Spondyloepiphysäre und metaphysäre Dysplasie

Spondyloepiphyseal, metaphyseal and spondylometaphyseal dysplasias are a group of hereditary skeletal diseases, which lead to small stature, axial deformities of the lower extremities and spinal deformities. They differ in pathophysiology, heredity and in their clinical and radiologic appearance. The orthopaedic surgeon treats the spinal manifestations and the axial malalignment of the disease. Among the spinal deformities there are instabilities of the upper cervical spine as well as structural deformities like kyphosis and scoliosis. More frequently, the axial malalignment caused by congenital coxa vara, severe genu varum or genu valgum requires treatment. These deformities are managed by corrective osteotomies of the proximal femur, supracondylar or proximal tibial osteotomies around the knee and by temporary epiphyseodeses. Despite a high recurrence rate requiring repeated surgery the patients report great satisfaction with the treatment results. Well-timed orthopaedic treatment helps avoid or delay the inevitable long-term sequelae of untreated patients such as painful degenerative changes of the spine or early onset of severe osteoarthritis.     

Intramedulläre Knochenendoskopie

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.     

Neuromuskuläre Restblockaden

Even after administration in routine clinical dosages, muscle relaxants can lead to long-lasting residual blockades which increase the risk of severe postoperative pulmonary complications. Even without the additional effects from analgetics, sedatives or anaesthetics, a partial neuromuscular blockade, which cannot reliably be avoided either by the anaesthetist alone or by the additional use of nerve stimulators (train-of-four [TOF] ratio 0.5-0.9), can cause reductions in the vital capacity and the hypoxic breathing response, as well as obstruction of the upper airway and disruption of pharangeal function. The extent of neuromuscular recovery after an operation depends on the muscle relaxant used, the duration of administration, the anaesthetic technique and possible accompanying illnesses of the patient. It must basically be assumed that residual neuromuscular blockades are more frequent after administration of slow acting muscle relaxants such as pancuronium, than after the use of medium or rapid acting substances. If the course of a neuromuscular blockade is continually monitored during the whole anaesthetic procedure using the TOF ratio and not only occasionally at the end, a TOF ratio of 1 measured with an acceleromyograph (e.g. TOF-watch) promises an adequate neuromuscular recovery from the effects of muscle relaxants.     

Vaskuläre Malformationen

The therapy of extended vascular anomalies necessitates a differentiated interdisciplinary treatment regime; therefore, exact knowledge of the classification of these anomalies is essential. The system was established by the International Society for the Study of Vascular Anomalies (ISSVA) and classifies vascular anomalies into proliferating vascular tumors and congenital vascular malformations. The vascular malformations are subdivided into high-flow and low-flow malformations. To confirm the initial clinical diagnosis it is necessary to obtain diagnostic tomographic images of the vascular lesion and magnetic resonance imaging (MRI) is the imaging modality of choice complemented by magnetic resonance angiography (MRA). The indications for therapy depend on the clinical characteristics of the vascular malformation and should be planned in an interdisciplinary setting. In addition to open surgery interventional radiology including percutaneous sclerotherapy and transarterial embolization have evolved as crucial elements of the interdisciplinary treatment management of vascular malformations.     

Radiolunäre und radioskapholunäre Arthrodese bei chronischer Polyarthritis

INTRODUCTION: In 75% of all cases of rheumatoid arthritis the wrist is affected and in 12% is the region of initial manifestation of this chronic inflammatory joint disease. To prevent destruction of the wrist through carpal dislocation, radiolunate and radioscapholunate arthrodeses have increased in importance. METHODS: During a 6.5-year period, 28 radiolunate and 4 radioscapholunate arthrodeses were performed in 30 patients. The indication for operation was progressive carpal translation and increasing subluxation of the wrist in which existent radiological damage had not reached more than grade III according to the classification of Larsen and co-workers. RESULTS: The results obtained during the follow-up study (median: 17.3 months) showed in most treated patients after partial arthrodesis of the wrist no or fewer complaints concerning swelling and pain and an acceptable remaining range of motion of the wrist in everyday life. In patients with preoperatively existing ulnar deviation less than 15 degrees progressive carpal collapse and dislocation could be mostly prevented. CONCLUSION: All told radiolunate and radioscapholunate arthrodeses successfully stabilized the wrist in patients suffering from rheumatoid arthritis.     

