Konservative Therapie der Arthrose

Therapy of osteoarthritis requires a combination of pharmacological and non-pharmacological modalities. Management should be individualized according to the constitutional features of the patient, comorbidities, disease status, treatment availability and costs. Paracetamol is the analgesic of choice. Beside NSAIDs and intra-articular steroids, SYSADOA have symptomatic effects and may modify structure. Patient education, exercises, orthopaedic devices and physical therapy are indicated as supportive therapy. Alternative therapy modalities should be discussed with the patient using the available evidence and the cost/benefit ratio.     

Therapie der isolierten Femoropatellararthrose

Background

Isolated osteoarthritis of the patellofemoral joint occurs in 9% of patients over 40?years of age and women are more often affected. Options of treatment are varied and not sufficiently justified by the literature.

Materials and methods

A literature research with keywords in the field of femoropatellar osteoarthritis was carried out in the relevant databases. Studies were categorized into different treatment options and analyzed.

Results

There are almost no level I studies comparing the different treatment options. In the literature there are indications that relief of pain can be achieved by conservative treatment, arthroscopic surgery, cartilage conserving surgery and isolated arthroplasty.

Conclusion

In view of the fact that there are almost no prospective randomized controlled trials, none of the options for treatment can be highly recommended. There is still no gold standard for the treatment of isolated patellofemoral osteoarthritis.     

Therapie der posttraumatischen Arthrose am Sprunggelenk

When assessing the causality of rotator cuff tears, the focus was previously on analysis of the accident with the core message that certain accident sequences are “suitable” to cause an injury to rotator cuffs, while others are not. Despite a great deal of scientific knowledge about the development of diseases of rotator cuff tendons, there are no new results about the conditions which can lead to isolated or combined injury of a healthy tendon of the shoulder. In view of fundamental verdicts of the Federal Social Court from 2005, 2006 and 2012 the medical assessment in the field of statutory accident insurance is primarily based on the actual and individual medical findings. This presupposes that the expert opinion is based on current scientific knowledge on the analysis of facts regarding medical findings. Only then can findings be given a value for answering medical and legal questions. This article provides the legal basis for the assessment and the current medical knowledge on damage to rotator cuffs of the shoulder.     

Medikamentöse Therapie der Arthrose

Osteoarthritis is one of the most common and economically important chronic diseases amongst adults, especially those of a senior age. There now exists a range of effective medications, which either alone or in combination can alleviate the symptoms of the disease and improve the quality of life. Because these medications are not always sufficiently effective and must sometimes be interrupted due to side effects, a large arsenal of active agents is necessary. Alleviation of pain and inhibition of inflammation are the primary goals of pharmacotherapy, whereby the objective is to return an active or transiently painful, decompensated osteoarthritis to a latent (silent, pain-free) condition. This therapeutic goal can almost always be accomplished by using analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), or intraarticular injection of glucocorticoids. The main problem in administering NSAIDs is their gastrointestinal toxicity,for which a prophylactic medication (e.g., simultaneous application of misoprostol or switching to a COX-2 selective NSAID) should be considered especially with risk groups.The newly developed COX-2 selective NSAIDs represent a true enrichment of our therapeutic options. The spectrum of indications for COX-2 selective NSAIDs should in the future correspond to that of older NSAID preparations, providing that no as yet unknown and serious side effects come to light from their use. Pharmacological results published until now confirm that a clinically relevant analgesic and/or anti-inflammatory effect is associated with the use of SYSA-DOAs (symptomatic slow acting drugs in osteoarthritis). However, no clinical studies exist which can positively confirm prevention of morphologically recognizable cartilage defects in man, or a slowing down or reversal of any progressively developing joint cartilage destruction by any individual medication. Neither the benefits, risks, pharmaceutical quality, nor composition of Orthokin are known, and for this reason its use can not be recommended. Pharmacotherapy should only be considered as one of the three pillars of a long-term,stage-adjusted, and individually customized therapy, the other two of which are represented by nonpharmacological measures and surgical treatment.     

Therapie der posttraumatischen Arthrose am Sprunggelenk

Trauma und Berufskrankheit - Trotz der nun mehrere Jahrzehnte umfassenden Erfahrung mit der endoprothetischen Versorgung des Sprunggelenks ließ sich die Überlegenheit der Prothese bisher...     

