Zeitschrift fur Orthopadie und ihre Grenzgebiete最新文献

In order to treat patients with postoperative acute pain effectively, we have developed a standardised algorithm for analgesia. This process includes three levels and the appropriate supply of medication. The therapy level is defined based on the scale of the operation. Accordingly, the prescription and handling of the pain medication is simplified for the attending physician and nurses. The pain level has to be measured by the nursing staff sing a visual analogue scale (VAS). Thus, the efficiency of the analgesics will be continuously evaluated and controlled. The standardised supply medication can be applied in those cases with pain levels > or = 4 (VAS). It is possible to up- or down-grade the level within the system depending on the actual pain experienced by the patient. With this structured pain therapy algorithm we now have a guideline for the consistent postoperative analgesic treatment of patients.

Aim: Based on hypothesis that calcific tendonitis of the supraspinatus tendon (CTSSP) could be associated with glenohumeral imbalance, glenohumeral stress distribution was analyzed.

Methods: 26 patient shoulders with CTSSP, unsuccessfully treated by non-operative measures, were examined. A group of 26 macroscopically normal shoulder specimens served as controls. Analysis of glenohumeral stress distribution was indirect evaluating glenoid subchondral bone mineralization by computed tomography osteoabsorptiometry. Density distribution of glenoid subchondral bone mineralization and the position of the two most frequent density maxima were analyzed.

Results: Patterns of subchondral mineralization and position of the anterior density maximum were significantly different between both groups. CTSSP mostly presented with a monocentric, anteriorly increased mineralization indicative for a regional increase of stress. The inferior shift of the anterior density maximum demonstrates a parallel shift of glenohumeral stress distribution.

Conclusion: Mineralization patterns indicate that glenohumeral stress distribution is not physiologic in CTSSP. Moreover, it is comparable with glenohumeral stress distribution as observed in atraumatic antero-inferior glenohumeral instability. Relevance of this observation should be proven for etiology of CTSSP.

Aim: Osteoarthritis (OA) is characterized by an irreversible destruction of articular cartilage. This is associated with a multiplicity of factors, causing an increased catabolic metabolism in cartilage. However, the prevalence of the OA is very variable in different joints. Therefore , we conducted a comparative analysis of chondrocytes derived from knee and hip joints with respect to their expression of inflammatory factors, such as IL-1beta, IL-1beta-receptorantagonist, iNOS, components of cartilage matrix (collagen I, II, and VI) as well as vimentin.

Methods: Different cytokines and proteins were detected by immune-histochemical staining of cartilage samples ex vivo. Further, chondrocytes were isolated from OA knee and hip joints, expanded in vitro and gene expression patterns were investigated by quantitative RT-PCR.

Results: Chondrocytes from knee and hip joints of OA patients express collagenes I, II and VI, IL-1beta and IL-1beta-RA, iNOS as well as Vimentin. A significant difference in gene expression patterns was not found in chondrocytes from the hip joints versus the knee joint ex vivo or in primary culture cells in vitro. However, in vitro the expression of type I collagen exceeded the expression of type II collagen. The IL-1beta-expression was high ex vivo, remained low during primary culture but was significantly elevated after primary culture in hip chondrocytes.

Conclusion: Osteoarthritic gene expression patterns in cells derived from hip or knee joints ex vivo and in primary culture were not significantly different. We conclude that the rather frequent occurrence of OA in these joints in comparison to the ankle joint may be associated with a close physiological relation of cells in these joints. However, future studies which will include ankle cartilage must be investigated in further detail.

Aim: The aim of this study was to determine the outcome after total hip replacement (THR) with the WOMAC and the SF-36 as well as to identify the most responsive items and to elucidate the reasons for increased pain postoperatively.

Methods: 73 patients filled out the questionnaires preoperatively and 3, 6, 12, 24 months postoperatively. All mean subscales and the responsiveness for each question were calculated. The patients with increased pain postoperatively were reassessed.

Results: All WOMAC subscales and six of the eight SF-36 subscales showed significant improvements after THR (p < 0.05). The most responsive items were the pain and disability questions (SRM, ES > 1.5). Two patients with a higher pain score postoperatively had associated symptomatic degenerative lumbar spinal disease.

Conclusions: The WOMAC and the SF-36 are valid measures of the outcomes of THR in their German translations and document the good results after THR. Two years after THR the patients reach the same health state compared to an age matched control group in the population. The WOMAC contains more questions of higher responsiveness than the SF-36. A higher pain score postoperatively may be caused by degenerative disease of the lumbar spine.

Aim: Computer assisted navigation of the acetabular cup in THR requires reliable digitalisation of bony landmarks defining the frontal pelvic plane by user driven palpation. According to the system recommendations the subcutaneous fat should be held aside during epicutaneous digitalization. To improve intraoperative practicability this is often neglected in the symphysis area. In these cases the fat is just compressed and not pushed aside.

Method: In this study soft tissue thickness was assessed by ultrasound and pelvic geometry was measured in 72 patients to quantify potential misinterpretation of cup anteversion triggered by the simplified palpation. As reference we employed data of the same patients that had been acquired by recommended palpation.

Results: Anteversion misinterpretation averaged at 8.2 degrees with extremes from 2 to 24 degrees. There were no correlations between soft tissue thickness or misinterpretation and body weight, height and pelvic size. Anteversion misinterpretation was highly significant worse compared to the reference data.

