Topographic relations between the neural and ligamentous structures of the lumbosacral junction: in-vitro investigation.

Transient or persistent alterations in the L5 lumbar nerve root have been described as a complication after the reduction of spondylolistheses. In a retrospective analysis of our own patients, we observed a higher incidence of transient motor and sensomotor deficits after single-sitting anatomic correction of May-erding grade IV anterolistheses and spondyloptoses. These findings are consistent with those of other authors. The deficits pertained to muscles in the innervation range of the L5 nerve root, without there being any evidence of intradural root damage or nerve compression. In vitro studies have shown distraction and translation of the nerve root to be pathogenetically relevant mechanisms, leading to damage during intraoperative reduction. Additional alteration of neuronal structures may be caused by ventral parts of the iliolumbar ligament complex during the reduction maneuver. In order to reveal extradural constrictions of the L5 nerve root that might predispose towards intra- or perioperative damage, we examined anatomic specimens to determine the course and neighboring relationships of the lumbosacral plexus, especially in relation to pelvivertebragenic ligamentous connections. In addition to the morphologic considerations, we conducted translation tests, which were designed to simulate changes in shape and size of the epineural layer, as well as in vitro measurements of the resulting pressure on the nerve. In addition to a range of variations in the attachment of the iliolumbar ligament complex, which was always located dorsally to the nerve roots, we found a ligamentous connection formed by connective tissue between the sacrum and the fifth lumbar vertebral body on the caudal margin of the ligament apparatus in 14 out of 30 specimens. Its course was constantly ventral to the L5 nerve root, which was also adherent to the periosteum of the sacrum distal to this constriction in one-fifth of the specimens. The average pressure exerted on the nerve root during the distraction and translation process was over 30 mmHg in the area of this lumbosacral ligamentous connection, at a distance of greater than 20 mm. When the translation distance was further increased, perineural fatty tissue was discharged, due to increasing perineural pressure.

[Ambulatory diagnosis and therapy of gonarthrosis]. / Ambulante Diagnostik und Therapie der Gonarthrose.

AIM OF STUDY: To develop recommendations for appropriate diagnostic procedures and conservative treatment of knee osteoarthritis in outpatients. MATERIAL AND METHODS: Following a consensus conference and expert reviews basic recommendations were developed. RESULTS: While standardized radiographic assessment is mandatory, MRI investigation should be restricted to problems apart from osteoarthritis. Indications for physical therapy, bracing and pharmaco-treatment depend on the severity of the disease. Guidelines for intraarticular injections are presented. CONCLUSION: Effective treatment of knee osteoarthritis must be based on available recommendations and guidelines.

[Repositioning injuries of nerve root L5 after surgical treatment of high degree spondylolistheses and spondyloptosis--in vitro studies]. / Repositionsverletzungen der Nervenwurzel L5 nach operativer Behandlung höhergradiger Spondylolisthesen und Spondyloptosen--In vitro Untersuchungen.

Temporary or persistent paralysis of the fifth lumbar nerve root have been frequently reported as complications following reposition of high degree spondylolisthesis. According to an outcome analysis of sixty-four patients, we found an increased incidence of motor damages after reduction of Meyerding degree four anterolisthesis or spondyloptosis. There were no signs of intradural root compression or nerve injury tracable. In order to detect extraforaminal strictures, the anatomic course of the lumbosacral plexus and its relation to neighbouring structures, especially pelvivertebral connective tissue junctions were recorded in cadavric measurements. Beside an number of variations in origin and course of the iliolumbar ligament complex, we observed a junction between os sacrum and the anterior part of the fifth lumbar vertebrae in 14/30 specimen, constantly running anterior to the fifth lumbar nerve root. In addition the nerve was fixed to the sacral periostium a few centimeters distal this crossing in about 20% of all cases. Pathophysiological effects were measured in reposition trials, using a continuous pressure monitoring system. A reposition of more than 20 mm resulted in a perineural pressure > 30 mmHg. This caused a nerve fiber deformation at the edge of the compressed nerve segment. Increased pressure leads to a nodular displacement of perineural fat as well as intraneural fascicles.