Operative Therapie der Klavikulapseudarthrose

Objective

The objective in treating clavicular non-union is an anatomic reconstruction of the clavicle with an iliac crest bone graft and anatomic locking compression plates.

Indications

Non-union or bony defects of the clavicle larger than 1.5 cm.

Contraindications

Any suspicion of infection, elevated risk of transplant necrosis or recurrent non-union due to concomitant disease, medication, cigarette smoking (>10 cig./d), poor therapeutic compliance regarding specific postoperative management and poor physical status.

Surgical technique

Patient in beach chair position with a flexible affected arm. An longitudinal skin incision is made below the clavicle with subsequent incision through the clavipectoral fascia and the periosteum, complex multidimensional osteotomy of the clavicle with medial and lateral axial correction of the pseudarthrosis up to vital bone, harvesting of a tricortical iliac crest bone graft with the size measured in preoperative computed tomography (CT) according to the length of the healthy contralateral clavicle. Final shaping of the iliac crest bone graft regarding the future clavicular position, positioning of the anatomic plate (LCP superior anterior clavicle plate with or without lateral extension, Depuy Synthes, Umkirch, Germany) and drilling and screw insertion under radiological guidance. If necessary additional attachment of the iliac crest bone graft with suture cerclage (FiberWire, Arthrex, Karlsfeld, Germany) or screw should be carried out. A final radiological examination and hemostasis of the iliac crest with a Lyostypt collagen hemostatic fleece and the clavicle. Drains might be needed and wound closure layer by layer with sutures.

Postoperative management

Arm sling protection for 6 weeks with physiotherapeutic exercises and increased range of motion every 2 weeks and unrestricted range of motion from week 7 onwards. Full weight bearing is not allowed before week 12 and X-ray examinations to confirm bone healing should be done 3, 6, 12 and 24 weeks postoperatively. Implant removal at an earliest time point of 2 years can be performed when full osseous integration of the graft is radiologically confirmed.

Results

At our department 10 consecutive patients suffering from clavicular non-union have been treated with this technique with a minimum follow-up of 1 year. All patients showed anatomic restoration of the radiologically confirmed healed clavicle with very good patient satisfaction.     

Operative Therapie der Narbenhernie

Secondary ventral hernia or incisional hernia occurs in at least 20?% of cases after laparotomy and most patients are symptomatic. The pathogenesis of incisional hernia is believed to be based on a defect in collagen synthesis indicating the necessity of covering the whole original incision with a non-resorbable, macroporous mesh. These meshes can be used on top of the fascia (onlay), in a retromuscular fashion (sublay) or intraperitoneally (IPOM). The IPOM technique is the preferred procedure during laparoscopic repair of ventral hernias. The clear advantage of the laparoscopic approach is the dramatically reduced rate of wound complications, especially infections. Major defects of the abdominal wall require plastic reconstruction with the component separation technique in both anterior and posterior approaches. The component separation technique must be combined with retromuscular mesh augmentation enabling a recurrence rate of less than 10 % and an acceptable morbidity to be achieved.     

Zur operativen Therapie der Chondropathia patellae und der femoro-patellaren Arthrose

The operating procedure according to Bandi with reducing the pressure in the femoro-patellar joint has proved its value in the treatment of the chondropathy of the patella and the isolated arthrosis of this joint. This is demonstrated by the results of 62 patients with an average follow-up of 2 1/2 years. In 15 cases the results were not satisfying. On the basis of these cases the proper indication and the skilled operative technic are outlined.     

Operative Therapie der distalen Radiusfraktur

Distal dislocated radius fractures are now mostly treated surgically. Closed reduction and internal fixation with Kirschner wires are increasingly giving way to internal fixation with screws or fixed-angle plates and to the use of the fixateur externe. For fractures with concomitant severe soft tissue injury treatment with a bridging external fixator and adequate soft tissue management are first necessary. External fixation is needed in addition, however, once soft tissue repair has been achieved by means of internal fixation with screws or K-wires, and the external fixator should remain in place until the fracture has started to heal. If possible preference should be given to the use of nonbridging fixators. Conservative treatment can now no longer be justified except for stable and nondislocated fractures. Arthroscopy/assisted reconstruction of the carpal articular surface is the subject of some controversy and is not yet accepted as a standard procedure.     

