Pigmentierte villonoduläre Synovialitis Seltene Differentialdiagnose einer poplitealen Raumforderung

Pigmented villonodular synovitis (PVNS) is a disease that involves the lining of joints, bursae and tendon sheaths. The incidence is low and estimated to be 1.8 patients per million population. The cause of PVNS is unclear and discussed to be either inflammatory or neoplastic. PVNS has been described in 2 forms different for prognosis and treatment (nodular and diffuse). The articular form almost appears in the knee joint as we describe below in a 14 year-old patient. PVNS was first defined in 1941 by Jaffe e.a. [7]. Because of the uncommon occurrence of the disease it is difficult to amass patient series to allow confirmed statements on therapy and outcome. Larger patient series raise out of long periods of time. Differences in outcome and recurrence rates exist for the nodular and diffuse form. Clinical findings are moderate pain and swelling of joints due to effusion and synovial proliferation. Magnetic resonance imaging shows typical findings. Surgical procedures are recommended as open or arthroscopic synovectomy for the diffuse form of PVNS, local excision for the nodular form and arthrodesis or prosthetic replacement for joint destruction.     

Knochentransplantation mit Hüfttotalendoprothese bei diffuser pigmentierter villonodulärer Synovitis

Pigmented villonodular synovitis (PVNS) is a rare benign but aggressive disease of the synovium. If the hip is involved early destruction of the joint is common due to the tight structure of the capsule and arthroplasty is unavoidable in these cases. We implanted a cemented total hip replacement in a 17-year-old female patient who had histologically confirmed PVNS. Because of massive bony destruction in the acetabulum a reconstruction with homologous bone (two femoral heads) from the bone bank was necessary. After 5 years the bone transplant had become integrated, there were no signs of recurrence and the patient was pain-free with a normal joint function. There were no signs of loosening.     

Diagnostik von Knorpelschäden des Kniegelenks

BACKGROUND: The study was aimed to evaluate the validity of clinical, radiological and MRI examination for cartilage defects of the knee compared with arthroscopic finding. METHODS: Seven-hundred seventy-two patients who were suffering from knee pain over more than 3 months were evaluated clinical (grinding-sign) and with radiography and magnetic resonance imaging (MRI) and subsequent arthroscopy. RESULTS: The grinding sign had a sensitivity of 0.39. The association of a positive grinding test with high grade cartilage defects was significant (p<0.000). In 97.4% an intact chondral surface correlated with a normal radiological finding. Subchondral sclerosis, exophytes and a joint space narrowing was significantly associated with high grade cartilage defects (p<0.000). The accuracy of MRI was 59.5%. The MRI resulted in an overestimation in 36.6% and an underestimation in 3.9%. False-positive results were significant more often assessed in low-grade cartilage defects (p<0.000). CONCLUSIONS: Clinical signs, x-ray imaging and MRI correlate with arthroscopic findings in cases of deep cartilage lesions. In intact or low-grade degenerated cartilage often results an overestimating of these findings.     

Die Transplantation autogener Knorpelzellen in Gelenkflächendefekte des Kniegelenks

Objective Repair of articular cartilage defects of knee to restore a pain-free joint function. Indications Full-thickness chondral or osteochondral posttraumatic lesions and osteochondritis dissecans defects that have not been successfully repaired with methods such as debridement, drilling, and microfracturing. Contraindications Osteoarthritis. Rheumatoid arthritis. Sugical Technique During arthroscopy, the cartilage lesion is evaluated, and cartilage slices weighing 200–300 mg are harvested from the upper medial femoral condyle, a minor load bearing area. The chondrocytes are isolated enzymatically and grown in culture to increase the cell number during approximately 2 weeks. During the second operation, an arthrotomy is performed through a medial or lateral parapatellar approach. The defect is carefully debrided. A periosteal patch is obtained from proximal tibia, placed over the defect and sutured to the surrounding cartilage. The suture line is sealed with fibrin glue, and the chondrocytes are injected into the defect under the patch. Results Recently, Peterson has presented results in 213 patients with a follow-up between 2–10 years. He reported good to excellent results in 90% of 57 patients with single femoral condyle lesions, in 84% of 32 patients with osteochondritis dissecans and in 74% of 27 patients with femoral condyle lesions in combination with anterior cruciate ligament reconstruction. In 32 patients the patella was grafted and 22 improved, in twelve patients the trochlea was grafted and seven improved, and in 53 patients multiple lesions were grafted and 42 improved. Second-look arthroscopies were performed in 46 patients, 26 of them were biopsied; the transplanted tissues showed a hyaline-like appearance in 21 patients (80%).     

