[The methodological quality of rehabilitation guidelines]. / Methodische Qualität von Leitlinien in der Rehabilitation.

INTRODUCTION: The concepts of clinical guidelines contribute to the decision-making and improvement in the quality of medical supply. This paper provides a literature research on rehabilitation guidelines and their evaluation by the "German Instrument for Methodological Guideline Appraisal (DELBI)". METHODS: The clinical guideline research was conducted with the help of an online database as well as expert surveys conducted between August and October 2007. The literature research was updated in October 2008. Only those guidelines that satisfied specific criteria were included in the evaluation. RESULTS: Although the research yielded 124 guidelines, only 28 were included in the evaluation after applying the criteria. In total, the evaluation was heterogeneous. With regard to each domain, the mean degree of fulfillment reached between 2.1% and 58.3%. DISCUSSION: Due to an extensive and detailed literature research and expert survey, all relevant clinical guidelines for rehabilitation, which are valid in Germany, could be gathered. A first examination of the guidelines seems to reveal several deficiencies. Possible reasons are discussed. CONCLUSION: This paper reveals a detailed survey of the clinical guidelines for rehabilitation. Compared to acute-care medicine, the number of available guidelines is distinctly smaller. With regard to the DELBI criteria, an enormous development in the quality of guidelines for rehabilitation is still necessary. Some of these might be due to inaccurate documentation, which will have to be considered in a further update.

[Operation documentation. A program for the detection and statistical documentary evaluation of surgery reports]. / Operationsdokumentation. Ein Programm für die Erfassung und statistisch-dokumentarische Auswertung von Operationsberichten.

A computer program specifically designed for surgical data retrieval was tested for longer than one year. By using the information contained in operation reports, with this program statistical analysis may be achieved. The reports are generated and printed using a personal computer running MS-DOS. Entering data does not cause any additional effort for the secretary. The selection of requested data is possible with any combination of criteria, and the resultant information is displayed on the computer terminal screen or printed on the computer printer. A combination of terms is used instead of a numeric code for data entry allowing far greater selectivity, with a reduced risk of data loss due to wrong numeric code entry.

Human fetal and adult chondrocytes. Effect of insulinlike growth factors I and II, insulin, and growth hormone on clonal growth.

Clonal proliferation of freshly isolated human fetal chondrocytes and adult chondrocytes in response to human insulinlike growth factors I and II (IGF I, IGF II), human biosynthetic insulin, and human growth hormone (GH) was assessed. IGF I (25 ng/ml) stimulated clonal growth of fetal chondrocytes (54 +/- 12 colonies/1,000 inserted cells, mean +/- 1 SD), but IGF II (25 ng/ml) was significantly more effective (106 +/- 12 colonies/1,000 inserted cells, P less than 0.05, unstimulated control: 14 +/- 4 colonies/1,000 inserted cells). In contrast, IGF I (25 ng/ml) was more effective in adult chondrocytes (42 +/- 6 colonies/1,000 inserted cells) than IGF II (25 ng/ml) (21 +/- 6 colonies/1,000 inserted cells; P less than 0.05, unstimulated control: 6 +/- 3 colonies/1,000 inserted cells). GH and human biosynthetic insulin did not affect clonal growth of fetal or adult chondrocytes. The clonal growth pattern of IGF-stimulated fetal and adult chondrocytes was not significantly changed when chondrocytes were first grown in monolayer culture, harvested, and then inserted in the clonal culture system. However, the adult chondrocytes showed a time-dependent decrease of stimulation of clonal growth by IGF I and II. This was not true for fetal chondrocytes. The results are compatible with the concept that IGF II is a more potent stimulant of clonal growth of chondrocytes during fetal life, whereas IGF I is more effective in stimulating clonal growth of chondrocytes during postnatal life.

[Intrathoracic dislocation of the head of the humerus]. / Intrathorakale Humeruskopfluxation.

Intrathoracic displacement of the proximal humerus following axillary luxation is a rare injury; but with ipsilateral serial costal fracture and/or single costal fracture with contused lung it has to be included in the considerations concerning differential diagnosis and the tactics of surgical approach. The primary measures are determined by the extent of pulmonary damage; the further course is marked by aseptic necrosis of the head of the humerus. On the basis of our study case we are describing a typical course, and discussing its problems taking into consideration the individual publications available so far.

[Cruciate ligament replacement--current status. Carbon fiber implants]. / Kreuzbandersatz--aktueller Stand. Kohlenstoffaserimplantate.

The substitution of cruciate ligaments with carbon fibre implants is a treatment method for chronic ligament instabilities which is sufficiently reliable and can be easily standardized. The good bio-compatibility of the material is sufficiently demonstrated, its biomechanical properties - above all the tensile strength - are excellent. The poor resistance to shearing forces of the carbon fibre implants has to be considered as a limiting factor. The risk of a rupture of the implant can be considerably reduced by coating the prospective intra-articular ligament section and by smoothing off the borehole edges. A check-up investigation of 96 out of 112 operated patients showed good or satisfactory results in 3/4 of the examined patients.

