[Prioritization or unlimited resources in orthopedics and trauma surgery?] / Priorisierung oder unbegrenzte Ressourcen in Orthopädie und Unfallchirurgie?

The development of the healthcare system in Germany is increasingly approaching human and economic limits. A social consensus and a political concept at which point priorities are promoted and for which services the money should be primarily spent, do not exist on the whole. As soon as it becomes clear that resources are limited and that is now, prioritization has to be introduced to avoid the alternative threat of rationing of treatment benefits. The goal of prioritization is to rationally and optimally use the existing but limited resources. Medical progress and the relationship to the demographic development are the variables in the future. The individual care of the patient, patients' needs and dependence on access to treatment are the foundations of ethical actions. They must be at the center of attention for doctors and nurses because, after all they are the patient's advocates in the complex healthcare system. At the same time, unjustified claims for entitlement must be rejected just as a preservation of vested rights. Efficiency and economic considerations in diagnostics and treatment are not mutually exclusive. The physician acts as a mediator between the claims of the patient to be treated, the individual realization and the existing resources in the healthcare system.

[Injuries in elderly patients: maximal management versus minimal osteosynthesis depending on active life style and economic resources]. / Verletzungen des alten Menschen: Maximalversorgung versus Minimalosteosynthese in ihrer Abhängigkeit von aktiver Lebensgestaltung zu ökonomischen Ressourcen.

The increasing expenses of health care maximize the costs for the whole of society. Nobody is able to pay them any longer. There are two reasons for this expansion: 1. Increase in the number of people over 65 years of age, over the next 5 years totalling about 23.6% in the whole of Europe; 2. Innovative developments in medicine regarding technological aspects and life-prolonging methods. Injuries in the elderly often show an unstable balance in the regulation of daily life and somatic fitness. The aim of treatment is to restore activity as before and to reach full weight-bearing ability. Rehabilitation is done after acute surgery in a geriatric hospital as intensively as possible. Increasing unemployment leads to a decrease of wage contingents. With less capital rationalization becomes urgent and rationing more probable. There is no medical indication for this except an economic one. This has to be justified by the politicians, not by the physicians.

[Three-dimensional computerized tomography in trauma surgery. A case presentation]. / Dreidimensionale Computertomographie in der Unfallchirurgie. Eine Kasuistik.

Three-dimensional images of bone structures can easily be reconstructed from computed tomography data. The technique and the advantages of contemplating reconstructions of bone defects in different directions are described. A special software programme allows to combine all data which are given by the standard CT. The slice diameter is two millimetres. The reconstruction shows bone surfaces in all required views. In traumatic and orthopaedic surgery 3-D-CT is useful in the analysis, detection and preoperative planning of comminuted bone injuries of the spine, pelvis, knee, shoulder and the calcaneus. With this technique it is possible to see the bone in its topographic constellation, to observe fractures in unusual directions and to identify fragments from each other. The surgeon gets a lot of additional information which is helpful to decide on the incision, the reduction and the fixation of fragments. Undesirable effects during operation are reduced, which leads to a more accurate treatment and subsequent better results.

[Regeneration capacity of the iliac crest after spongiosa removal in humans--induction by phosphate ceramics?]. / Die Regenerationsfähigkeit des Beckenkammes nach Spongiosaentnahme beim Menschen--Induktion durch Phosphatkeramiken?

The starting point for the investigation of calcium phosphate ceramics is given by the bone regeneration, including osteo-conduction, osteo-stimulation and osteo-induction. The amount of the autogenous bone, which can be used for transplantation to induce the organo typical regeneration, is a small one. Based on animal experiments we created a standardized model for investigation of bone regeneration, using the human iliac crest. The empty iliac crest was filled by hydroxylapatite, tricalcium phosphate, Kiel bone or it remained empty as a control group. Clinical examination, X-ray control, blood chemistry and documentation were done with 104 patients divided in these four groups. Radiography, histological examination and morphometry were done with biopsies of 40 patients. The results show a bony ingrown into the ceramic material. The pores were filled by lamellar bone with new grown osteons. The ceramic granules are complete integrated. The ceramic blocks are only fixed at the edges and at the surface by bone trabeculae. The Kiel bone is surrounded by fibrous tissues without any contact to new built bone. It doesn't act as a bone substitute. The bone regeneration in the not fulfilled iliac crest was fast and of a hard quality of lamellar bone and of big amount. Both ceramics show remarkable degradation. The tricalcium phosphate brakes into pieces and shows dissolution. The hydroxylapatite in smaller particles. The degradation stopped, if the particles were surrounded by new bone. These ceramics can be used as augmentation material in combination with autogenous bone. They act as bone substitutes. The integration and bonding to new bone is complete and can be loaded by mechanical strength.

[The regenerative ability of the iliac crest following spongiosa removal in man--induction by phosphate ceramics? I]. / Die Regenerationsfähigkeit des Beckenkammes nach Spongiosaentnahme beim Menschen--Induktion durch Phosphatkeramiken? Teil I.

