[Trauma surgery - a lasting motivation]. / Unfallchirurgie - eine bleibende Motivation.

Retirement is a caesura already determined on the day of assumption of office. With an abundance of tasks and a long period of enthusiasm the turning point slips out of memory or is simply repressed. We should have the good sense to think about alternatives in advance after running a hospital for so many years. There is an abundance of tasks within and outside the profession. The continuation of long established collegial alliances all over the world presents an excellent opportunity to maintain surgical skills as well as to retain motivation in trauma care and to obtain a broader view of human society.

[Open arthrolysis of posttraumatic elbow stiffness]. / Die offene Arthrolyse der posttraumatischen Ellenbogensteife.

BACKGROUND: The incidence of relevant posttraumatic functional deficits in the sense of elbow stiffness with less than 30 degrees in extension or flexion less than 120 degrees , is unknown. A differentiation can be made between intraarticular, extraarticular and combined causes. An open procedure is indicated in elbow stiffness after correct analysis of the situation and failure of conservative treatment. MATERIALS AND METHODS: An open procedure was carried out on 35 patients between March 1995 and November 2001, 10 (3-24) months after the trauma. The mean age of the 24 men and 11 women was 45 (range 17-75) years. Of the patients 15 had distal humerus fractures, 10 radius head or neck fractures and 12 proximal ulnar fractures. RESULTS: Of the patients 11 (31%) had an excellent result in the Cauchoix and Deburge score, 15 (42%) a good, 4 (11%) a fair, 4 (11%) a bad and 1 (3%) a very bad result after a mean follow-up of 21.5 (range 9-60) months. Of the patients 11 (31%) had an excellent result in the Mayo elbow performance score, 14 (40%) a good, 5 (14%) a fair and 5 (14%) a poor result. CONCLUSION: Open arthrolysis for severe posttraumatic elbow stiffness carried out 10 months (range 3-24 months) after the accident led to good results in most cases with a clear improvement in functional mobility.

[Early clinical outcome after navigated total knee arthroplasty. Comparison with conventional implantation in TKA: a controlled and prospective analysis]. / Klinische und radiologische Ergebnisse nach navigierter Knieendoprothetik. Analyse einer kontrollierten und prospektiven Studie im Vergleich zur konventionellen Implantationstechnik.

BACKGROUND: Navigated implantation of total knee prostheses has become more and more popular within the last decade in orthopaedic surgery. Although improved alignment after navigated knee surgery has been reported previously in the literature, only a few studies meet the criteria of a level-1 evidence-based medicine study. We present the results of a controlled and prospective study comparing early clinical outcomes after computer-assisted versus conventional implantation in total knee arthroplasty (TKA). METHODS: Within a 15-month period, all patients admitted for primary TKA were followed prospectively. Each patient was evaluated using the Knee Society Score (KSS) preoperatively, 10 days after surgery, and 3 months after surgery. The patients were divided into two groups, and the implantation technique altered between the two treatment options: each conventional implantation was strictly followed by a computer-assisted procedure and vice versa. RESULTS: From March 2003 to June 2004, we did 34 computer-assisted (group A) and 35 conventional knee arthroplasties (group B) in 62 patients. There was no difference in the preoperative status of the patients. Surgeries in group A took significantly longer than in group B. The average deviation from correct alignment was significantly reduced in group A. 66 of 69 of the TKAs were available for follow-up examinations after 10 days and after 3 months. No significant differences were found in the overall KSS scores or in the subgroups. CONCLUSIONS: The intraoperative use of a computer-assisted navigation system during implantation of a total knee prosthesis reduced the average varus/valgus deviation from the anatomical long leg axis. A disadvantage of the computer-assisted surgical procedure may be the longer operating time. Long-term follow-up of the presented data is needed in order to show whether the improved average alignment is advantageous for patients and/or results in a longer service life of the TKA.

