Allogene Meniskustransplantation

Loss of meniscal cartilage leads to degenerative arthritis. Therefore, it is important to save the meniscus whenever possible. But not all damaged menisci can be treated by partial resection or repair. The concept of meniscal transplantation has been suggested and has been become more common in recent years. Meniscal transplantation should be considered for the young patient who has not developed advanced osteoarthritis. Ligament stability and normal knee alignment are further requirements for meniscal transplantation. At this time, meniscal allografts provide the best a priori conditions to prevent degenerative arthritis, but the use of allografts includes the risk of disease transmission. Open and arthroscopically assisted techniques have been described. Correct size matching and positioning as well as secure fixation of the meniscal horn are important for successful meniscal allograft transplantation. Even though controlled clinical studies have not yet provided clear evidence that meniscal transplantation prevents degenerative arthritis, pain relief and functional improvement have been found in follow-up studies.     

Das Konzept der stationären Stufendiagnostik bei Patienten mit lumbalem Rückenschmerz

Concepts for treating back pain by considering recent advancements in understanding chronic pain have been increasingly discussed over the last years. In general, any kind of therapy requires a most accurate diagnosis; however, in cases of lumbar back pain matching clinical observations with known structural pathologies is not always straight forward. Here, we suggest a concept of in-patient gradual diagnosis of patients with back pain that includes stepwise structural and functional components. We emphasize that in addition to the specific (classifiable) factors causing back pain (e.g. compression of lumbar nerve roots, facet joint associated pain syndrome, sacroiliacal dysfunction, segmental instability) also unspecific (non-classifiable) causes as well as disease-associated and/or determining bio-psychological or social factors need to be considered. With this study, we aim to introduce the procedure and assess the value of in-patient gradual diagnostics. We will describe different approaches, which we will evaluate for specific indications.     

Plantare Lisfranc-Luxationsfraktur

We report a 30-year-old patient suffering a plantar dislocation fracture after he dropped a heavy weight on his foot. The patient was treated immediately after diagnosis was secured by CT scan. Median approach and dermatofasciotomy of the foot were followed by anatomic reduction of the fractures and the Lisfranc dislocation and fixed by internal osteosynthesis. After 3 months the patient was able to ambulate pain free without walking aids. Plantar dislocation is a very rare direction of comminuted Lisfranc dislocation fractures. The outcome may be favorable with early reduction and stable internal fixation of the fractures. One always has to be aware of the major soft tissue trauma associated with complex Lisfranc dislocation fractures.     

Entwicklung des Lernzielkatalogs „Muskuloskelettale Erkrankungen, Verletzungen und traumatische Notfälle“ für Orthopädie-Unfallchirurgie im Medizinstudium

Background

The development towards a combined speciality of orthopaedic and trauma surgery requires not only consolidation and revision of the postgraduate education training programme but also the development of a catalogue of learning objectives as a uniform basis for undergraduate medical training in the new speciality at German medical schools and teaching hospitals.

Materials and methods

Based on the Frankfurt catalogue of learning objectives for trauma surgery and the Ulm catalogue of learning objectives for orthopaedics, a task force of experts developed a combined catalogue of learning objectives for the new speciality. Experts from both specialities classified the learning objectives into two levels of knowledge and four grades of skills competence, in addition to objectives for attitudes and social competence.

Results

The section on general operative specialities contains 120 items classified into 39 learning objectives for knowledge and 83 for skills. Two learning objectives comprise both knowledge and skills. The section on orthopaedic and trauma surgery comprises 141 learning objectives, including six items for skills and 138 for knowledge, as well as three learning objectives for both knowledge and skills. In addition, 22 learning objectives deal with aspects of attitude and social competence.

Conclusion

Although this alliance of orthopaedics and trauma surgery is recent, the commission has developed not only a collection of topics but a joint catalogue of learning objectives for undergraduate training that can be used nationwide. This catalogue paves the way for modern education that looks to the future. The integrated recommendations for content prioritisation, links to other subjects and specialities, and the integration of didactic methods facilitate local implementation of the learning objectives without loss of academic freedom.     

Knieendoprothetik beim Unterschenkelamputierten

We present the case of a 62-year-old man with posttraumatic osteoarthritis after a tibial head fracture. A below-knee amputation of the same limb had been performed years ago because of a chronic diabetic foot ulcus. The patient underwent total knee replacement, and the 2-year postoperative clinical outcome was very good. The problem of how to address missing anatomic reference points for the implantation of the tibial component in below-knee amputees and the question whether navigation offers a potential benefit in this situation are discused.     

