Die hintere untere Kapselplastik zur operativen Behandlung der hinteren Schulterinstabilität

Operationsprinzip über einen hinteren Zugang wird die stark überdehnte hintere und untere Gelenkkapsel nach oben geschwenkt, um das erweiterte Kapselvolumen zu verkleinern. Die L?nge der lateralen Kapseldissektion und die Ausdehnung des verschobenen Kapselgewebes kann dem Grad und der Richtung der Laxizit?t angepa?t werden. Ein abgel?stes hinteres Labrum wird vor der Kapselraffung am Glenoidrand reinseriert. Zus?tzliche kn?cherne Verst?rkungen sind nur selten notwendig, zum Beispiel bei Glenoidhypoplasie oder bei Revisionseingriffen. übersetzer der engl. Originalfassung: Oberarzt Dr. B. Wittner, Stuttgart.     

Die Operation des Tarsaltunnelsyndroms

Operationsprinzip Durchtrennung des Retinaculum musculorum flexorum, der verdickten Faszie am kranialen Rand des Musculus abductor hallucis sowie der lateralen verdickten oder aponeurotischen Faszie des Musculus abductor hallucis und Kl?rung der Ursache der Nervenkompression. Der Nervenverlauf wird einige Zentimeter weit auch nach distal und proximal überprüft: Beseitigung der Kompressionsursache durch Spaltung einer einengenden Faszie, Resektion einer Exostose, Entfernung eines Ganglions oder anderer Gewebsver?nderungen.      

Prognostisch relevante Faktoren in der Behandlung des posttraumatisch instabilen Schultergelenks

The purpose of this prospective study was to determine concomittant lesions of glenohumeral dislocation and their correlation with the outcome, to determine the influence of various stabilizing operation techniques on the outcome. 106 shoulders [104 patients, 81 men, 23 women, mean age 36 (16-83) years] operated because of shoulder instability after at minimum one shoulder luxation between 1988 to 1995 were evaluated 3 years (0.8-8 years) postoperatively using Constant score. Preoperative arthroscopy was performed to document intraarticular lesions. There were 7 reluxations (5 because of a new accident), mostly after Putti-Platt procedures. The average modified Constant Score was 66 (10-85) points (maximum 85). 29 patients (27%) had less than 60 points, mostly because of pain and restriction of function, and were evaluated as poor. Lesions of rotator cuff, long biceps tendon and subscapularis tendon had a bad prognosis. The severity of arthroscopically found lesions correlated with the outcome. Operations with shortening of subscapularis tendon or using a bone graft gave bad results. Anatomic reconstruction of the labrum-ligament complex in combination with a plasty of the extended capsule gave best results. Preoperative arthroscopy can determine the extent of different lesions after shoulder luxation which influence the outcome and is useful to select the optimal operation technique.     

Isolated traumatic rupture of the subscapular muscle tendon as an adolescent injury

Introduction. Until now no case of a traumatic tear of the subascapularis muscle in children was described in the German speaking literature. Using the example of 2 cases of a 12 and 14 year boys youth history, clinic, diagnostics and therapy will be presented. Methods. The accident happened in extension and external rotation of the arm without dislocation. Beside the complete tear of the SCP-tendon in one case an accompanying expanded humeral flake fracture at the minor tuberosity was found. Under protection of the epiphysis line the refixation was performed using suture anchors. Results. The post-operative control after 12 months showed a complete tendon healing, no arthritis or delayed bony ingrowth with return to full activity. Conclusion. Isolated traumatic SCP-tears can be occur also in young patients. As major consequence, it is necessary to perform a thorough clinical examination with additional apparative diagnostics (Sonography, MRI). This way, this rare but important lesion can be detected early and lead to adequate surgery without any delay.     