[Cryotherapy as analgesic technique in direct, postoperative treatment following elective joint replacement]. / Kryotherapie als Analgesietechnik in der direkten, postoperativen Behandlung nach elektivem Gelenkersatz.

The application of crushed ice or hydrogenated silicate, a micro-crystalline substitute has been used as a method to treat posttraumatic and postoperative irritations of the locomotor system for a long time. Closed systems using pumps can be viewed as further development as they enable continuous, water-free cooling of operating areas. The analgetic effect of postoperative cold therapy was evaluated in a prospective clinical trial, including 312 patients after total knee or hip arthroplasty. Conventional cold packs, consisting of microcrystalline silicate were compared to a continuous applicable closed system. Continuous cryotherapy resulted in a depression of skin temperature to 12 degrees C, whereas intermittent cooling only caused a mean temperature decrease of 1 degree C. Clinically continuous cold application leads to a more than 50% decrease of analgetic demands in both, systemic and regional application (p < 0.001). This observation was found in a significant correlation with patient's pain sensation as well as primary range of motion. Intermittent cryotherapy was found to be ineffective in postoperative pain relieve in hip- and adequate in knee arthroplasty patients. We could not report an influence on postoperative blood loss, as discussed in previous reports.

Pathoanatomic findings in radiohumeral epicondylopathy. A combined anatomic and electromyographic study.

Several authors believe that a compression syndrome of the radial nerve or its muscle branches is responsible for the clinical picture of radiohumeral epicondylopathy. Various structural and functional stenoses have been discussed as possible causes. We performed systematic electromyographies (EMGs) on the extensors subdividing from the radial epicondyle and found significant changes (P < 0.05) in 27/51 patients regarding latency, velocity of nerve conduction and rate of polyphasic potentials. Especially affected were the extensor carpi radialis brevis and the extensor digitorum muscle. In order to clarify causal anatomic correlations, we performed a longitudinal and cross-sectional study on a total of 40 arms from cadavers. We found constant variations from the topographic anatomy published in the standard literature which corresponded to the EMG results in the area between the epicondyle and place of entry into the supinator muscle. In addition, we observed a regularly occurring ulnar deviation from the distal part of the extensor carpi radials brevis origin which protrudes over the plane of insertion of the joint extensor tendon aponeurosis and forms in most cases the arcade of Frohse. Because the deep radial branch and its parallel muscular branches cross this part at an obtuse angle, we think that dynamic pressure on a nerve without structural influences is the pathoanatomic result of this heterogeneously interpreted clinical picture.

Diagnostic and therapeutic strategies for the operative treatment of radiohumeral epicondylopathy.

We examined the extent and effect of an assumed neuromuscular transmission disorder by performing a prospective clinical study on 75 patients with therapy-resistant radiohumeral epicondylopathy. Before operating, we diagnosed with electromyography an increased rate of polyphasic potentials of the long wrist extensors as well as a prolonged motor latency of the respective muscles. Disordered neuromuscular recruitment combined with a reduced maximum strength and elasticity corresponding to the suspected damage to the distal part of the motor neuron could be proven. Both effects were significantly reversible (P < 0.001) through operative intervention. We found a significant correlation (> 0.90) between the normalization of the motor latency and increased strength. Subgroups were formed according to different preoperative diagnostic efforts and differing radicality regarding the type of soft-tissue operation performed; thus, the clinical validity of the findings diagnosed in the anatomical/ electrophysiological part of the study was additionally examined. The failure rate varied between 10% and 30%, depending on the radicality of the tenotomy, which could be interpreted as a general indication for a complete extensor carpi radialis brevis tendon release. In this connection it is remarkable that the clinical result of electromyographically localized damage in the area between the epicondyle and arcade of Frohse could not be improved through open neurolysis. Dealing with strictures located on the proximal side of the epicondyle on the other hand, this technique seems to play an important role in the recurrence prophylaxis.

[Significance of the radial compression syndrome for the diagnosis and surgical therapy of so-called epicondylitis humeri radialis (Epic. hum. rad.)]. / Die Bedeutung der Radialiskompressionssyndrome (RKS) für die Diagnostik und operative Therapie der sogenannten Epicondylitis humeri radialis (Epic.hum.rad.).