Intraartikuläre Mittelgelenkfrakturen

The results of treating fracture dislocations of the proximal interphalangeal joint are often unsatisfactory for the patient because conservative methods cannot prevent stiffness of the joint. Thus, early functional treatment with external fixation systems is increasingly favoured. This therapy combines the principles of ligamentotaxis and the possibility of early movement of the injured joint. The frequently modified pins and rubbers traction system is especially effective. It is cheap, easy to apply, and well accepted by patients due to its light weight and small size. This paper gives an overview of the therapeutic options and the clinical results of treating fractures of the proximal interphalangeal joint.     

Subtrochantäre Femurfrakturen

Subtrochanteric femoral fractures are proximal femoral fractures which are located between the trochanter minor and an area of 3 cm below the minor trochanter on the femoral shaft. About 10–15?% of all proximal femoral fractures correspond to this fracture site. Elderly or geriatric patients are generally affected and the injury is often the result of a fall in the home, while high-energy trauma is the cause in a small group of generally younger patients. Clinical evaluation of the affected extremity shows disability of axial weight-bearing and pain during compression and rotation of the hip joint. Basic diagnostics include conventional x-rays of the injured femur in the anterior–posterior and lateral planes. These subtrochanteric femoral fractures are almost always treated surgically due to the inherent high degree of instability. The main goals of surgical intervention are to achieve anatomic fracture reduction and primary full weight-bearing stability of the corresponding leg. Intramedullary interlocking nails are used for primary treatment, while extramedullary implants are often used in revision surgery. Early mobilization and intensive respiratory exercises are necessary to prevent early postoperative complications.     

Endovaskuläre AAA-Therapie

Purpose. We analyzed the clinical efficacy of endovascular AAA repair in midterm follow-up and scrutinized the causes of graft-dependent endoleaks (type I EL). For this purpose, we investigated whether a restrictive patient selection can reduce the incidence of type I EL. Patients and results. A consecutive series of 83 patients who underwent elective endovascular AAA repair during 4/1995 and 9/1999 was analyzed. Mean follow-up was 12 months. Twenty tube grafts and 63 bifurcated grafts were used. With the help of a risk score classifying preoperative AAA morphologies into three risk groups, morphological AAA difficulties and clinical outcomes were set in reference and morphological alterations of the crucial fixation sites were amassed. Perioperative mortality was 1 of 83 (1.2%) and primary technical success 80 of 83 (96.4%). We observed one rupture 36 months postoperatively that responded to endovascular treatment. Conversion was 6 of 83 (7.2%). Type I EL occurred in 13 of 83 patients (15.7%). Of 13 type I EL patients, 9 (69.2%) responded to secondary endovascular treatment, while 4 of 13 patients (30.8%) had to be converted due to type I EL. While 70 of 83 patients (84.3%) without type I EL showed a significant decrease of maximum AAA diameter (D_max) 12 months postoperatively, D_max did not show shrinkage in 13 of 83 patients (15.7%) with type I EL (p=0.0035). In 4 of 20 patients (20%) treated with tube grafts, type I EL occurred besides a significant dilatation of the distal aortic neck 12 months postoperatively, whereas in 16 of 20 patients (80%) treated with tube grafts, neither type I EL nor a significant dilatation of the distal aortic neck was observed (p=0.0354). Of 63 patients treated with bifurcated devices, 9 (14.3%) showed type I EL and a significant dilatation of iliac artery diameters 18 months postoperatively, while 54 of 63 patients (85.7%) without type I EL did not show a significant expansion (left common iliac artery p=0.0269, right common iliac artery p=0.0071). We found a significant relationship between preoperative AAA morphologies with a higher risk score and the occurrence of type I endoleaks (p=0.022). Conclusions. The causes of the complications in the cohort observed were morphological alterations of the aortoiliac vessels, technical difficulties regarding the exact fitting of endovascular grafts, or a combination of these problems. Restrictive morphological patient selection, precise preoperative imaging, and differentiated graft choice as well as correct fitting of the graft will have the potential to decrease the incidence of type I endoleaks in the future.     

Primäre Knochenheilung

Ohne ZusammenfassungMit 3 Abbildungen     

Testikuläre Ischämie

Background

Ischemia and reperfusion (I/R) lead to cellular damage. A disturbance of testicular perfusion occurs during the therapy of cryptorchidism and in cases of testicular torsion. This results in the activation of mediator cells with an increasing synthesis of mediators of infection like TNF-α and the expression of cell adhesion molecules like ICAM (intercellular adhesion molecule) and VCAM (vascular cell adhesion molecule) at the cellular surface.