Intraoperative localization of calcification in the supraspinatus via a percutaneous marking suture after preoperative ultrasound.

In a prospective study, we evaluated the efficiency of a technique for localizing calcification via a marking suture. In 27 patients, we measured the distance between the center of the calcification and the long head of the biceps preoperatively. Intraoperatively, we determined the distance detected by ultrasound on the articular side of the cuff under arthroscopic visualization. In this position, a spinal needle was inserted through the supraspinatus tendon. A PDS suture was passed through the spinal needle into the joint. The spinal needle was then removed. The entrance point of the PDS suture into the supraspinatus tendon was localized in the subacromial space after resection of bursal tissue. We perforated the cuff with a spinal needle in this area to definitively detect the calcification. The calcification was pressed out of the cuff with a probe. With this technique, calcification could be removed arthroscopically in all patients. This operative technique led to a reduced operative time, with a mean of 19 minutes.

Regression and correlation analysis of preoperative versus intraoperative assessment of axes during navigated total knee arthroplasty.

OBJECTIVE: Modern computer assisted surgery (CAS) systems allow accurate positioning of the implants in navigated Total Knee Arthroplasty (TKA). However, when an operation is performed with a navigation system, it is important to know if the anatomical situation of the knee is reflected equally in both the preoperative image (e.g., CT) and the intraoperative navigation setup. In this study, we compared the preoperative anatomical situation to the virtual intraoperative situation of the navigation setup. MATERIAL AND METHODS: We analyzed 24 navigated operations. Intraoperatively, the condylar twist angle (CTA) was documented with the navigation system by measuring the angle between the transepicondylar axis (TEA) and posterior condyle axis (PCA). This data was compared with the preoperative data from the CT scan. RESULTS: Statistical analysis revealed that there was no correlation between the pre- and intraoperative data (r = 0.095). CONCLUSIONS: Statistically, there is no possibility of collecting the same angles and axes when using the two different methods (CT and navigation) on the same knee. It is not possible to copy the preoperative anatomical situation exactly with the virtual intraoperative data. Reasons for this include systematic errors, as well as inter- and intraobserver errors in both methods.

[Paraparesis following stable L4 burst fracture Possible correlation with preexisting degenerative stenosis of the spinal canal]. / Paraparese nach stabiler LWK-4-Fraktur Möglicher Zusammenhang mit vorbestehender degenerativer Spinalkanalstenose.

A patient with degenerative stenosis of the lumbar spinal canal developed paraparesis of both legs following a stable L4 burst fracture. However, neither the stenosis nor the fracture have caused a significant narrowing of the spinal canal. Surgical decompression and dorsal stabilization has led to relief of the neurological deficit. This case demonstrates that even a stable burst fracture may cause paraparesis and that a degenerative spinal canal stenosis is a predisposing factor.

[Intramedullary bone endoscopy. First clinical application of a novel endoscopic technique]. / Intramedulläre Knochenendoskopie. Erste klinische Anwendung einer neuen endoskopischen Technik.

After successfully testing the new technique of IBE (intramedullary bone endoscopy) in vitro, we present the first clinical applications of the new endoscopic method. In two selected cases (cement removal in revision joint arthroplasty/complication management after intramedullary loss of a reamer) the technique of IBE was performed in vivo for the first time. Removal of cement under endoscopic guidance and salvage of the lost reamer was easily possible using the special endoscopic tools. With the new technique of IBE, endoscopic intramedullary manipulation is easily possible in vivo.

[CT analysis of leg alignment after conventional vs. navigated knee prosthesis implantation. Initial results of a controlled, prospective and randomized study]. / CT-Analyse der Beinachse nach konventioneller vs. navigierter Knieendoprothese. Erste Ergebnisse einer kontrollierten, prospektiven und randomisierten Studie.