25 patients with Tennis Elbow were examined after surgery (= retrospectively), 25 before surgery (= prospectively). All of the patients were operated on according to the Wilhelm and Wachsmuth method. 5-18 months after surgery (on average 10), both groups underwent clinical examinations. Those patients who still had symptoms were given neurophysiological examinations. Both groups were compared with each other. The following results were obtained from the comparison: 1) 7 patients (28%) in the retrospective group were dissatisfied with the results of surgery and still had symptoms specific to the disease. In the prospective group, only 2 patients (8%) complained of similar problems. 2) 6 of the above-mentioned 7 dissatisfied patients in the retrospective group agreed to a postoperative neurophysiological examination. This revealed in five out of six patients damage to the radialis nerve. 3) At the clinical examinations of the 25 prospective patients, 17 were suspected of having radial compression syndrome. In 9 patients, this suspicion was confirmed by the neurophysiological findings. A neurolysis of the N. radialis was performed on these nine patients during surgery. All of these patients were satisfied with the results of surgery at the follow-up examination. The above results permit the following conclusions: 1) The failures in surgical treatment of Tennis Elbow can in part be put down to radial compression syndrome. 2) A thorough clinical examination, which in particular takes radial compression syndrome into account, should be carried out on every Tennis-Elbow-patient. 3) The neurophysiological examination of the main extensors of the hand should be an obligatory part of pre-operative preparations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Immobilization damage]. / Der Immobilisationsschaden.

Prolonged immobilization can threaten the surgical result. The reduction of the muscle diameter is reported to be between 10 and 60% after four weeks of immobilization depending on the different muscle groups. Particularly the oxidative type-1 fibers, the "slow twitch fibers" are concerned. However, the sequelae of immobilization of muscle are reversible, which is in contrast to the detrimental effects immobilization has on the bone. Inactivity osteoporosis is occurring in three stages with bone loss as much as five to twenty times that of other calcipenic disorders. The physiological coupling of bone resorption and bone remodeling is lost. Immobilization leads to arthrosis changing the cartilage matrix composition quantitatively and qualitatively as well as cartilage morphology histologically and electron-microscopically. The result of immobilization is shortening of all fibrous tissues. The loss of the ligament-specific orientation of fibrils leads to significant reduction in tensile strength. The sequelae of immobilization emphasize the importance of early functional therapy. Continuous passive motion speeds up wound healing, and the tissue-structure is improved.

Glucosamine sulfate in osteoarthritis of the knee.

Glucosamine sulfate is a drug used for the treatment of osteoarthritis (OA), based on its pharmacological and metabolic activities on the cartilage and chondrocytes, complemented by mild anti-inflammatory properties and a favorable pharmacokinetic profile. The aim of this study was to define the activity and safety of glucosamine sulfate on the symptoms of patients with OA, using a multicenter, randomized, placebo-controlled, double-blind, parallel-group study design. The study included 252 outpatients with OA of the knee (Lequesne's criteria), radiological stage between I and III, and Lequesne's severity index of at least 4 points and symptoms for at least 6 months. Patients were treated with either placebo or oral glucosamine sulfate 500 mg t.i.d. for 4 weeks, with weekly, with weekly clinic visits. Responders to treatment were defined as patients with a reduction of at least 3 points in the Lequesne's index with a positive overall assessment by the investigator. The Lequesne's index was 10.6 +/- 0.45 S.E.M. points in both groups at the start of the study. This decreased to 7.45 +/- 0.5 points in the treatment group (average 3.2) and 8.4 +/- 0.4 points in the placebo group (average 2.2) (P < 0.05, Student's t-test). The responder rate in the evaluable patients was 55% with glucosamine (N = 120) vs 38% with placebo (N = 121). These proportions were 52% vs 37% in an intention-to-treat analysis (P = 0.014 and 0.016, respectively; Fisher's Exact Test). The medications were well tolerated throughout the study, with no difference between the glucosamine and placebo treated groups. It is concluded that glucosamine sulfate may be a safe and effective symptomatic Slow Acting Drug for OA.

[Sternocostoclavicular hyperostosis--case reports and differential diagnosis]. / Sternocostoclaviculäre Hyperostose--Kasuistik und Differentialdiagnose.