Methods

The expression of the cytokines IL-10 and TNF-α and the adhesion molecules ICAM and VCAM after defined testicular I/R injury in nine male transsexuals was evaluated with rt-PCR. Furthermore we examined lactate and the diameter of the testicular tubulus under ischemic conditions.

Results

During ischemia ICAM, IL-10, and VCAM do not show significant changes on the side of testicular ischemia and the contralateral side; the same was seen for the tubulus diameter. TNF-α and the testicular lactate values showed a significant change of the expression pattern.

Discussion

The statistical changes of TNF-α and testicular lactate are the expression of leukocyte migration, infectious reaction, and immune response. To what extent the TNF-α expression represents a severe immunological reaction remains undefined. This human study shows primary results for the immunological understanding of and cellular response to testicular ischemia.     

Subtrochantäre Nierenzellkarzinommetastase

A 60-year-old man presented to our institution with a singular subtrochanteric renal cell carcinoma metastasis of the right femur. Tumor resection and implantation of a cemented femoral head preserving prosthesis was considered as the best treatment option to obtain a good hip joint function. After successful surgery (R0 resection) the patient was immediately mobilized with full weight-bearing. One year postoperatively the patient presented with good joint function and absolute mobility. X-ray examinations revealed a good position of the implanted prosthesis without signs of tumor recurrence or femoral head necrosis. Implantation of a femoral head preserving prosthesis is a good option for the treatment of subtrochanteric/diaphyseal tumors of the femur.     

Hepatobiliäre Tumorchirurgie

Surgical R0 resection of primary and secondary hepatobiliary tumors, such as colorectal liver metastases, hepatocellular carcinoma, cholangiocellular carcinoma and gall bladder carcinoma, remains the only potentially curative treatment option. The extent of involvement of lymph node metastases seems to be an independent prognostic factor in these tumors. The prognostic value of a systematic lymph node dissection in hepatobiliary tumors still remains unclear as there is a lack of prospective randomized trials. However, local lymphadenectomy (hepatoduodenal ligament and retropancreaticoduodenal lymph nodes) can be easily performed with low mortality and morbidity rates and may be helpful in better staging of the patients. Further randomized trials are necessary in order to define the relevance of lymph node dissection in hepatobiliary surgery     

Sekundäre Kieferspaltosteoplastik

Secondary cleft osteoplasty as part of the treatment of patients with cleft lip, jaw and palate is performed between the ages of 6 and 12 years to reconstruct the bony defect in the alveolar ridge area. Graft material is usually obtained from the iliac crest, followed by reconstruction of the nasal floor, osseous augmentation, and wound closure. This procedure serves physiological eruption of cleft-adjacent teeth during orthodontic treatment and, amongst numerous others benefits stabilizes the upper jaw segments.     

Neuromuskuläre Skoliosen

The therapy of neuromuscular scolioses has to be tailored to the needs to the individual patient; there are no universally valid schemes of treatment. Detailed knowledge of neuromuscular diseases and their course is essential. For this reason, an interdisciplinary team is desirable; only in this way can all medical and surgical aspects of the underlying disease--which interfere with the therapy of the scoliosis--be treated successfully. The continual improvement in medical treatment of neuromuscular disease in recent decades has led to a significant increase in life expectancy. In addition, the severe consequences of failure to treat spinal deformities have become clear. Neglect or inadequate treatment of neuromuscular scolioses can have dramatic consequences, including inability to sit and serious impairment of cardiorespiratory status. The goal of treatment is therefore to prevent the spinal deformities leading to a dangerous worsening of respiratory status. Moreover, the therapy should improve function, which in most cases means restoring a stable sitting position. From the mechanical viewpoint this means restoration of spinal balance with a vertical spinal axis at right angles to a horizontal pelvis.     

Solitäre Kalkaneuszysten

Zusammenfassung Die Differentialdiagnose der solitären Kalkaneuszysten erstreckt sich von den solitären benignen Zysten bis zu malignen Tumoren. Im Zentrum des Fersenbeinkörpers sind 10–50% der Zysten als intraossäre Lipome situiert. Wir fanden in unserem Krankengut in einem Jahreszeitraum von mehr als 20 Jahren bei 4 operierten Fersenbeinzysten im histologischen Befund 3 Lipome und 1 Tuberkel. Das Durchschnittsalter entspricht der Studie nach Milgram. Zu bemerken wäre, daß alle 4 Patienten aus einem einzigen Siedlungsgebiet, in dem der Bergbau ehemals das zentrale wirtschaftliche Interesse war, stammen. Auch aus unserer Erfahrung sollten diese Zysten wegen der Gefahr der Spontanfraktur operativ ausgeräumt und mittels Spongiosaplastik aufgefüllt werden, um einerseits die Dignität der Zyste zu verifizieren und andererseits die drohende Spontanfraktur zu vermeiden.