The starting point for the investigation of calcium phosphate ceramics is given by the bone regeneration, including osteoconduction, osteostimulation and osteoinduction. The amount of the autogeneic bone, which can be used for transplantation to induce the organo typical regeneration, is a small one. Calcium phosphate ceramics are used as bone substitute. The basic knowledge of clinical employment is summarized. A new model for investigation of bone regeneration is introduced. In part II the results will be discussed.

[Standardized bone model for incorporation of bone, bone ceramics or other materials into the implant bed]. / Standardisiertes Knochenmodell zur Untersuchung des Einwachsverhaltens von Knochen, Knochenkeramiken oder sonstigen Stoffen in das ersatzstarke Implantatlager.

To investigate the regeneration of human bone in a good and firm layer, a new model is introduced. It has been developed by us because of therapeutical necessity, but then is continued in the course of further investigations independent from further therapeutical procedure. We use the iliac crest as a bony layer for implants that are the object of research. For the therapy in cases of delayed bone healing, pseudarthrosis, bony defect or corrective osteotomy, the cancellous bone is removed. The empty iliac crest is then filled up with material we intend to investigate. On the occasion of further operations that became necessary because of the underlying bone disease, we had an opportunity to obtain sample of bone and material by hole-drilling through the iliac crest. The bony cylinder can be examined by histological technique. We used this procedure on 105 patients up to now. There were no specific complications caused by this technique at the iliac crest. 37 biopsies could be taken and will now be examined. In future it may be possible to incorporate new bone in this layer for a further therapy and to fill up the lost donor sites.

[Reconstruction of large femoral defects in exchange operations following artificial hip replacement]. / Die Uberbrückung langstreckiger Femurdefekte bei Austauschoperationen nach künstlichem Hüftgelenkersatz.

Loosening of the implant is one of the most serious complication in case of total hip replacement. It is caused by the growth of a secondary cancellous channel and in destroyed bone cement. From 1981 to 1986 we operated 63 patients to exchange a loosened hip prosthesis. With 15 patients we have seen a severe damage of the femur shaft. Big parts of the bone tube were missed. To insert the new stem we had to reconstruct the proximal femur and the calcar region by autogenous cortico-cancellous bone grafts in seven cases. In three cases a large defect of the lateral femur cortex was reconstructed by extended cancellous bone graft. In five cases we found a cominuted fracture of the femur shaft. The osteosynthesis was performed by plating. The screws were inserted through the bone into the stem. They find a very strong grip in the polyacetal material. 14 of 15 patients operated in this manner could achieve a walking ability. Most of them improved one step higher in the evaluation scheme according to Merle d'Aubigne. One patient suffering from a septic loosening showed a severe exacerbation with septicemia and ended in a disarticulation of the hip joint. The so called isoelastic prosthesis gives a chance to reconstruct the femur tube. It allows unhindered calcification of bone graft and acts as a forming model for new bone. With this we are able to restore the movement of hip joint as well as weight bearing and working ability of the limb. Additional osteosynthesis is possible to perform.(ABSTRACT TRUNCATED AT 250 WORDS)

Post-traumatic osteomyelitis. Pathophysiology and management.

Osteomyelitis is one of the most severe complications that can arise following operative treatment of bone. It requires a long-term treatment. The patient can never be sure that it heals completely. The pathophysiology depends on: (1) the extent of soft tissue damage and impairment of blood supply; (2) inoculation of bacterial flora; (3) the instability of the fracture area; and (4) the general defensive condition of the organism. The symptoms of acute osteomyelitis are those of acute inflammation. They appear 1 week to 3 months after operation. The diagnosis can only be made on clinical examination by an experienced surgeon. X-Ray findings are lacking. The treatment of acute osteomyelitis involves debridement of soft tissue and bone sequesters, refixation of the fragments, most often by means of an external fixator, and suction drainage or wet dressing. The reconstruction of the bone is done in a second step. The cancellous bone grafting is performed from a medial approach. Closure of the soft tissue follows. In the case of chronic osteomyelitis scarring, fistulas and muddy secretion are present. The function of the bone is disturbed. X-Ray examination shows loosening of the metal and failing structure of the bone. In this case too, the first step is the debridement of soft tissue and bone. All the metal inside is removed. Stabilization is achieved by means of an external fixator. Once the fracture area has been cleaned, cancellous bone grafting is done once, twice, or even more frequently. For wound closure it is necessary to rotate muscle groups, to cover the bone with dermatomic skin, or to use microvascular flaps.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical problems in fracture of the scaphoid bone]. / Die klinische Problematik der Kahnbeinfraktur.