Engpaß-Syndrom des Nervus peronaeus superficialis

Zusammenfassung Operationsziel Dekompression des Nervs durch Spaltung und Resektion der ihn einengenden Faszie. Indikationen L?nger bestehende und konservativ nicht beeinflu?bare Schmerzen und Dys?sthesien. Kontraindikationen Fortbestehen der Beschwerden nach Infiltration des Engpasses mit einem Lokalan?sthetikum. Operationstechnik L?ngsinzision über der markierten Stelle des Hauptdruckschmerzes. Aufsuchen des Nervs und seiner Durchtrittsstelle durch die Unterschenkelfaszie. Spaltung und Resektion der Faszie um den Engpa?. Ergebnisse Sechs Patienten (ein Mann, fünf Frauen; Durchschnittsalter 50,2 Jahre) wurden operiert und nach durchschnittlich 48,5 Monaten (drei Monate bis 10,5 Jahre) kontrolliert. Bei fünf Patienten rasche Beseitigung der Schmerzen und Dys?sthesien. Bei einer Patientin wurde lediglich Besserung erzielt; es lag hier offenbar eine zweite, weiter peripher gelegene Druckstelle vor, die von einem früheren Gipsverband herrührte und nicht beachtet worden war.     

Die operative Behandlung der Klavikulapseudarthrose

Operationsprinzip Klavikulafrakturen k?nnen-nach konservativer Behandlung-bei ungenügender Reposition oder Fixierung und nach Osteosynthese mit ausgedehnter Devastierung und/oder unzureichender Stabilisierung in einer Pseudarthrose übergehen. DiePlattenosteosynthese der Klavikulapseudarthrose, gew?hrt die zur Ausheilung erforderliche mechanische Stabilit?t; bei atrophen Pseudarthrosen oder Defektpseudarthrosen wird sie durch eineautologe Spongiosaplastik, bei gleichzeitig vorliegender Verkürzung durch Interposition eines kortikospongi?sen Blocks erg?nzt. Das (seltene) posttraumatische kostoklavikul?re Syndrom wird in der Regel durch, die stabile Osteosyn-these der Pseudarthrose allein bereits erfolgreich behandelt.      

Ruptur der Ursprungssehne des Caput longum musculi bicipitis brachii

Ohne Zusammenfassung      

Mittelfristige Ergebnisse nach arthroskopischer subakromialer Dekompression (ASD) unter besonderer Berücksichtigung laufender Rentenantragsverfahren

The objective was to evaluate mid-term results after arthroscopic subacromial decompression (ASD) with special focus on the bias due to an application to social insurance for pension based on sickness disability. The study group consisted of 42 patients (28 male, 14 female). ASD was performed in 1993 or 1994 for impingement stage II. The mean age was 49,5 years. Thirty-nine patients (93%) were evaluated by an independent observer for an average follow-up of 3,5 years (range 1.5–5). Patients satisfaction with the outcome was assessed by a visual analog scale graded from 0 (extremely dissatisfied) to 10 (extremely satisfied). The functional result was assessed using the Constant score. At follow-up the mean VAS value was 6,4±3,4. The Constant score improved from 49,6±18,5 to 84,8±14,3. The subgroup of patients having applied to social insurance for pension had significantly worse results compared with the remaining patients: VAS: 4,9±3,1 vs. 7,5±3,1; Constant-Score: 76,1±12,7 vs. 88,3±13,5. The fact that patients try to get benefit from social insurance based on sickness disability significantly biased the outcome after ASD.     

Neuromuskuläres Monitoring Eine Standortbestimmung

In this article current indications and limitations of neuromuscular monitoring are reviewed. Attention is mainly focused on detection of residual curarisation. New insights in the pathophysiological consequences of residual neuromuscular blockade and the actual criteria of complete recovery are discussed. Surprisingly in this context, despite the benefit of neuromuscular monitoring, its utilisation in clinical practice is rather an exception than the routine. A lack of standardisation of neuromuscular monitoring is probably the major problem on the way to a widespread utilisation of the monitoring.     