Human nasal septal cartilage: local distribution of different enzyme activities in healthy adults and acromegalic patients.

Septal cartilage was obtained during septoplasty from healthy adults or during transnasal hypophysectomy from acromegalic patients. Small strips of cartilage were excised from five different areas of the septum: the anterior free end, the suprapremaxillary area, the central area, the posterior area, and the caudal prolongation of the septum. Five different enzymatic pathways were analyzed in these areas. Cathepsin D, an acid proteinase, did not show a specific local activity pattern and was not influenced by the augmented growth hormone level in acromegaly, whereas cathepsin B, a neutral proteinase, showed its highest activity in the caudal prolongation and the posterior area and was significantly increased in all areas in acromegaly. Beta-hexosaminidase activity was highest in the central and posterior area and caudal prolongation of the septum. In acromegaly, a significant increase of its activity was found in the suprapremaxillary and posterior area. Acid phosphatase activity was highest in the caudal prolongation of the septum, but its activity was significantly increased in all tested areas in acromegaly. Alkaline phosphatase activity could only be found in the posterior area and the caudal prolongation in healthy adults. However, in acromegaly this enzyme could be detected in the central area and the posterior end of the suprapremaxillary area suggesting an altered process of mineralization. A distinct local pattern of enzymes related to intercellular substance metabolism and mineralization can be demonstrated in the septal cartilage of healthy adults and acromegalic patients.

Clonal proliferation and cell density of chondrocytes isolated from human fetal epiphyseal, human adult articular and nasal septal cartilage. Influence of hormones and growth factors.

The present study characterizes the cell density and cellular growth characteristics of functionally and morphogenetically different human cartilages. In fetal epiphyseal, in postnatal nasal septal and in articular cartilage the influence of aging on cell density and in vitro growth characteristics were investigated. Cell density was highest in fetal epiphyseal cartilage and lowest in articular cartilage. In vitro growth of isolated chondrocytes as measured by clonal growth in a semisolid assay was almost identically high in fetal epiphyseal and septal cartilage and significantly lower in articular cartilage. Cell density increased with age in the nasal septal cartilage whereas no age dependency was found in the other cartilages. The stimulatory effects of human biosynthetic insulin, human growth hormone and partially purified IGF I on clonal growth of chrondrocytes were assessed. Only IGF I stimulated clonal growth of chondrocytes and its stimulatory effect was significantly higher in postnatal than in fetal chondrocytes.

Growth of the human septal cartilage: cell density and colony formation of septal chondrocytes.

Human chondrocytes from 24 patients (5 to 52 years) with septal deviation were isolated in different areas of the septal cartilage. Cell density was counted, and the chondrocytes were grown in an assay system for determining the number of chondrocytes capable of proliferating. High cell density and excellent proliferative capacity were found in the anterior free end of the septal cartilage in all age groups. The central area showed the highest growth index in childhood, and increasing cell density from childhood to puberty. Generally the growth index decreased with age in all septal areas. The results help to explain some clinical observations: increasing septal cartilage even in adults, growth of nasal tip in adults, regenerative potential of septal cartilage after injuries or surgery, importance of the central area for septal growth and surgery.

Patterns of growth in human septal cartilage: a review of new approaches.

Recent results of the growth activities of the septal cartilage in children, adolescents, and adults are reviewed. Cartilaginous biopsies were obtained during septoplasty . Matrix synthesis was measured by in vitro incorporation of labeled sulphate; DNA synthesis was measured by in vitro incorporation of labeled thymidine. The cell density of the septal cartilage was determined by cell counting, and chondrocytes were grown in culture in an assay to determine the number of chondrocytes capable of proliferation. With data from these 4 types of experiments 5 different areas could be distinguished in human septal cartilage: (1) anterior free end, (2) suprapremaxillary area, (3) central area, (4) posterior area, and (5) caudal prolongation. Metabolic activities, degree of cell replication, and proliferative capacity are highest in childhood in all areas; they decline with age, but remain surprisingly high in the central area and in the anterior free end, even in adults. These results help to explain some clinical observations and may help the rhinosurgeon in his decision to resect the septal cartilage, especially in children.

[Transplantation of isolated chondrocytes in articular cartilage defects. Regeneration of adult hyaline cartilage with fetal chondrocytes]. / Transplantation isolierter Chondrozyten in Gelenkknorpel-Defekte. Untersuchung zur Regeneration adulten hyalinen Knorpels durch fötale Chondrozyten.

Viability and proliferative capacity of the chondrocytes are particularly important for a successful cartilage graft. This can be demonstrated by a new in vitro colony-forming assay. Only fetal or neonatal chondrocytes are considered to be applicable according to these criteria. Single cell suspensions prepared from articular cartilage can be transplanted without technical problems. In animal experiments articular cartilage regenerated after transplantation of neonatal chondrocytes, whereas only connective tissue was found in controls.