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Solitary calcaneal cysts

Differential diagnosis of solitary calcaneal cysts extends from benign cysts to malignant tumours. In all, 10–50% of these cysts are located at the centre of the calcaneal body in the form of intraosseous lipomas. Among our patients treated over a period of more than 20 years, there were four who underwent surgery for calcaneal cysts; the respective histological findings showed three lipomas and one tuberculoma. The average age of these patients corresponded to that of Milgram's study. It should also be remarked that all four patients came from a region in which mining was of central economic importance. Our experience has shown that such cysts should be surgically removed and filled with plastic spongiosa material in order both to check whether the cysts are benign or malignant and to avoid an imminent spontaneous fracture of the heel bone.

     

Vaskuläre Malformationen

Vascular malformations are localized defects of vascular morphogenesis. Contrary to infantile hemangiomas, which are vascular tumors and go through a phase of proliferation followed by regression, they never regress. They grow commensurately with the patient and may become symptomatic at adolescence or in young adults. Trigger effects, such as trauma or hormonal influences may stimulate growth and symptoms. Clinical indications for vascular malformations at the time of birth are bluish discolorations of the skin (e.g. venous malformations) or cherry-red spots (e.g. capillary malformations or combined malformations). Children may show signs of asymmetric increased growth of extremities or increased girth on the affected side, or pain resulting from coagulation effects in truncular (thrombosis of the pelvic veins in atresia of caval veins) or extratruncular (thrombophlebitis in venous malformations) malformations. A buzzing sensation during light contact in combination with brownish skin discolorations (Stewart-Bluefarb syndrome), localized enhanced skin temperature and dilated subcutaneous draining veins are signs of a high-flow arteriovenous malformation (AVM). Large AVMs may lead to high-output cardiac failure in children and young adults. Large VMs may show localized intravascular coagulation with high D-dimer levels and low platelet counts. After surgery, pregnancy or trauma this condition may deteriorate to disseminated intravascular coagulation. Typical consequences of enduring VMs are venous insufficiency or severe arthrosis (e.g. due to hemarthrosis) and recurrent erysipelas with lymphatic malformations (LM), which can severely reduce the quality of life.     

Primäre Varikose

The classic varicose vein operation still represents the "gold standard" in the operative therapy of varicose veins. The results of this procedure in view of perioperative complications are very good, with the incidence of perioperative deep venous thrombosis varying between 0.05% and 0.1%. Recurrence rates between 6% and 60% are published. However, the true recurrence rate is unknown since an exact definition of recurrent varicosis is still lacking. In recurrent varices it is essential to distinguish between disease progression, including neorevascularisation, and technical errors. Endovascular procedures for elimination of the superficial venous system - radiofrequency obliteration and endovenous laser therapy - meanwhile have established themselves as alternative, minimally invasive procedures. The perioperative complication rate of endovenous procedures is very low and comparable to that of the classic operation. Good results, with occlusion rates of the treated vein around 87% to 93% up to 2 years postoperatively, have been published for both endovenous laser therapy and radiofrequency obliteration. For the latter, 5-year results were published, with occlusion of the treated vein in 87%. Results in the literature for radiofrequency are better documented than for endovenous laser treatment because there are now five prospective randomised trials for the former and most publications for endovenous laser treatment are single-center experiences. The advantage of endovenous procedures, especially radiofrequency obliteration, over the classic operation is the lower rate of perioperative pain and better quality of life. The spectrum of operative treatment methods of the superficial venous system has increased tremendously due to new technical developments. For the surgeon this implies the necessity of informing patients conscientiously about the pros and cons and available results of each procedure, and carefully weighing which methods are at the time best for the patient.     

Periazetabuläre Navigation

Following a period of conservative treatment of acetabular fractures in the past, the use of classifications and defined acetabular surgery indications was introduced because of an increasing number of extended surgical approaches for operative stabilization of acetabular fractures. This development has enabled minimally invasive procedures using three-dimensional (3D) visualization and navigation techniques in the operating room (OR), with the expectation of reduced intraoperative morbidity and optimized surgical precision. Most common in acetabular navigation is 3D C-arm-based navigation, which has enabled new techniques in combination with other modern OR systems. In special cases, techniques based on computed tomography and 2D C-arms are still used.