Pterional orbital decompression in traumatic orbital hematomas

The results are presented for pterional orbital decompression in 12 patients with symptomatic traumatic retrobulbar hematoma after various traumatic mechanisms. Pre- and postoperative course, neuroradiological findings, additional brain or facial injuries as well as outcome of eye function are analyzed in detail. Mean time delay between trauma and decompression was 56 h (2.4 days), with a wide range from 2 h to 15 days. Preoperative exophthalmos and pupillary disturbances as well as restrictions of extraocular movements decreased in all patients after orbital decompression and removal of the retrobulbar hematoma if the bleeding was localized. Visual acuity remained normal or showed significant improvement in seven patients, four of whom experienced complete recovery. In three patients the eye remained amaurotic. No complications related to the operation were seen. The pterional orbital decompression described here represents an effective alternative approach for patients with sight-threatening retrobulbar hematoma, especially in cases where it is necessary to gain space for the orbit in addition to evacuating space-occupying blood or bone clots and treating neighbouring lesions. Immediate detection and adequate treatment of orbital hematomas is mandatory to achieve an acceptable outcome of eye function.     

Verletztenrenten auf unbestimmte Zeit nach distalen Radiusfrakturen

Of 280 work-related radial fractures reported during 1 year to a commercial workmen's compensation board, 18 resulted in retirement for an indefinite length of time, i.e., annuity payments continued for more than 3 years following the accident. The probability of payment for life is relatively high in these cases. The quality of treatment was evaluated based on the records of the liability insurance association and the X-rays. In addition, answers were sought for the question of whether better healing results could have been achieved with additional justifiable expenditure. The quality of the radiological experts' reports was also assessed. One lesson learned from the project is the realization that special attention should be paid to fractures in persons older than 50 years since they achieve conspicuously suboptimal results.     

Transepiphysäre Verschraubung von Ausrissen der vorderen Eminentia intercondylaris unter arthroskopischer Kontrolle

Operationsprinzip Arthroskopische Reposition des Fragments. Schraubenosteosynthese nach Zugschraubenprinzip von distal ohne Arthrotomie.      

Diagnostisches Konzept der akuten Infektion des Schultergelenks

Zusammenfassung. Einleitung: Bakterielle Gelenkinfektionen stellen auch heute noch eine ernstzunehmende Situation dar, die h?ufig zu irreparablen Sch?den am betroffenen Gelenk führen. W?hrend bei den h?ufigeren Kniegelenkinfektionen das diagnostische Management weitgehend standardisiert ist, finden sich infolge der geringen Incidenz von Infektionen des Schultergelenks nur wenige Angaben in der Literatur. Patienten und Methode: Im Rahmen einer retrospektiven Studie wurden die Ergebnisse von 15 Patienten analysiert, die im Zeitraum von 1990–1999 nach einer Infektion des Schultergelenks in der BG-Klinik Bergmannsheil Bochum behandelt wurden. Erfa?t wurden folgende Parameter: ?tiologie, Intervall bis zum Auftreten der ersten Symptome, klinische Symptomatik, diagnostische Verfahren, intraoperativer Befund (Klassifikation nach G?chter), operative Therapie, Keimspektrum. Die Diagnostik erfolgte nach einem festgelegten Algorithmus, bestehend aus CRP-Bestimmung, Gelenksonographie, sonographisch kontrollierter Gelenkpunktion sowie der Anfertigung eines Gram-Pr?parats. Alle infizierten Gelenke wurden anschlie?end revidiert. Ergebnisse: 14 Infektionen traten nach einer Gelenkinjektion auf. Als diagnostisch wegweisende Befundkonstellation trat bei allen Patienten eine CRP-Erh?hung in Kombination mit einer schmerzhaften Bewegungseinschr?nkung des betroffenen Gelenks auf. In allen F?llen konnten im pr?operativen Gram-Pr?parat Kokkenbakterien nachgewiesen werden. Die nach Abschlu? des diagnostischen Algorithmus gestellte Diagnose einer akuten Gelenkinfektion wurde intraoperativ in allen F?llen best?tigt. Zwei Patienten mit verz?gerter Zuweisung verstarben im septischen Multiorganversagen unter maximaler Intensivtherapie trotz radikaler chirurgischer Revision. Schlu?folgerung: Bei verd?chtigen klinischen Beschwerden nach typischer Anamnese empfehlen wir die zielgerichtete Diagnostik nach dem oben genannten Algorithmus. Bei einer akuten Gelenkinfektion mu? eine zeitaufwendige Diagnostik vermieden werden, da versp?tet diagnostizierte Infekte der Schulter zu hochgradigen Bewegungseinschr?nkungen, im Extremfall sogar zu einer vitalen Bedrohung des Patienten führen k?nnen.      

