Zeitschrift fur Orthopadie und ihre Grenzgebiete最新文献

Aim: In navigated knee arthroplasty the hip centre is determined by rotary motion of the femur (pivoting). The accuracy of this functional hip centre determination in vivo is unclear. In the following paper the accuracy of pivoting in the determination of the hip centre was examined.

Methods: Navigated (TC-PLUS, Solution, PLUS Orthopedics) total knee arthroplasty (PI Galileo, PLUS Orthopedics) was performed on 25 patients with primary arthritis of the knee joint. The position of the femoral component and the hip centre were postoperatively determined by computer tomography. Through comparison with the intraoperatively documented data, the deviation of the pivoted from the true hip centre in the frontal and sagittal planes was calculated. The degree of arthritis of the hip was determined on plain radiographs according to Kellgren.

Results: The mean deviation was determined to 1.0 +/- 0.7 degrees in the frontal plane and 2.5 +/- 1.6 degrees in the sagittal plane (p = 0.002). This corresponds to a mean overall deviation of 20 +/- 10 mm. The data were continuously, non-parametrically distributed without any outliers. A great range of motion (ROM) in the frontal as well as sagittal planes during pivoting resulted in a less accurate determination of the hip centre. There was no correlation to the degree of arthritis of the hip.

Conclusion: The results indicate a recommendable ROM during pivoting for maximal accuracy of hip centre determination of 20 to 30 degrees in the sagittal plane and 30 to 40 degrees in the frontal plane. Arthritis of the hip is not a contraindication for functional determination of the hip centre.

Aim: Total hip arthroplasty (THA) is a standard procedure in orthopaedic surgery. Planar radiography of the implant is routinely performed to ensure that the operation has achieved the desired result. This study investigates the influence of varying the X-ray beam on the analysis of the radiograph.

Method: Twenty-three patients were analysed after implantation of a total hip replacement. Besides a CT scan of the pelvis, symphysis- and hip-centred radiographs were available. The cup anteversion was calculated using two published algorithms. The CT-based data were the gold standard.

Results: Our study revealed a significant major error in the analysis of the symphysis-centred radiographs when compared with the hip-centered radiographs. Widmer's algorithm showed a significant superiority over Pradhan's formula.

Conclusion: The best approximation of the anteversion angle was achieved using Widmer's technique by centering the X-ray beam onto the hip.

Aim: The morbidity of fixator-assisted distraction osteogenesis should be reduced by intramedullary lengthening devices. The ISKD (intramedullary skeletal kinetic distractor) is a new, fully implantable mechanical lengthening nail. In a prospective cohort trial the possibilities and limitations of the device used on femur and tibia are examined.

Methods: 22 patients with a mean age of 25 (range: 16-46) years were treated with an ISKD for femoral (n = 16) and tibial (n = 6) lengthening. The average leg length discrepancy was 48 (range: 25-80) mm. The follow-up was 21 (range: 7-37) months. Clinical and radiological results and complications were evaluated.

Results: The results of femoral and tibial applications of the ISKD are different. At the tibia, in three patients a pseudarthrosis occurred and slow callus formation was observed twice. An equinus contracture became evident in 2 patients. At the femur, in one case the lengthening was not accomplished with the device. Five patients were manipulated under anaesthesia at least once to achieve the aim of distraction. Three of these patients received retrograde implantation of the ISKD. An infection or interlocking screw failure was not observed either at the femur or the tibia.

Conclusion: The ISKD reduces fixator-associated problems but incorporates its own difficulties which are mainly based on the guidance of the device. Careful patient advice in monitoring the lengthening process is mandatory. At the femur 8 cm of lengthening can be achieved but the nail tends to "block". Proper reaming and osteotomy techniques are important. A lengthening of more than 1 mm/day is recommended to prevent early consolidation. At the tibia weak callus formation and soft tissue contractures occur, therefore not more than 4 cm lengthening should be planned, the distraction speed has to be reduced noticeable below 1 mm/day and the initial immobilisation should be for more than a week.

Aim: This study was performed to evaluate the influence of the postoperative activity level on tibial bone tunnel enlargement following anterior cruciate ligament reconstruction using a mid-third patellar tendon autograft.

Methods: A clinical and radiological assessment was performed on 50 patients (21 male, 29 female, mean age 32 years, range 18 to 57 years) following ACL reconstruction using a patellar tendon autograft. The average follow-up examination was performed 18 (12 to 30) months after the operation.

Results: 33 patients (66 %) developed a tibial bone tunnel enlargement > 1 mm. We found a positive correlation (+ 0.59) of the grade of activity and the muscle status (+ 0.56) to the tibial bone tunnel enlargement. Patients with a major tibial bone tunnel enlargement performed at a higher (p < 0.05) postoperative activity grade (5.2 versus 4.1 in the Tegner grading), rated higher in the Lysholm (88 versus 77 points) and IKDC scores (p < 0.05) and reported a better subjective functional outcome (p < 0.05). There was no significant correlation of the results of the knee stability tests and the age of the patients to the grade of tibial bone tunnel enlargement.

Conclusions: In ACL reconstruction using a patellar tendon autograft we recommend early rehabilitation as the concomitant tibial bone tunnel enlargement does not significantly influence the clinical outcome or knee stability.