Endovaskuläre Therapie des Aortenbogens

Background

Open surgical treatment represents the gold standard for pathologies of the aortic arch. Despite surgical, anesthesiological and technical developments of open surgery, hypothermic circulatory arrest with a high perioperative risk is still necessary and cannot therefore be used for multimorbid patients. Endovascular techniques have made impressive developments over the last 20 years and are the treatment of choice for pathologies of the descending aorta. In emergency situations, such as ruptured or symptomatic aneurysms and in multimorbid patients, endovascular techniques are currently becoming a treatment alternative for lesions of the aortic arch. Due to the complexity of the aortic arch with its supra-aortic vessels, angulation and proximity to the heart, endovascular treatment is a challenging task.

Objective

Which therapy options are offered by endovascular techniques for individual patients?

Results

Endovascular treatment options for the aortic arch include hybrid debranching procedures and endovascular techniques, such as fenestrated and branched stent grafts, chimney graft procedures and in situ fenestration. Customized fenestrated and branched stent grafts are considered to be a good alternative treatment for patients unfit for open surgery and could become the treatment of choice in the future. Chimney grafts and in situ fenestration are suitable as valuable bail-out strategies for aortic arch pathologies.

Conclusion

Endovascular techniques are rapidly developing and improving and have currently become a valid alternative treatment in specialized centers for high risk patients with aortic arch pathologies.

     

Endovaskuläre Behandlung des Aortenbogenaneurysmas

There are a variety of treatment options for complex aortic arch pathologies. The key to success in aortic arch surgery includes an understanding of the pathology, reasonable indications including correct decisions on treatment options and an uneventful procedure. In modern aortic arch surgery it is not the available treatment option but the pathology which should define the best form of treatment. One of the aortic arch treatment options is implantation of the double-branched Relay aortic arch stent graft prosthesis including a carotid-subclavian bypass on the left side. This device consists of the main body and two stent grafts dedicated to supra-aortic vessels. The main body includes two internal tunnels as proximal landing zones for the supra-aortic stent grafts. During the main body implantation the brain perfusion remains uninterrupted. The first results after double-branched stent graft implantation are promising. In the first published series with 15 patients, the perioperative mortality and stroke incidence were 7%. There was no endoleak type Ia or type III; however, the number of patients is low and the long-term results are not available at present.     

über das HÄufigkeitsverhÄltnis der Tuberkulose und der nichtspezifischen einfachen chronischen Synovitis des Kniegelenks

Ohne Zusammenfassung     

Resection des Kniegelenks mit späterem Bruch an der Resectionsstelle

Ohne Zusammenfassung     

Eine operative Nearthrose des Kniegelenks nach zweijähriger funktioneller Beanspruchung

Ohne Zusammenfassung Mit 8 Abbildungen im Text.     

Das primäre Carcinom des Wurmfortsatzes

Ohne Zusammenfassung (Mit 1 Abbildung.)     

Pigmentierte Läsionen der Mundschleimhaut

Primary malignant melanoma of the oral cavity is an exceedingly rare event. The most frequently affected sites are the palate and the gingiva of the maxilla. The lack of symptoms often causes diagnostic delay. We report on a 78-year-old man with a history of melanotic pigmentation on the hard palate for many years. Due to tumor growth an incisional biopsy was performed which yielded the diagnosis of mucosal melanoma arising in a preexisting blue nevus. Mucosal melanomas of the upper airway are not classified as other melanomas but with their own TNM classification due to their special behavior. Although the classification by Clark cannot be applied, thickness and size of the tumor are known prognostic indicators.     

Ligament bracing – Augmentierte Primärnaht bei multiligamentären Verletzungen des Kniegelenks

Objective

Reconstruction of knee stability by primary ligament sutures and additional augmentation after knee dislocation.

Indications

Acute knee dislocation Schenck type III and IV. Operative treatment should be performed within 7 days after injury.

Contraindications

Chronic instability after knee dislocation, refixable bony avulsions, critical soft tissue, infection, lack of compliance.

Surgical technique

Supine position with electric leg holder. Short arthroscopic assessment of concomitant injuries. Schenck type III medial injuries and Schenck IV injuries: anteromedial parapatellar arthrotomy. Injuries type Schenck III lateral: anteromedian arthrotomy. Armoring of ligament stumps for transosseus sutures. Placement of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) drill tunnels. Extracortical diversion of the suture armorings and insertion of augmentation systems. Fixation of the PCL augmentation in 70–90° flexion. Fixation of the ACL augmentation in 20–30° flexion. Knotting of the transosseus ligament sutures. If necessary (postero-)lateral and/or medial stabilization.