Die Bedeutung der laparoskopischen Technik beim primären colorectalen Carcinom

Zusammenfassung. Bei Patienten, die wegen eines prim?ren colorectalen Carcinoms elektiv reseziert wurden, wurde in einer prospektiven Studie untersucht, aus welchen Gründen die Operation konventionell durchgeführt wurde, wenn bei allen Patienten die laparoskopische Operation grunds?tzlich angestrebt wird. Damit sollte die gegenw?rtige Bedeutung der laparoskopischen Technik in der elektiven Behandlung des prim?ren colorectalen Carcinoms gekl?rt werden. Von 111 Patienten, die innerhalb von 12 Monaten operiert wurden, wurde bei 22 Patienten der Tumor laparoskopisch reseziert und bei 4 Patienten ein laparoskopisch-assistiertes Verfahren gew?hlt. Alter, Geschlecht und Tumorstadien waren vergleichbar zwischen den Gruppen. Die Operationszeiten waren in der laparoskopischen Gruppe deutlich l?nger, die des postoperativen Ileus und Verweildauer waren kürzer. Die h?ufigste Indikation zur konventionellen Resektion waren Rectumcarcinome (n = 29), gefolgt von Verwachsungen (n = 15), randomisierten Patienten (n = 14) und infiltrierenden Tumoren (n = 12). Allgemeine Risikofaktoren waren weniger bedeutend. Die laparoskopischen Operationstechniken spielen zur Zeit noch eine untergeordnete Rolle in der prim?ren Behandlung des colorectalen Carcinoms (24–37 %). Operationstechnische Gesichtspunkte lassen eine sphinctererhaltende Resektion von Rectumcarcinomen im mittleren und unteren Drittel noch nicht empfehlen. Allgemeine Risiken sind selten eine alleinige Kontraindikation zur laparoskopischen Resektion.      

Karl E. Hammerschmidt Humanist, Naturwissenschaftler und Narkosepionier

Karl Eduard Hammerschmidt was born in Vienna in 1901. There are indications that after studying law he passed on to studies in medicine and surgery in Vienna, though it has to be said there is no trace of his attaining any qualification. After this he worked in various scientific sectors and in recognition of his achievements he was accepted as a member of the Kaiser Leopold Academy of Researchers in Natural Sciences in Bonn. From February 1847 to March 1848 he induced numerous general anaesthetics with ether, working with Dr. J. Weiger, a dentist in Vienna. On 11 July 1847 he published preliminary statistics based on 1560 dental operations performed under ether anaesthesia and also on numerous experiments performed on himself and investigations conducted with ether in animals and in healthy subjects. From the viewpoint of scientific research into and widening of the applications of ether anaesthesia, his most meritorious achievements include the early publication of a staging classification for ether anaesthesia, the introduction of an anaesthetic protocol for patients that also lent itself to data recording for statistical purposes and the early realization that the ability to hear is retained for a very long time during anaesthesia. In 1848 Hammerschmidt was obliged to flee to Istanbul by way of Hungary because of his involvement in the October Revolution. Once there, he continued to work as a doctor and later became Professor of Medicine at the University of Istanbul. He converted to Islam, taking the name of Abdullah Bey, and also became a colonel in the Turkish army. He was one of the founders of the Red Crescent, the humanitarian sisterorganization of the Red Cross, and the Turkish Post commemorated this with the issue of a stamp honouring him when the organization celebrated the centenary of its formation in 1968. In 1869 the Hapsburg dynasty also honoured him with orders and distinctions. He died in Istanbul in 1874 as a highly esteemed personage.     