Aim: The conservative and operative treatments of plantar fasciitis tend to be tedious. Unsatisfactory results are common in chronic cases. This study was performed in order to test the hypothesis that the analgesic and anti-inflammatory effect of a single injection of Botulinum toxin A (BoNT A) induces a significant reduction of symptoms.

Method: 25 patients were included and followed-up for 14 weeks. Prior to injection, all of them had undergone at least two trials of conservative treatment. To determine the optimal treatment dose, 6 patients were injected subfascially with 100 units BoNT A (Dysport), another 6 with 200 units BoNT A. As result of this pre-trial, another 13 patients were treated with the higher dose. The patients documented maximum pain and continuous pain on a visual analogue scale. The strength of the lower leg and foot muscles was clinically assessed.

Results: A significant reduction of maximum and continuous pain was seen 2 weeks after injection in the group of 19 patients treated with 200 units BoNT A and persisted until the end of the follow-up. Adverse effects such as weakness of the muscles or systemic reactions have not been observed.

Conclusion: This pilot study shows the efficacy of a single application of 200 units BoNT A as a treatment option for chronic plantar fasciitis.

In the treatment of circumscribed osteochondral lesions of the knee and the ankle joint autologous osteochondral transplantation (AOT) has been established as one of the possible operative therapies. However, there is less experience with the use of AOT on other joints (shoulder, elbow). The care of osteochondral defects of the hip joint with autologous osteochondral transplantation can still be regarded as an absolute rarity. Facing a focal osteochondral necrosis in a young female adult after LCP disease in childhood, we report about an autologous osteochondral transplantation at the femoral head using the diamond bone cutting system.

Osteochondritis dissecans is a disorder with a prevalence of 0.01 to 0.06 %. Men between 16 and 36 years of age are most commonly affected by it. In the western hemisphere, the knee is affected by this progressive disorder in 75 % of the cases, specifically the medial femoral condyle (70 - 80 %). The etiology is uncertain, although genetic defects, micro-trauma, ossification disorders and ischemia have been implicated. Pathogenetically, Osteochondritis dissecans is classified in four stages, whereas in stage one, there is merely a subchondrial edema. Without therapy this could lead to stage 4, with a free osteochondral joint fragment. Treatment is analogous with the stage of the disorder. Whereas conservative treatment may yield full recovery during stage 1, starting in stage 2, invasive treatment should be considered. When the cartilage surface remains intact retrograde procedures are indicated. If the cartilage is injured anterograde therapies, like the chondral or osteochondral transplantation, should be used.

Purpose: The aim of this study was the development of a simple procedure to calculate functional kinetic parameters from the plantar pressure distribution measurement which is used in many orthopaedic practices and clinics as a standard measurement device. The special purpose is the comparison of functional parameters between datasets taken before and after a surgical operation, for example the correction of a hallux valgus.

Method: In the gait laboratory, pressure distribution measurements were recorded from healthy test subjects and patients with different foot diseases. The test subjects walked barefoot over the measurement plate which is integrated in a gangway. The device records a "movie" of the pressure distribution in the unrolling of the foot. It takes 72 pressure distribution pictures per second. By integrating the pressure over all segmental areas, i. e., pressure distribution picture for pressure distribution picture, the temporal progress of the total ground force can be calculated. By integration of the pressure only over a certain part of the foot, the ground force on that certain anatomic structure can be calculated, for example, the ground reaction force upon then hallux. By integration of the pressure over the same segmental areas considering their lever distance to the axes of the ankle joint, the external joint moment can be calculated. For this, the musculature of the lower leg must generate an internal moment, which exactly compensates the external moment.

Results: In the case of a correction of a hallux valgus, the percentage of the total external moment with regard to the upper ankle joint can be measured which is taken on by the hallux and metatarsal I. This allows us to verify a functional improvement through the operative treatment. With patients after one-sided injuries of the foot and ankle joints, the functional success of a treatment can be quantified by means of a comparison of sides, for example, after a fracture of the calcaneus.

Conclusion: The determination of muscular ankle joint moments from the pressure distribution measurement improves the objectivity when reviewing the functional success of a therapy in different orthopaedic or surgical interventions at the foot and ankle joint.

Aim: On the way to the unification of the European Union (EU), Germany has passed a new medical professional education system at the 106 (th) German medical board in Cologne in 2003. The medical board has established a new residency programme for the specialty of orthopaedic surgery, which was previously separated into orthopaedic and trauma surgery. An exchange of orthopaedic surgeons within the EU is therefore less complicated. For an exchange outside the EU, an international comparison especially with the USA is warranted.

Method: We analysed and compared the German "Assistenzarzt System" with the residency programme of the USA regarding the specialty of orthopaedic surgery and further sub-specialisation programmes.

Results: After evaluation of both systems, a high conformity in the basic training for orthopaedic surgery was demonstrated. However, there is a difference between the two systems regarding specialisation after residency training with the German "Oberarzt" on the one side and the American fellow system on the other side.

Conclusion: This study demonstrates that the German orthopaedic training matches well with the American residency programs. There is potential for acknowledgement of the German title "Orthopaedic surgeon" in the USA. In some states, such as Pennsylvania, European medical specialists are given institutionally restricted work permission for limited periods of time. It remains, however, questionable if there is a general political intent for the USA to acknowledge German or European residency programs.