Fragestellung: Indikationen und Grenzen der Kniegelenkarthroskopie bei älteren Patienten werden aufgezeigt.

Fragestellung: Welche Ergebnisse lassen sich durch die Hüftarthroskopie in Abhängigkeit von Lebensalter, Arthrosegrad und intraoperativen Maßnahmen erzielen?

ACL replacement is a sufficient therapy for patients over 40 years of age with symptomatic knee instability following ACL rupture. The subjective and objective clinical outcome is comparable to the good results of ACL replacement in younger patients without any significant differences.

The results of our integrated conservative and operative concept of therapy to compensate insufficient shoulder muscles following brachial plexus palsy or other nerve damages are presented.To improve stability and function of the shoulder in case of deltoid and supraspinatus paralysis 19 patients (3 female; 16 male; average age 37 years, range 17 to 61 years) underwent a shoulder arthrodesis. In 69 patients (12 female; 57 male; average age 31 years, range 19 to 69 years) a trapezius transfer was performed. The indication for a rotation osteotomy of the humerus to improve loss of external rotation due to paralytic infraspinatus muscle was determined in 5 male patients (average age 30 years, range 15 to 42 years). Our results are based upon an average follow-up of 21 (6-70) months after shoulder fusion, 21 (2-68) months after trapezius transfer and 28 (3-62) months after rotation osteotomy of the humerus.The trapezius transfer resulted in increased function of abduction of 6.6 degrees to 35.9 degrees (10 degrees-90 degrees) and forward flexion of 12.6 degrees to 30.9 degrees (5 degrees-85 degrees). A more stable condition of multidirectional shoulder instability was experienced by 64 patients (92.8%), and 65 patients (94.2%) were subjectively satisfied with the outcome of the operation. The strength and extent of functional improvement was, on average, greater following shoulder arthrodesis: abduction 10.3 degrees to 57.4 degrees (20 degrees-80 degrees), forward flexion of 12.6 degrees to 57.1 degrees (20 degrees-105 degrees). 17 patients (89.5%) were subjectively satisfied with the outcome. Patients who had undergone external rotation osteotomy showed an average deficiency of external rotation of 30 degrees before operation. After osteotomy an improvement of 29 degrees to 3 degrees external rotation was achieved. All patients were satisfied with the increase of function.In patients with failed shoulder muscles, particularly after brachial plexus palsy, secondary operations according to the individual pattern of muscle failure result in an improvement of shoulder function and stability, as well as patients' satisfaction. Therefore, adequate conservative treatment before and after reconstructive operations is of great importance.

Studienziel: Methode: Ergebnisse: Schlussfolgerungen: Aim: Method: Results: Conclusions:

AIM:Total hip arthroplasty is a common operation but there are few data describing the learning curve of this operation. The aim of the presented study is to prove and describe the learning curve in total hip arthroplasty.METHOD:Between 1991 and 1993, 168 patients were included in this prospective study, operated by three surgeons having different experiences in operating total hip arthroplasty. Perioperative complications and postoperative X-rays were analysed. Patients were re-examined clinically and radiologically and by a questionnaire 5 years after operation.RESULTS:Radiological complications of the first 84 operated patients were statistically significantly higher than those of the following 84 patients, except for minimal bone fractures and leg lengthening. The learning curve of all surgeons was finished after 20 operations independent of their experience. Clinical results were not influenced by the learning curve at follow-up.CONCLUSIONS:Regardless of the experience of the surgeon, the learning curve in total hip arthroplasty is finished after about 20 operations for each surgeon. Intensive preoperative planning and exchange of experience inside and outside every clinic will shorten the length of the learning curve.

Introduction The Following article deals with the problem of peroneal eliciting. This means a eliciting of the two peroneal tendons against each other. It has to be differentiated from peroneal tendon dislocation or subluxation. Method: In three patients, a peroneal click was found without symptoms of dislocation of the tendons over the fibula. In these cases the indication for resection of the peroneal brevis tendon was seen, Results: Postoperatively no pain, swelling, and peroneal click were present. The partial loss of function of the peroneal brevis tendon seems to be negligable. Conclusion: In case of pain and swelling over the peroneal tendons, peroneal eliciting should be included in a differential diagnosis. Resection of the peroneal brevis tendon is an effective treatment in these cases.

Between April 1994 and April 1998, triceps to biceps transfers were done for three men with post-traumatic lesions of the brachial plexus and consequent loss of elbow flexion. Their mean age at the time of their accidents was 33 years (range 19-41) and at the time of muscle transfer 40 years (28-46), with a mean observation period of 21 months (12-31). The transfer resulted in active elbow flexion in all patients with a mean of 113 degrees (90 degrees-130 degrees) and a degree of strength 4-5 (contraction against resistance) with no remaining deficit of passive extension. Two patients were satisfied with the result of the operation and the other was content. No complications were noted. The transfer of the triceps muscle to the tendon of the biceps muscle on loss of elbow flexion resulted in adequate movement and degree of strength. The triceps to biceps transfer involves operating close to the elbow joint and minimal complications, is cosmetically satisfactory, and is particularly suitable for co-contraction of triceps and biceps.