Operative Therapie der benignen Prostatahyperplasie

Open simple prostatectomy is not only the oldest but also the most effective treatment option for benign prostatic obstruction. Laser enucleation has been established as a transurethral minimally invasive alternative especially but not exclusively for large volume prostates. To date two laser systems, holmium:YAG laser enucleation of the prostate (HoLEP) and thulium:YAG laser vapoenucleation of the prostate (ThuVEP) have been established. Both treatment modalities have similarities in terms of wavelength and surgical technique but differ in the type of energy released (pulsed versus continuous wave). The HoLEP and ThuVEP procedures lead to a significant improvement in symptoms, quality of life, urinary flow and post-void residual urine. Surgery-related morbidity, especially bleeding complications is significantly reduced with laser enucleation. For HoLEP the durability of the results was shown for a follow-up interval of up to 10 years while for ThuVEP the follow-up interval reached 18 months due to the shorter time since clinical implementation of this method.     

Operative Therapie der erektilen Dysfunktion

Zusammenfassung Mit dieser Arbeit soll im Zeitalter der Dominanz der oralen Pharmakotherapie bei der Behandlung erektiler Funktionsstörungen eine kritische Übersicht über den aktuellen Stellenwert der operativen Therapie der erektilen Dysfunktion gegeben werden. Als mögliche Therapieoptionen werden die penile Venenchirurgie, die arterielle Revaskularisationschirurgie und die penile Prothesenchirurgie beurteilt.Die Venenchirurgie hat heute aufgrund der Wirksamkeit der oralen und intrakavernösen Therapeutika, bedingt durch den Pathomechanismus der kavernovenösen Insuffizienz und durch die publizierten enttäuschenden Langzeitergebnisse ihren Stellenwert gänzlich verloren. Ähnlich verhält es sich mit den penilen Revaskularisationsoperationen, die heutzutage nur noch bei einem hochselektioniertem Patientengut ihre Berechtigung hat. Wichtige Selektionskriterien sind Patientenalter und Ausschluss eines Diabetes mellitus.Einzig die penile Prothesenchirurgie behauptet gegenüber der medikamentösen Therapie der Erektionsstörungen ihren Stellenwert. Hier überzeugen die guten Langzeitergebnisse, die hohe Patienten- und Partnerinnenzufriedenheit bzw. -akzeptanz und die funktionelle Haltbarkeit der in ihrer Mehrzahl dreiteilig, hydraulischen Implantate.

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Operative Therapie der bakteriellen Spondylodiszitis

Objective

Bacterial spondylodiscitis is a rare entity in spinal surgery. This study analyses the postoperative results of 53 patients, focusing on the history, the treatment, and the course of the disease.

Material and Methods

This retrospective study is based on the patients’ medical charts, including the laboratory and microbiological data.

Results

Twenty-nine patients suffered from different neurological deficits ranging from isolated mild hypaesthesia (n=1) to complete paraplegia (n=6). Depending on the affected area and the extension of the infection, surgery was done either as simple decompression in 16 cases or as decompression combined with a ventral or dorsoventral stabilization in 37 patients. Staphylococcus aureus was the most important triggering organism (n=23). After a median follow-up of 11.25 months, three patients had died, and 22 patients were still disabled because of persisting pain or neurological disturbances.

Conclusion

Because of persistent neurological deficits and possible lethal complications, spondylodiscitis remains a severe problem. Management comprises targeted antibiotic therapy and surgery in selected cases.     

125. Operative Therapie der Becken-Beinvenenthrombose

Zusammenfassung Die Spätresultate nach venöser Thrombektomie konnten durch zwei Maßnahmen wesentlich verbessert werden: 1. Intraoperative Lumenkontrolle durch Gefäßendoskopie, 2. Verhinderung der Reocclusion durch temporäre arteriovenöse Fistel (Vollmar 1968). Von 119 Patienten (Ulm 1970–83) zeigten 75% eine volle Lumenwiederherstellung (Phlebographie, mittlere Nachbeobachtung 8 Jahre), und sehr gute Funktion in 63% (Phlebodynamometrie). Mit der verbesserten operativen Technik ist die Erhaltung des Klappenapparates möglich. Die Letalität betrug 1,8% und die Incidenz klinisch relevanter Lungenarterienembolien lag unter 2%.