Postoperative management

Limited weight bearing with 20 kg for 6 weeks. Stabilizing brace (e.g., Hypex-Lite®, Albrecht) generally for 12 weeks. Mobilization under tension of the quadriceps muscle for 6 weeks.

Results

In total, 20 patients have been treated using the principle of “ligament bracing”. So far 8 patients (aged 18–60 years, median 33 years) have been assessed with a follow-up of 10–15 months (median 12 months) postoperatively. In all, 6 patients showed stable knees with good results. Recurrent instability of the ACL was observed in 2 patients; the collateral ligaments and PCL were stable. For the evaluation the following scores were used: IKDC score, Tegner score, and Lysholm score. To objectify the data, stress radiography and physical examination were performed. Using the operative technique mentioned above, no complications occurred. During follow-up 2 patients reported a deficiency of flexion.     

Endovaskuläre Therapie des symptomatischen Aortenulkus

Introduction

A cause for acute aortic syndrome is penetrating atherosclerotic ulcer (PAU). Due to its limited localization and its high comorbidity, stent grafting is a promising treatment.

Methods

Between May 2001 and March 2003, five patients with symptomatic PAU were treated with stent grafts. Acute thoracic pain was found in every patient. CT scan showed ruptured sclerotic plaques (n=5) as the “entry” for aortic intramural hematoma (n=5 patients), pleural effusion (n=3), mediastinal bleeding (n=2), and hemothorax (n=1).

Results

Primary technical and clinical success was achieved in all five patients. In the follow-up period (mean: 15.4 months, range: 6–28 months) angio-CT revealed in all cases complete regression of the intramural hematoma, no aortic leak, and no expansion of the aorta at the former site of rupture.

Summary

Symptomatic PAU is a potentially fatal lesion. In relation to asymptomatic PAU or classic dissection, its spontaneous outcome is considerably bad. Looking at the low morbidity and mortality of the method, endovascular stent grafting could expand the scope of options for treating this disease.     

Bikondyläre Fraktur des distalen Humerus

The treatment of bicondyle joint fractures involves the anatomical reconstruction of the joint condyles and transcondylar fixation of the joint block. Thus, metaphyseal defects can be filled with autogenous spongiosa. Finally, the joint block is repositioned on the humoral shaft. In order to obtain an exercise stable retention, a bicondylar plate osteosynthesis is carried out.     

Komplexe osteoligamentäre Verletzungen des Ellenbogens

BACKGROUND: Hinged external fixation is a recognized method to treat instabilities after complex dislocations and fracture-dislocations of the elbow. The hinged external fixator allows stabilization of the elbow while preserving flexion and extension. METHODS: Eighteen patients with an average age of 47 years (range 35-67) were treated with a hinged external fixator between April 2001 and March 2006 for 6 weeks. In 11 patients an internal fixation had to be done; six were treated initially with an AO fixator. After 8 days (3-14), we changed to a hinged external fixator. RESULTS: At 39 months (12-71) of follow-up, all 18 elbows were stable. One stress-fracture of the ulna after pin removel occurred. The mean Mayo Elbow Performance Index (MEPI) was 78 points. Five (28%) patients had an excellent result, six (33%) a good result and seven (39%) a fair result. The average DASH score (disabilities of the arm, shoulder and hand) was 18 points, which indicates a discrete impairment. CONCLUSION: The treatment outcome of complex instabilities treated with a hinged external fixator using our technique is comparable to outcomes from other studies.     

Ergebnisse der SaluCartilage-Implantation bei viertgradigen Knorpelschäden im Bereich des Kniegelenks

AIM OF STUDY: This prospective report presents SaluCartilage hydrogel implants, an alternative therapy option in the treatment of chondral defects. METHODS: For the prospective study between October 2002 and July 2003, 18 patients suffering from stage IV chondral defects received 49 hydrogel implants and were subsequently examined by means of clinical, radiological, and magnetic resonance imaging assessment. The knee function was classified using the McDermott score. RESULTS: The average McDermott score was improved to 75 points (p<0.05) after 3 months postoperatively and to 80 points (p<0.05) 6 months postoperatively, but after 12 months it decreased to 69 points. After 3 and 6 months, the MRI showed in all patients that there was fluid around the hydrogel implants without dislocation. After 12 months postoperatively the hydrogel implants had been destroyed in two patients. CONCLUSION: The short-term results showed subjective and objective improvement of the medical conditions probably because of the placeholder function. This alternative should be critically discussed because of the inadequate connection to the bone with risk of dislocation.