Introduction: Is operative shortening of the achilles tendon an adequate therapy in cases of elongation following conservative treatment of achilles tendon rupture? Methods: From 11/89 to 12/97, 12 patients underwent achilles tendon shortening (9 mate, 3 female, average age 43 years). All patients had an elongated tendon following conservative treatment of achilles tendon rupture. We were able to examine 8 patients (67%) after the operation. The average follow-up period was 35 (7-103) months with an average span between the primary trauma and surgery of 22 (8-45) months. Results: Prior to surgery, all patients complained of weakness, gait disturbance and limitation of activity. At follow-up a subjective weakness of the plantar flexion remained in five and an objective weakness in all patients. We found a decrease of the isometric plantar flexion strength to 52% of the non-operated lower extremity while the maximum calf circumference was only 5% decreased. Only two patients reported of a gait disturbance and activity limitation whereas three patients were free of complaints, Using a modified Trillat score (1 967), 7 patients rated good or very good (1 poor). Conclusions: Achilles tendon shortening in case of elongation following conservative treatment of achilles tendon rupture helps to decrease gait disturbance and limitation of activity whereas a lack of the isometric plantar flexion strength persists. In our opinion an early decision for achilles tendon shortening might prevent this deficit.

"Trapezius-transfer for shoulder paralysis: 6 patients with brachial plexus injuries followed for 1 year." Acta Orthopaedica Scandinavica, 70(4), pp. 407–408

INTRODUCTION:We investigated the value of Magnetic Resonance Imaging compared to the clinical examination for meniscal lesions.MATERIAL AND METHODS:From 1991 to 1995 we did arthroscopic evaluation at 824 patients with the diagnose "meniscal lesion". 73 of them had an MRI-examination elsewhere before surgery.RESULTS:During arthroscopy we found 473 lesions of the medial meniscus and 160 of the lateral meniscus. The MRI-examination had an accuracy of 70% for the medial meniscus (sensitivity 79%, specificity 63%, positive predictive value 64%, negative predictive value 78%) and 78% for the lateral meniscus (sensitivity 50%, specificity 86%, positive predictive value 50%, negative predictive value 86%). The clinical examination had an accuracy of 73% for the medial meniscus (sensitivity 98%, specificity 39%, positive predictive value 69%, negative predictive value 88%) and 87% for the lateral meniscus (sensitivity 67%, specificity 92%, positive predictive value 65%, negative predictive value 93%).CONCLUSIONS:We conclude, that by an experienced examiner a meniscal lesion can be diagnosed adequately by clinical examination alone. The different radiologists who did the MRI examination in our study belong to different outward departments and used different apparatus with sometimes insufficient quality of the pictures. Therefore the sensitivity and specificity of the MRI for meniscal lesions is markedly lower than in other studies of departments where a close cooperation between the radiologist and the orthopedic surgeon is performed.

UNLABELLED:The results of an integrated concept of therapy are presented including a description of indications and the various operative procedures to compensate insufficient shoulder muscles following brachial plexus lesion.PATIENTS AND METHODS:To improve stability and function of the shoulder in case of deltoid and supraspinatus paralysis 12 patients (1 female; 11 male; average age 29.4 years, range 17 to 56 years) underwent a shoulder arthrodesis. In 54 patients (11 female; 43 male; average age 30.3 years, range 18 to 69 years) a trapezius transfer was performed. The indication for a rotation osteotomy of the humerus to improve loss of external rotation due to paralytic infraspinatus muscle was determined in 4 male patients (average age 29.8 years, range 16 to 42 years). Our results are based upon an average follow-up of 2.0 (0.5-7.5) years after shoulder fusion, 1.9 (0.5-4.5) years after trapezius transfer and 1.6 (0.5-3.5) years after rotation osteotomy of the humerus.RESULTS:The trapezius transfer resulted in increased function of abduction of 6.2 degrees to 37.1 degrees (5 degrees-80 degrees) and forward flexion of 15.1 degrees to 36.2 degrees (10 degrees-90 degrees). A more stable condition of multidirectional shoulder instability was experienced by 50 patients (92.6%) and 49 patients (90.7%) were subjectively satisfied with the outcome of the operation. The strength and extent of functional improvement was, on average, greater following shoulder arthrodesis: abduction of 9.6 degrees to 65 degrees (40 degrees-90), forward flexion of 15.4 degrees to 59.2 degrees (30 degrees-90 degrees). 10 patients (83.3%) were subjectively satisfied with the outcome. Patients who had undergone external rotation osteotomy showed an average deficiency of external rotation of 20 degrees before operation. After osteotomy an improvement of 32.5 degrees to 12.5 degrees external rotation was achieved. All patients were satisfied with the increase of function.CONCLUSIONS:In patients with brachial plexus palsy, secondary operations according to the individual pattern of paralysis result in an improvement of shoulder function and stability as well as patients satisfaction.