Sternocostoclavicular hyperostosis (SCCH) is a disorder related to collagenoses. SCCH is typically characterised by the triad of swelling of the sternoclavicular and/or sternocostal joints of the first or second rib, palmar and plantar pustulosis (PPP), only limited elevation of inflammation indicating laboratory parameters. Till today the etiology is unclear and no causal therapy is known. Symptomatic treatment consists of administration of NSAID and cortisone, irradiation and even limited resection of the clavicle and rib.

[Isokinetic measurements in adolescent runners]. / Isokinetische Messungen bei jugendlichen Läufern.

The aim of the investigation was to study the course of the isokinetic parameters--peak torque, time range of tension development and fatigue index--in an age range from 13 to 19 years and to compare the results with those of competitive athletes of the same age specifically trained in running. For this purpose measurements of the flexors and extensors in the upper ankle joint, knee and hip were taken. The average for the six muscle groups correlated significantly in all three parameters not only with the age development but also with the degree of training. The individual muscle groups, however, differed widely. An increased frequency of injuries by certain ratios of peak torques between flexors and extensors was not found. Instead already in the physiological age development occurred relations that were connected with an increased frequency of injuries. Prospectively this suggests that the time range of tension development has additional influence here.

The complex between a tissue inhibitor of metalloproteinases (TIMP-2) and 72-kDa progelatinase is a metalloproteinase inhibitor.

Human rheumatoid synovial cells in culture secrete both 72-kDa progelatinase and a complex consisting of 72-kDa progelatinase and a 24-kDa inhibitor of metalloproteinases, TIMP-2. In addition, the culture medium contains TIMP-1, the classical inhibitor of metalloproteinases, with a molecular mass of 30 kDa. TIMP-1 does not form a complex with free 72-kDa progelatinase. Free progelatinase and progelatinase complexed with TIMP-2 can be activated with the organomercury compound p-aminophenylmercury acetate. The activated complex shows less than 10% the enzyme activity of activated free gelatinase. The progelatinase-TIMP-2 complex could be shown to be an inhibitor for other metalloproteinases, such as gelatinase and collagenase secreted by human rheumatoid synovia fibroblasts, as well as for the corresponding enzymes from human neutrophils.

[Indirect humerus fracture in sports]. / Die indirekte Humerusfraktur im Sport.

The humeral spiral fracture as a result of violent muscle activity is not uncommon in throwing sports. Two cases of this injury (in a javelin thrower and in a handball player) are described. The complex mechanical reasons are discussed.

[Treatment of unreduced anterior shoulder dislocation]. / Die Behandlung der veralteten vorderen Schulterluxation.

We evaluated the results of treatment in six patients with unreduced chronic anterior dislocations of the shoulder. In three patients the dislocations had not been recognized by the initial treating physician. In the remaining three patients the dislocations initially had been diagnosed but reduction had failed and the dislocations had remained unreduced. In one of the six shoulders the dislocation was left unreduced. The dislocation existed for 3.5 years and there was absence of disabling functional impairment, pain or neurovascular disturbance. In five of six shoulders the function was severely impaired. One of five shoulders with an anterior dislocation of three weeks duration could be reduced by closed manipulation. Four shoulders underwent open reduction. In all patients the humeral head could be preserved. Associated osseous lesions of the glenoid or the humeral head (Hill-Sachs lesions, fractures) were treated by rotation osteotomies according to Weber and the Eden-Lange-Hybinette procedure. Preoperatively all shoulders were graded as poor. Postoperatively the results in one was graded as excellent, in three as good and in one (algodystrophy of the left arm) as fair.

[Treatment of spondylolisthesis in adults using the dorsal approach with the fixateur interne and a special repositioning device]. / Die Behandlung der Spondylosisthesis beim Erwachsenen von dorsal mit dem Fixateur interne und einem speziellen Repositionshilfsgerät.