The body reaction to carbon fibre particles implanted into the medullary space of rabbits.

It is thought that abrasion particles can produce a tissue reaction when alloplastic material is used for prosthetic devices. Therefore it is important to examine the reaction of the tissues and the body to microparticles before introducing a new material. Carbon reinforced carbon is a new material which is suitable for artificial joints because of its physical properties (strength and elasticity). Carbon fibre fragments with a diameter of 7 microns and a length between 20-100 microns were injected in the medullary canal of 16 rabbits, and evaluated after periods of 2 and 12 weeks. Phagocytosis of small carbon fibre fragments by macrophages occurs, but only a minimal foreign body reaction to the intramedullary carbon fibre fragments. There is a small amount of fibrosis around some carbon fibres and a small amount of new bone formation with inclusion of carbon. Only a few carbon fragments are transported to the parenchymal organs. There is no foreign body reaction.

Surgical management of acute injury of the ligaments of the knee joint.

Objective loss of stability is the indication for surgical reconstruction of acute knee ligament injuries. The final diagnosis is established under anaesthesia preceding the operation. This examination also determines the incision and approach. All structures of the knee joint are checked, lesions are precisely reconstructed. This is done by fine sutures in the case of interligamentary ruptures, pull-out sutures with cruciate lesions present, and fixation plate reinsertions of avulsions with or without osseous flakes. Menisci torn from their capsular base should be reinserted whenever possible. Lesions of the cartilage call for adequate primary management. Incisions are closed subsequent to suction drainage. The leg is positioned in a splint in elevation. Early functional therapy is indicated.

[Closure of abdominal wall defects without tension using a carbon cloth implant (author's transl)]. / Eine spannungsfreie Uberbrückung von Bauchwandbrüchen durch ein Kohlenstoffasertuch.

On 20 rabbits a defect in the abdominal wall was closed by a carbon cloth (SIGRATEX KDS). A tensile force test and a histological examination was performed. Eleven days and 3 months after implantation, 10 animals with an operative-produced abdominal wall hernia and 10 normal animals were controls. A tensile force test on the specimen 3 months after implantation revealed a strength twice as high as on the normal abdominal wall. Eleven days after surgery the strength was equal to the scar tissue of the hernias. Histologically, a connective tissue ingrowth into the implant was observed, which enveloped the single carbon fibers. Collagen fibers in the direction of the carbon filaments were present. Foreign body giant cells were always seen. These results indicate that a carbon cloth seems to be suitable for the repair of abdominal wall hernias.

[The use of carbon fiber strands for replacement of collateral ligaments at the knee joint (author's transl)]. / Kohlenstoffasern als Bandersatz am Kniegelenk, eine biomechanische und histologische Untersuchung.

Two different anchorage systems of carbon fiber strands were tested on 16 human cadaver knees. To pull the C-strands out of the scale and channel anchorage almost the same force was necessary as to break the natural collateral ligaments. The ingrowth of connective tissues and newly formed bone around the C-fibers was studied in 11 sheep. A biomechanical strength test revealed, 3 months after implantation, a 60% strength compared to the natural ligaments. Histologically a C-fiber connective tissue composite with collagen fibers was found. Newly formed bone closely surrounded the carbon. These results indicate that carbon fiber strands are suitable for ligament replacement, which allows early joint motion. Good long-term results could be assumed as a result of the high biocompatibility.

[In vivo synthesis of cartilage after transplantation of chondrocytes in animal experiments (author's transl)]. / In vivo knorpelsynthese durch Chondrocytentransplantate im Tiermodell.

Long-term results after cartilage transplantation are not satisfactory owing to poor viability of the chondrocytes. In vitro experiments with isolated fetal and neonatal rabbit chondrocytes revealed a much better proliferative ability compared with adult cartilage derived cells. Cryopreservation of cell suspensions did not decrease the proliferative ability. In in vivo experiments, cultured neonatal, fetal, and cryopreserved rabbit chondrocytes were tested in transplants and compared with cell-free controls or radiated chondrocytes. These chondrocytic transplants showed good viability and seemed to synthesize cartilage matrix, which could be stained with safranin, whereas only fibrous tissue was found in controls.

[In vitro study of isolated chondrocytes concerning the prognosis of transplanted cartilage]. / In-vitro-Untersuchungen an isolierten Chondrozyten zur Prognose von Knorpeltransplantaten.

In order to find out reliable criteria to conclude on the prognosis of transplanted cartilage the quality of isolated rabbit chondrocytes was assayed in vitro. Using a semisolid medium a culture system is introduced, which is able to detect colony forming units of chondrocytes. Furthermore their proliferative and differentiating capacity was investigated. Colony formation in vitro follows a strict dose response relationship. An inverse relationship was observed between the age of the donor and the colony incidence in vitro. Cells from neonatal cartilage could be induced to grow as fibroblastic colonies in the presence of conditioned medium from fibroblastic monolayer cultures. No effect, however, could be observed with chondrocyte derived conditioned medium.