CT-gesteuerte Sakroplastie unter Verwendung insufflierbarer Ballons

OBJECTIVE: The procedure of sacroplasty was introduced recently and involves the percutaneous application of cement to the sacral bone. Currently there are no standardized data available reflecting clinical results such as leakage rates or other complications. The aim of this study was to evaluate the feasibility and results of a balloon-assisted, CT-guided cement application in a controlled experimental approach. MATERIAL AND METHODS: The trials were conducted on preserved human cadaveric specimens (n=6). The cement application was supported by kyphoplasty balloons (Kyphon) on the right hand side, and was performed without balloons on the opposite side. CT scans were obtained for preoperative planning and postoperative assessment, while CT fluoroscopy was used for intraoperative guidance (Philips Brilliance 64). RESULTS: The procedure revealed a good feasibility with an average procedure time of 36.9+/-2.4 min (range 33.1-38.9). The chosen scan protocol produced the following effective doses: 0.99 mSv in females and 0.63 mSv in males per scan and 0.33 mSv (females) and 0.25 mSv (males) per CT fluoroscopy image. Extraosseous cement spreading was not observed after both balloon-assisted and conventional application. CONCLUSION: The CT-guided technique presented in this study enables surgeons to perform sacroplasty with high precision and moderate radiation exposure. Further clinical studies are necessary to show if the balloon-assisted cement application can promote lower leakage rates than the conventional technique in patients with sacral fractures.     

Rekonstruktive Maßnahmen bei Zehenfehlstellung nach Kompartmentsyndrom

Compartment syndrome of the lower extremities has various etiologies. Patients suffer from toe deformity due to incorrect healing following compartment syndrome. They are restricted in their mobility as a result, even though the primary causes of the compartment syndrome in the lower extremities have long since healed. The toe deformities cannot be specifically attributed to compartment syndrome. Instead, they are a typical response to biomechanical changes in the foot. Following compartment syndrome, they are the result of a relative shortening of the tendons and a loss of function and contraction of the muscle; in patients with splay foot and flat foot, the toe deformity is caused by bone and connective tissue pathology. Identical surgical measures are used.     

Freies gefäßgestieltes Knorpel-Knochen-Transplantat bei avaskulärer Nekrose des proximalen Kahnbeinpols

The formation of a scaphoid pseudarthrosis with avascular necrosis in the area of the carpus is a The formation of a scaphoid pseudarthrosis with avascular necrosis in the area of the carpus is a dreaded complication after conservative or operative treatment of a scaphoid bone fracture, which previously often led to partial or total stiffening operations on the wrist. Vascularized bone grafts can be used to increase the bone fusion rates in the presence of scaphoid pseudarthrosis with avascular necrosis. On a note of caution, it must be mentioned, though, that such a procedure in the presence of avascular necrosis of the proximal pole with destruction of cartilage can lead to premature radiocarpal arthritis, because a friction-free gliding in the area of the proximal scaphoid pole is no longer ensured as a result of the lacking cartilage cover.We confronted these problems in a 20-year-old male patient with avascular necrosis of the proximal scaphoid bone pole and destruction of the corresponding scaphoidal cartilage cover. We transplanted a free vascularized cartilage-bone graft from the medial femoral condyle, which was adapted in form and size to the proximal scaphoid bone pole with corresponding cartilage cover and was connected to the radial vascular bundle. This novel operation technique is described in this report and appears to be a promising way of avoiding premature radiocarpal arthritis when treating scaphoid bone pseudo-arthrosis with avascular necrosis in the presence of cartilage destruction.     

Neue Aspekte der Rechtsprechung bei andrologischen Fragestellungen

In recent years there have been several Supreme Court adjudications concerning andrological issues. Among other things it was reconfirmed that drug therapy for erectile dysfunction does not have to be paid by compulsory health insurance providers. In contrast one Supreme Court decided that cryoconservation of ejaculates has to be paid by compulsory health insurance providers under certain circumstances. Vasectomy in men under guardianship is performed approximately 100 times per year in Germany. Before vasectomy is performed judicial authorisation has to be obtained in an extensive court proceeding. The Tissue Act regulates the implementation of the EG guideline 2004/23/EG into German law. This is only important for urologists who perform MESA/TESE procedures. Current case law does not allow use of the title Männerarzt as patients can confuse it with the official title andrologist.