Fourteen patients with spondylolisthesis were operated in the Orthopaedic Clinic of Ulm (RKU) from October 1984 to December 1986. All patients suffered from low back pain, 13 had symptomes of nerve root compression, 6 had intermittent spinal claudication. All patients were treated by segmental distraction, reduction of the slipped vertebra and a ventral interbody fusion. The operative technique required first the dorsal approach for distraction and reduction using the fixateur interne (Dick) as well as a self developed special instrument for the reduction of the vertebra (repositeur). The ventral interbody fusion was performed in a one-stage procedure. The self developed special instrument (repositeur) is described and its construction principals, mechanics and its applications. Distraction and reduction of spondylolisthesis was achieved totally or nearly complete with this instrument in all but one patient. In one case the transpedicular screw ripped out. Always the foramina intervertebralia were opened to physiological width. Pain and neurological symptomes completely disappeared in all patients and no additional spinal operation was necessary. No infection and no pseudarthrosis did occur. Our clinical results are discussed in regard to other publications. Operative treatment of spondylolisthesis using the fixateur interne and a new developed special instrument for reduction.

Semiarthroscopic synovectomy of the hip.

A new surgical procedure, semiarthroscopic synovectomy of the hip is described. The operation enables a radical synovectomy to be performed without the risk of necrosis of the femoral head from temporary luxation. The early results have been encouraging and the method appears to offer a low-risk alternative to conventional radical synovectomy.

[The importance of isokinetic measurement of force in sports and rehabilitation]. / Die Bedeutung isokinetischer Kraftmessung in Sport und Rehabilitation.

The musculature serves as motor of the human body and hence promotes our movement within our environment. Its organ-specific performance is the translation of force into movement. This force can be described by means of different qualities - maximal force, speed and endurance. These properties are essential for sports activities and also set limits for the achievement of athletic records. Muscular force can be evaluated by different means. Measurement of force via isokinetic systems enables quantitative measurement of effective muscular forces in various body positions which are frequently comparable under conditions specific to different types of sports. The relevance of these measurements in sports and rehabilitation is documented in this article. Two different groups of subjects (72 sportsmen and 73 patients after capsular ligament reconstruction in the knee joint) were examined. The measurement values: dynamic maximal force, energy of acceleration, average performance and the hamstring/quadriceps ratios (H/Q quotient) are measured at different speeds. The maximal force shows intraindividual differences depending on the speed. These differences are due to different conditions of training and different distribution of muscle fibre types. The acceleration energy enables assessment of differences in the ability to exercise force. Likewise, the different muscle performances can be described by means of the appropriate individual performance maximums. In rehabilitation, muscle atrophy caused by immobilization can be measured and described. Measurement of force by means of isokinetic systems enables the analysis of muscular forces with their different properties, and hence to give advice in training matters and to supervise and control popular recreational sports and competitive sports activities.(ABSTRACT TRUNCATED AT 250 WORDS)

[New possibilities in the detection and surgical therapy of synovitis of the hip joint]. / Neue Möglichkeiten zur Erkennung und operativen Therapie der Hüftsynovialitis.

Missing pathognomonic clinical and radiological signs, an early diagnosis of hip joint synovitis is often impossible. Ultrasonography and arthroscopy of the hip joint are useful methods to accomplish recognition and exact description of chronic inflammatory hip joint diseases. These new diagnostic methods enable an early adequate treatment. Until today synovectomy of the hip joint is still a rare surgical procedure. Reasons are the difficulties in diagnosis of the synovitis and the insufficient radicality of synovectomy if the femoral head is not luxated temporarily. The semi-arthroscopic synovectomy of the hip joint allows a radical removal of the synovial membrane even in the fossa acetabuli, avoiding the inherent risks of a luxation of the femoral head.

[Indications and results of the surgical treatment of distal intra-articular humeral fractures in the elderly]. / Uber Indikation und Ergebnisse der operativen Behandlung von distalen intraartikulären Humerusfrakturen beim alten Menschen.

In this paper we review 16 patients with closed intercondylar fractures of the distal end of the humerus that had open reduction and internal fixation. All patients were older than 60 years of age. Using the classification system of Müller et al. 6 fractures were classified as type C2 and 10 fractures as type C3. The surgical procedures and the types of internal fixation of the fractures allowed early postoperative mobilisation (3rd postoperative day). A rating scale modified according to Cassebaum was used for the results. At a mean follow-up of 4.2 years 3 patients were rated as excellent 9 as good and 2 as fair. No severe complications were registered.