UNLABELLED: The following specific characteristics of injury cause the problems that occur in scaphoid bone fractures: 1. Mechanisms of accident: There are only a few typical circumstances that cause the injury: as there are false winding of a shrankshaft handle or a fall on the extended hand. In all the other cases the accident is neither realized by the injured person himself or by the physician. As a consequence the possibility of injury of the scaphoid bone is not taken into consideration. 2. SYMPTOMS: In a stable fracture the symptoms do not appear directly but may be clearly delayed or they may disappear very quickly after a short period of intensity, so that the accident is no longer taken any notice of. 3. Radiodiagnostics: Because of the anatomic position of the scaphoid bone any X-raying from a lateral view is difficult because the scaphoid is covered by other carpal bones. In case of an undisplaced fracture you often only see very fine fracture lines, which are only to be seen from a direct orthograde view. It is necessary to X-ray the carpus in different positions. 4. THERAPY: If there is the slightest chance of a scaphoid bone fracture an intensive therapy must be directly started. An immobilisation for a too short period may lead to a delayed union and end in a pseudarthrosis. This is also the case if you start the therapy too late. Then the fracture line is already filled up by fibrous tissue. The latest period of time to begin a conservative treatment is six to eight weeks after the day of the accident.(ABSTRACT TRUNCATED AT 250 WORDS)

Standard method for the investigation of bone transplants, ceramics, or other material in a human bony layer.

A new model for the investigation of human bone regeneration is introduced. We use the iliac crest as a bony layer for implants, which are the object of research. For therapy in cases of delayed bone healing the cancellous bone is removed. The empty iliac crest is then filled with the material we want to investigate. During a further operation necessitated by therapy of the bone disease, we obtain a probe of bone and material by drilling a hole through the iliac crest. This bony cylinder can be examined by histological techniques. We have used this procedure in 69 patients to date. No specific complications were caused by the implants. Fifteen biopsies could be taken and are now under examination. In the future it may be possible to breed new bone in this layer for further therapy and to fill the gaps at donor sites.

Corrective osteotomy of the distal radius after fracture to restore the function of wrist joint, forearm, and hand.

Eighty-two patients suffering from a severe deformity of the distal radius were operated on in the course of the past 7 years. The corrective osteotomy was done by implanting a corticocancellous bone graft to restore the correct angle of the joint surface and the correct length of the radius. In addition to this, a buttress T-plate was used, which could be removed 6 months later. In 80% of the cases the results with regard to the function of the patients' hands were good. The operative technique is standardized. It is possible to perform this kind of operation on patients of any age, and the procedure can check Sudeck's atrophy. When the obvious disability of the forearm is corrected the mobility of the wrist joint is simultaneously improved.

[Technic of synovectomy in the infected knee joint]. / Technik der Synovektomie beim infizierten Kniegelenk.

In case of early diagnosis as well as correct indication and operation technique, synovectomy is an essential part in the treatment of an infected knee joint. The new formation of the synovia has been demonstrated by clinical/empirical as well as experimental studies, so that the alimentation of the cartilage can be normalized. Postoperative scarring due to adherence has to be prevented by continuous therapeutic exercises. In case of severe early infections, already existent severe cartilage lesions, and fibrous ankylosis, arthrodesis by means of external fixation is the method of choice. In these cases neither a healing of the infection nor a satisfactory function of the knee joint can be expected after the application of synovectomy.

[Tension band osteosynthesis--a method fraught with complications in surgical fracture treatment?]. / Die Zuggurtungs-osteosynthese--eine komplikationsträchtige Methode der operativen Knochenbruch-behandlung?

Tension-band osteosynthesis is a simple and well-known procedure in the surgical treatment of fractures. An analysis of 180 patients, operated on in our hospital or admitted for corrective osteosynthesis, showed 23 mistakes of a minor degree and 20 major mistakes. Malpositioning of K-wires or cerclages caused the minor mistakes. Loosening of metal, failure of osteosynthesis or poor adaptation of fragments were responsible for the major mistakes. Tension-band osteosynthesis can only be successful if the principles of biomechanics are realised, if tension forces are transmitted by the implant, if bony buttressing is achieved by the fragments, and if torsion forces are converted into compressive forces (Pauwels).

[Expert testimony on rotator cuff rupture]. / Die Begutachtung der Rotatoren-manschettenruptur.

In giving an expert opinion, it is difficult to differentiate between the two possible causes of damage of the rotator cup, degeneration and trauma. After description of the anatomical problems, different causes for degenerative changes, especially of the supraspinatus tendon, are discussed. Various possibilities of accidents are analysed if they can cause damage of the rotator cup. The special conditions of the private accident insurance are discussed.

[Lymphatic pseudocyst as complication of a petty injury]. / Lymphpseudozyste als Komplikation eines Bagatelltraumas.

Diagnosis in another hospital primary failed; preliminary treatment unsuccessful; punction, operatively revision for 3 times and attempt at obliteration gave no improvement; systematically diagnostic procedure after the fourth relapse with lymphography and presentation of a lymphatic pseudocyst; identification of the feeding vessels; colouring with blue solution; operation with medial incision, ligature of the lymphatic vessels and exstirpation of the cyst wall; histologically investigation shows synovial cells; healing with solid cicatricial tissue.