Differenziertes Schilddrüsenkarzinom Zur Chirurgie und Bedeutung von Lymphknotenbefall

Introduction. Nodal treatment in papillary (PTC) and in follicular (FTC) thyroid carcinoma is still a subject of debate. Methods. 1974–95 therapeutic lymphadenectomy (30/95), 1996–1999 frequent prophylactic lymphadenectomy (32/57; P=0,005) was used for PTC, with therapeutic lymphadenectomy for FTC (15/115). ¹³¹I was used selectively for pN₁-tumours. Results. PTC: The incidence of pN₀-, but not of pN₁-status increased significantly (P=0,03). Nodal recurrence was observed in 5/89 (6%) with therapeutic, vs. 1/54 (2%) with prophylactic lymphadenectomy (P=NS), i.e. in 1/107 (0,9%) patients without evidence of nodal disease, vs. 5/36 (14%) of those with pN₁-status (P=0,0004). Survival at 25 yrs. in stages TNM I and II was 100%, i.e., independent of N-status. FTC: No nodal recurrence was observed. Conclusion. Occult untreated nodal disease represented no major clinical problem. Selective nodal treatment may offer optimal results; meticulous nodal dissection is indicated for N₁-tumours.     

Leiomyosarkom der Milzarterie

Leiomyosarcomas of vascular origin are a very rare group of tumors developing from smooth vascular muscle cells. The most common location are in large vessels, e.g. vena cava, saphenous vein or pulmonary artery, but fewer than 200 cases are reported in the literature. We report a case of a patient with a leiomyosarcoma of the splenic artery. This location has not been described previously.     

The BEHAC nail--a new intramedullary implant for managing 2-stage fractures of the humerus

The BEHAC-nail is a new implant for the treatment of complex humeral fractures, particularly for segmental fractures. It is an elastic intramedullary implant that is inserted retrograde into the distal humerus. The special feature of this nail is its proximal "loop design" which reduces the implant penetration at the proximal fixation site in the subchondral area of the humeral head in comparison to implants with tips such as Rush pins or Hackethal's nails. Thus, the risk of nail migration and perforation of the humeral head is less with the BEHAC-nail than with other nails. Another advantage of the "loop design" is that the humeral head fragment can be fixed adequately. Even short proximal fragments can be stabilized with this design. In contrast a short humeral head fragment cannot be held with implants like the UHN, HVN or Seidel's nail. The BEHAC-nail is a useful implant for segmental fractures of the humerus.     

Cyclic stretch enhances apoptosis in human lumbar ligamentum flavum cells via the induction of reactive oxygen species generation

Objective: The lumbar ligamentum ?avum (LF) is an important part of the spine to maintain the stability of the spine. In this study we aimed to examine whether mechanical force by cyclic stretch could induce apoptosis in human LF cells and investigate the underlying mechanism.

Methods: LF cells were isolated from six young patients undergoing spinal surgery and then cultured in vitro. LF cells were subjected to cyclic stretch and the poptosis was detected by flow cytometry. The level of intracellular reactive oxygen species (ROS) and caspase-9 activity were measured.

Results: Cyclic stretch at a frequency of 0.5?Hz with 20% elongation induced the apoptosis of human LF cells in vitro, and this was correlated with increased ROS generation and activation of caspase-9.

Conclusion: Our study suggests that cyclic stretch-induced apoptosis in human LF cells may be mediated by ROS generation and the activation of caspase-9.     

The roentgenmorphologic aspects of symptomatic calcifications in patients with calcifying tendinitis of the shoulder: determination of intra- and interobserver variabilities of Gärtner's classification

Aim of the study. The roentgenologic morphology of symptomatic calcified deposits of the rotator cuff can be classified according Gärtner.This classification influences therapeutic procedures and prognosis of clinical outcome in these patients. In the present study intraoberserver-reproducibility and interobserver-reliability of Gärtner's classification were tested. Methods. Plane radiographs of 100 patients with calcifications of the supraspinatus tendon were classified according the criteria of Gärtner by 6 independent observers twice within 4 months.Intraoberserver-reproducibility and interobserver-reliability were calculated by means of Cohen's κ-index. Results. κ-values of intraoberserverreproducibility had a mean of 0.4208 (SD 0.1299), κ-values of interobserver-reliability were 0.490 for the first and 0.474 for the second classification. Conclusions. Determination of intraoberserver-reproducibility gave insufficient to satisfactory results, interobserver-reliability was sufficient.The clinical use of Gärtner's classification to plan therapeutic procedures or to determine clinical prognosis in patients with calcifying tendinitis can be recommended only with limitations.