INTRODUCTION: Correct alignment of the leg is one of the significant factors for the outcome after TKA. Previous studies have shown that the use of a navigation system can improve the alignment. However, for the positioning of the femoral component no validated data are available. This article presents the first results of a controlled, prospective and randomised trial comparing navigation versus free-hand implantation in TKA with special reference to the rotation of the femoral component. METHODS: Since January 2003, all patients with primary arthrosis of the knee admitted to our hospital for TKA have been followed prospectively. For this first analysis, data were collected over a period of 5 months. Apart from the usual clinical evaluations, all patients had CT of the leg prior to the operation and 1 week postoperatively. Measurement of axis and rotation was performed by staff members of the X-ray department who had no knowledge of the operation technique (navigation vs. free-hand). RESULTS: Twenty five sets of CT scans have been analysed, from 12 navigated operations and 13 freehand procedures. All 12 of the navigated knees were within the interval of +/-3 degrees varus/valgus deviation, but only 8 of the 13 non-navigated knees met this criteria. The analysis of the rotation position of the femoral component revealed no difference between the two groups. CONCLUSION: By using an intraoperative navigation system, the accuracy of the alignment in TKA can be improved. Long-term studies will have to be carried out to verify whether this will lead to a lasting benefit for the patient. Concerning the rotation position of the femoral implant, no conclusion can be made regarding the recommended rotation position at this point of the study.

[Intramedullary bone endoscopy (IBE). First results of experimental intramedullary endoscopy of long bone]. / Intramedulläre Knochenendoskopie (IBE) Erste experimentelle Ergebnisse der Endoskopie des langen Röhrenknochens.

INTRODUCTION: Intramedullary preparation and endoscopy of long bone is not mentioned in literature. We present our first results of experimental intramedullary endoscopy of long bone. METHODS: Experimental tests were performed at 4 corpse bones (twice tibia, twice femur). RESULTS: Intramedullary endoscopy and preparation was possible in all cases. A good view for inspection of the medullary canal was achieved by using the endoscope (Wolf GmbH, Germany). CONCLUSION: Endoscopic preparation and intramedullary endoscopy in the long bone ist possible. By using the endoscopic tools, a "neocavum" for endoscopic manipulation could easily be created.

[Ruptures of the subscapular tendon. A diagnostic problem?]. / Rupturen der Subskapularissehne. Ein diagnostisches Problem?

Isolated ruptures of the subscapularis tendon are rare injuries which are often missed initially. After recent treatment of 3 patients treated in our clinic typical courses and pitfalls are demonstrated. Due to the traumatic genesis of subscapularis tendon ruptures, lesions of the rotator cuff must be excluded generally by an adequate diagnostic concept. Conventional x-rays of the shoulder in 2 views to exclude a bony lesion, clinical and ultrasound examination are seen as a standard because these methods will allow the correct diagnosis in most cases. Typical clinical signs for a subscapularis lesion are the "lift-off-test" and the "napoleon sign." The ultrasound examination should be done statically and dynamically by comparing the injured with the uninjured shoulder. The typical view in case of a subscapularis tendon rupture is a thinned tendon overlying the humeral head. In our opinion nuclear magnetic resonance imaging should not be the first diagnostic procedure. It should be reserved for such cases with unclear clinical and ultrasound results.

[Metaphyseal comminuted fracture. A therapeutic challenge]. / Der metaphysäre Trümmerbruch. Eine therapeutische Herausforderung.

The most frequent localization of fractures in elderly patients are the metaphysis of the distal radius, the metaphysis of the proximal humerus and the metaphysis of the proximal femur. Displaced fractures of the distal radius should be reduced anatomically with a broad indication for surgery. A unilateral frame is the method of choice in multi-fragmentary and articular fractures although this procedure carries some disadvantages. Displaced proximal fractures of the head of the humerus should be reduced and fixed operatively. Minimal invasive procedures like tension band fixation lead to better results than fixation with plates. Non-reducible four-part fractures require primary prosthetic replacement. If standard procedures in the treatment of distal fractures of the humerus fail because of severe osteoporosis, tension band fixation may allow functional post-operative treatment. Fractures of the trochanteric region of the femur can be stabilized by several dynamic standard implants that permit early weight bearing. If fixations should fail, corrective osteotomies or changing of implants--in rare cases combined with bone cement--may be necessary. Each case requires an individualized procedure in order to ensure optimal restoration of function and mobility in elderly patients.