Conclusion: In 31 % of the patients the anteversion misinterpretation of a navigation system would have been wrong by over 10 degrees and in 81 % over 5 degrees . Therefore the simplified palpation should not be utilized. For epicutaneous digitalization of the bony landmarks it is mandatory to push the subcutaneous fat aside.

Aim: Experiences in operation of scoliosis in cerebral palsy are very different. Therefore a therapeutic regiment does not exist. In this study we want to report our experiences.

Methods: This retrospective-clinical study (1986-2003) includes 46 patients with cerebral palsy who had been operated for scoliosis. The data focus in particular on the therapeutic strategies and its success and complications. Publications from 1946 to 2003 were reviewed and served for comparison.

Results: 28 female and 18 men during one period by median 3.4 years were after-observed. The post office-operationally reached correction of the curvature of all operation procedures was appropriate for median between 51 and 68 % depending upon localization of the curvature. In the last re-examination median a correction loss of 3-25 % existed. A fusion to S1 corrected a thoraco-lumbale or lumbale scoliosis significantly better than a fusion to L5. The posterior and the combined posterior-anterior operation procedure showed comparable correction results. The total complication rate was with 35 %.

Conclusions: Due to good correction successes and smaller complication rate we favor a posterior-anterior operation procedure. A fusion to S1 is indicated with thoraco-lumbale and lumbale fusion. Altogether complication rate was reduced in patients with scoliosis and cerebral palsy after operation at the spinal column in the last years.

Aim: In this prospective study we present a novel technique of matrix-based chondrocyte transplantation for the treatment of focal cartilage defects.

Method: 22 patients with chondral or osteochondral femoral defects were treated with 3D-collagen type-I gel seeded with autologous chondrocytes (CaReS). Overall handling of this novel method is described, and results after 2 years follow-up with regard to the ICRS-score are presented.

Results: 14 patients were treated because of a focal chondral lesion, in 8 cases subchondral bone had to be reestablished. The average defect size was 6 cm(2). In all cases cell-seeded matrix samples could be fixed with fibrin glue without any problems. The average surgery time was 69 min, length of the surgical approach was 8.2 cm. No surgery-specific problems had to be observed. A significant improvement in IKDC-score, functional score and overall rating after 3 or 6 months up to 2 years follow-up was detected. After 2 years post-OP 13 Patients were evaluated and matrix-based defect treatment by CaReS was rated good to excellent by 84.6 % of the patients.

Conclusion: Defect treatment with cell-seeded 3D-collagen gel is easy to handle with a good clinical outcome after 2 years follow-up. Further investigations with higher patient number, longer follow-up time and histological and biomechanical sample analysis are needed in order to establish this method as an improvement of conventional ACT.

Aim: Classification of pectoralis major muscle injuries and results of operative treatment in the Sportsklinik Stuttgart between 1998 and 2004 are analysed.

Methods: 10 sportsmen (2 judo, 8 body-building; 9 male, 1 female) with pectoralis major ruptures received operative treatment in this time period. After clinical examination we used ultrasound, in some cases MRI, for further diagnostics. The follow-up (1-5 years) included a clinical examination, ultrasound, sports level, cosmetics and an isokinetic strength assessment.

Results: In 4 cases we found a tear of the musculotendinous junction, 4 cases showed a tear at the humeral insertion and 2 other cases had tears of the muscle belly. There was no sports-specific injury. 6 ruptures underwent immediate (1 week) operative therapy and 4 ruptures had delayed (6 weeks to 4 years) repair of the injury. In 9 cases an anatomic repair was possible, in 1 delayed rupture only an extra-anatomic repair was possible. We had 1 complication with a post-operative wound infection. Based on injury localisation and operative treatment, we classified 3 types of pectoralis major ruptures. The follow-up evaluation showed in 7 cases very good and good results, 2 delayed cases still had a cosmetic defect with reduction of strength.

Conclusion: From our results on pectoralis major muscle injuries there are 3 types of rupture: type 1: rupture at humeral insertion, type 2: rupture of musculotendinous junction, type 3: rupture of muscle belly. This classification is essential for planning the operative technique and the incision. We recommend, after classification of the rupture, primary operative reconstruction of the pectoralis major muscle.

Aim: Here we present the clinical symptomatology of and therapy for necrotizing fasciitis.

Method: The case of a 35-year-old female patient with sustaining fractures of the 5 (th) and 10 (th) thoracic vertebrae and a pulmonary contusion and without any skin lesions is presented.

Results: Conventional x-rays and computed tomography revealed stable spine fractures not necessitating surgical intervention. Fifteen days after the accident the patient developed septic conditions. An interdisciplinary search (surgical, neurological, urological, internal medicine) for the septic focus first remained negative. After demarcation of necrotic skin areas at the upper left arm, bilateral necrotizing fasciitis was diagnosed at both thighs and at the lower left leg, necessitating continuous optimisation of the therapeutic strategy.

Conclusion: Local aggressive surgical therapy in combination with systemic antibiotic administration is the therapy of choice in treatment of the necrotizing fasciitis. It should be performed according to the principle "life before limb". In the presented case the patient recovered and good functional results could be achieved.