6 (IL-6) in affected joints. Lipopolysaccharide (LPS) stimulated peripheral MNC were used as positive controls. While soluble IL-1beta (median 167 pg/ml) and IL-6 (median 508 pg/ml) levels were significantly elevated in the synovial fluids tested, IL-1beta and IL-6 were demonstrated by flow cytometry in only a small subpopulation (<=11%) of mononuclear synovial fluid cells in 7/13 patients. Our results suggest that elevated IL-1beta and IL-6 levels in the synovial fluid of inflammatory joints are derived mainly from cells in the synovial membrane and only to a minor extent from cells in the synovial fluid itself.

[Synovectomy of the knee joint in rheumatoid arthritis. Follow-up studies]. / Synovektomie des Kniegelenks bei rheumatoider Arthritis. Verlaufsbeobachtungen.

A total of 156 synovectomies were performed to treat recurrent swelling of the knee joints in 148 patients with rheumatic diseases. The late results observed in 112 patients (72%) re-examined after an average follow-up period of 6.2 years are discussed. The subjective and objective findings in patients undergoing early surgery proved to be superior to those seen after late synovectomy. Also in comparison with a group of patients submitted to synoviorthosis, surgical synovectomy, in particular when carried out at an early stage, showed more favorable results. For this reason, should conservative treatment fail, and recurrent swelling of the knee joints persist, early surgical intervention ist recommended.

Is surface cooling effective for tissue preservation in free-flap surgery?

Effective tissue cooling can extend the period of safe ischemia. To determine whether the technique of surface cooling could produce an effectively low core temperature (4 degrees to 10 degrees C) in the flap core in a reasonable amount of time, bovine muscle/subcutaneous fat flaps, weighing 400, 800, and 2000 g, were brought to 37 degrees C and then surface cooled. Temperatures were then recorded every 5 min. All flaps were able to attain 4 degrees C in the core; the average times for the 400, 800, and 2000 g flaps to reach 4 degrees C were 136, 153, and 194 min, respectively. Although a clear inverse relationship existed between flap weight and effectiveness of core cooling, even relatively large flaps (2000 g) could still achieve sufficiently low core temperatures from surface cooling well within tolerable warm ischemia time. Concern for ischemia time generally should not interfere with efficient, orderly, free-flap surgery.

[Medium-term results of cement-free autophor hip endoprosthesis]. / Mittelfristige Ergebnisse der zementfreien Autophor-Hüftendoprothese.

Representation of middle-term observations of cementless ceramic THR (type Autophor) in a period of now nearly 18 years with altogether 1974 primary arthroplasties. The design of the conical shaped screwed ceramic socket proved to be very successful, its aseptic loosening rate amounted to 1.8% at last. We could confirm the favourable biocompatibility and wear behaviour of ceramic/ceramic joint pairing. The stem design had to be improved twice during the observation period due to upcoming aseptic loosening problems; the femoral component 900 S with macro- and microprofile, which has been in clinical use since 1984, shows an aseptic failure quote of less than 2% after 8 years. The very low average age of our patients with cementless THR at time of operation (48.9 years) proves, that--when using wear resistant biomaterials and surface enlarged prosthetic components to be implanted without bone cement--Charnley's strict age indication of THR may be abandoned.

ShrinkRapt: a database manager for the Macintosh.

The bad news about ShrinkRapt is that its clinical potential remains, mostly, potential. The good news is that ShrinkRapt works. It concentrates on the fundamentals, stimulates thinking, and appears to be backed up by a creative and dedicated company. It is versatile enough to fit many practice styles and volumes of record keeping. A solo practitioner with a part-time psychotherapy practice and a Macintosh in the office can enter data at the end of the day or the end of a session, typing up patients' progress notes while they are still fresh in memory and keeping abreast of session data and documentation requirements. At the end of the month, a few keystrokes generate bills and claims forms.

Sixteen-years' experience with ceramic hip prostheses.

The introduction of alumina ceramic combined with the self-locking principle by surface increase has many followers. There is no manufacturing company in the world that does not produce self-locking hip prostheses with ceramic components. Despite increased interim results with conventional prostheses by improved cement technique, the self-locking principle with wear resistant ceramic components is better, at least in young, active patients.

Initial experience with percutaneous placement of the PAS port implantable venous access device.

The authors evaluated a new venous access port designed for peripheral venous insertion in the interventional radiology suite. Forty ports were placed in 40 patients in either the brachial, cephalic, or basilic vein under fluoroscopic guidance. These ports have been used for blood transfusion, blood sampling, parenteral nutrition, chemotherapy, and antibiotic therapy. The ports have been in use for 4,241 consecutive patients days. There have been no clinically apparent venous thrombotic complications and only one device-related infection. The cost and risk of complication are less than those for a surgically placed chest wall port, and the cosmetic result is excellent. This port has had excellent patient, nursing, and clinical acceptance.

[Mesomelic dysplasia: presentation of a case and literature of Werner's syndrome]. / Mesomele Dysplasie: Falldarstellung und Literatur zum Werner-Syndrom.

The extremely rare Werner syndrome (tibial hemimelia, foot polydactyly, triphalangeal thumbs) is represented by an own case: a 21 year old female has been treated since her birth in the orthopedic department of Homburg/Saar university clinic. First, during several operative sessions, there was the correction of the bilateral completely webbed fingers and the resection of the supernumerary toes. Because of tibial hypoplasia there was need of bilateral operative club-foot-correction, too. Presentation of the course over 20 years with clinical and roentgenological late results. In several publications we find different classifications of the collective name, tibial hemimelia'; the symptom-triade congenital tibia-defect/foot-polydactyly/triphalangeal thumb was of special interest.