[Cement-free revision arthroplasty of the acetabulum--intermediate term outcome with trabecular-oriented acetabulum implant]. / Zementfreie Revisionsarthroplastik der Hüftpfanne--Mittelfristige Ergebnisse mit dem trabekulär orientierten Pfannenimplantat.

PURPOSE: In the case of hip revision arthroplasty, cementless implants combined with bone grafts are increasingly used to reconstruct the acetabular bone stock. The study on hand reports about the results with the trabecular orientated cup implant of CopflHolz after 10 years of application. METHOD: A total of 256 hip revision arthroplasties were prospectively recorded with a mean follow-up period of 5.6 years. For the osseous augmentation of the acetabulum, autogenous bone was used in 227 cases, allogenic spongy bone in 15 cases and mixed bony materials in 8 cases. The clinical and radiological follow-ups were done after 3, 6, 12 months and then in 2-years intervals. RESULTS: Within the 10 years follow-up 3 rerevisions must be done because of deep infection, 6 rerevisions because of aseptic loosening or primary instable fixation. The specific failure rate of the used cup implant amounts to 96.2% five years after revision arthroplasty, and 86.8% ten years after revision arthroplasty. Revealed from a radiological point of view, the transplanted spongiosa showed in 83.5% a complete osseous integration one year after the operation. Worse incorporation was conspicuous especially when allografts or mixed bone grafts were used. Clinically, a permanent improvement of motion, pain and walking ability was seen postoperatively. 91% of all follow-up patients were satisfied with the result of the revision arthroplasty. CONCLUSIONS: The trabecular orientated cup implant has proven itself worthy for cementless cup revision arthroplasty and will be an alternative to the cups and rings used up to now for the reconstruction of great acetabular bone deficiencies.

["Score systems as a measure for quality assurance in polytrauma?"]. / "Score-Systeme als Mass für Qualitätssicherung beim Polytrauma?"

Score systems in trauma try to aggregate the severity of injury in a single number of formula. They give a common basis to standardize logistics and outcome in trauma management. This holds true only if the score is valid, reliable, and based on a meticulous documentation of data. As errors cannot be excluded, individual decisions in trauma management can never rely on scores alone.

[Ultrasound imaging of the ventrocaudal labrum in ventral instability of the shoulder]. / Die sonographische Darstellung des ventrokaudalen Labrums bei der ventralen Instabilität der Schulter.

The significance of the anterior capsulolabral complex in anterior shoulder instability is well established. In cases of detachment of the ventrocaudal capsulolabral complex, definitive stability can be achieved only by operative refixation. These structures can only be imaged by invasive and cost-intensive methods such as MR arthrography and CT arthrography. We introduce an examination by ultrasonography: a 7.5 MHz linear transducer is used. The patient is in the supine position and both arms are abducted and externally rotated. The transducer is placed in the longitudinal direction, parallel to the border of the pectoral muscle with a ventrocaudal tilt. From March 1992 to October 1994 a number of 88 patients were preoperatively subjected to ultrasound examination before operative stabilization or arthroscopy. Eighty-three of the results were evaluable. Sixty-nine of the examinations showed evidence of detachment of the ligaments; 68 of them were confirmed operatively; 14 of the examinations showed no evidence of detachment; 12 of these results proved true operatively (sensitivity: 97.7%, specificity 92.3%). The sonographic procedure introduced seems to be valuable in detecting the Bankart lesion in anterior instability of the shoulder.