INTRODUCTION After treatment of infantile hip dislocation in terms of reduction and retention in plaster casts or splints a problem of therapy controlling exists. To assess if the femoral head is in correct position centered in the socket ultrasound is not possible, because one cannot achieve the necessary standard position. Computertomograms are associated with a hereditary taint of radiation and plain roentgenograms lack of presentation of the important cartilaginous structures. METHOD To control infantile hips after open or closed reduction from 1990 until 1996, 43 examinations by MR imaging were performed in 34 children. RESULTS In our series MRI was able to provide exact information about the position of the femoral head independently of its state of ossification. Also, a clearly visualisation of the different structures of the acetabular fossa, particular acetabulum, pulvinar, bony and cartilaginous acetabular rim and limbus was possible. Furthermore the MR images showed interpositioned soft tissue, intraarticular effusion and displayed cartilaginous parts of the acetabular rim. CONCLUSIONS MRI is an exact method to assess the anatomical and pathological conditions of the childlike hip joint. Because of the disadvantages of CT and X-ray, MRI is superior in terms of controlling the results after treatment of infantile hip dislocation.

INTRODUCTION:After treatment of infantile hip dislocation in terms of reduction and retention in plaster casts or splints a problem of therapy controlling exists. To assess if the femoral head is in correct position centered in the socket ultrasound is not possible, because one cannot achieve the necessary standard position. Computertomograms are associated with a hereditary taint of radiation and plain roentgenograms lack of presentation of the important cartilaginous structures.METHOD:To control infantile hips after open or closed reduction from 1990 until 1996, 43 examinations by MR imaging were performed in 34 children.RESULTS:In our series MRI was able to provide exact information about the position of the femoral head independently of its state of ossification. Also, a clearly visualisation of the different structures of the acetabular fossa, particular acetabulum, pulvinar, bony and cartilaginous acetabular rim and limbus was possible. Furthermore the MR images showed interpositioned soft tissue, intraarticular effusion and displayed cartilaginous parts of the acetabular rim.CONCLUSIONS:MRI is an exact method to assess the anatomical and pathological conditions of the childlike hip joint. Because of the disadvantages of CT and X-ray, MRI is superior in terms of controlling the results after treatment of infantile hip dislocation.

Dislocation of the fibular head is rare. In most of the cases a trauma caused by sports activity, sometimes associated with a tibia fracture, is described. Only a few publications exist about habitual dislocation of the fibular head without history of trauma. This article reports a case of bilateral habitual anterolateral dislocation of the fibular head in a 17-year-old female. There was no information about a neurological or other disease and no sign of generalized ligamentous laxity. Because of marked symptoms with severe pain after each sensation of dislocation which appeared several times a day, the patient was treated by using a part of the biceps tendon for fixation of the reduced fibular head.

The present study relates subjective and objective follow-up results more than 10 years following arthrodesis of the ankle and the hindfoot. One hundred and fifty-five arthrodeses (ankle joint, triple arthrodeses, subtalar, pantalar and talonavicular arthrodeses) were performed on 147 patients between 1968 and 1988. The most common indication was post-traumatic arthritis, followed by congenital deformity, idiopathic degenerative arthritis and rheumatoid arthritis. A variety of internal fixation devices were used in some cases; seventy-nine patients with 82 arthrodeses were reexamined clinically and radiographically, after a mean time of 11.1 years. Static and dynamic foot print measurements were recorded with a capacitive sensor system. Another 26 patients with 27 arthrodeses replied to a questionnaire. Subjectively, the average pain score improved significantly but the overall function score improved only slightly. Results were inferior in the talonavicular arthrodesis. Radiographical evaluation revealed bony union in only 59% of the arthrodeses, one-third at the talonavicular joint. Secondary degenerative arthritis of the foot and ankle occurred in 107 joints of the 82 feet re-examined. Evaluation of dynamic foot pressure measurements revealed an overall prolonged weightbearing on the midfoot region. An unacceptably low rate of bony union in some locations, a high incidence of secondary degenerative changes at neighbouring joints and a persistent abnormality of the plantar weightbearing pattern in the operated feet demonstrate unsatisfactory results with the techniques used more than 10 years ago. We now recommend stable internal fixation with optimum adaptation of the bone surfaces of the arthrodesis.

The effect of incongruous medial meniscal grafts on the articular surface was studied. We compared the cartilage degeneration in 4 Groups of 25 sheep knees. The histological changes were graded according to the score of Mankin, the morphological alterations by the score of Jackson. In Group 1 no surgery was performed. In group 2, the meniscus was totally detached from its base at the capsule and refixed without changes in the congruity or isometry. This group provided the basic data. In group 3, the contralateral medial meniscus was used as a transplant by reversing it. The reattachment was done according to isometric conditions. With this technique only the congruity of the tibial and femoral surface was modified. In group 4, the medial meniscus was completely removed. The results of group 1 (Mankin grade 0.58; Jackson grade 0.00) and group 2 (grade 0.50 and 0.47) showed no difference. The highest degree of degenerative changes occurred in the meniscectomized knees (group 4, grade 4.47 and 1.73), however considerable changes were also found in the knees with an incongruous meniscal graft (group 3, grade 3.37 and 1.27). The results suggest that incongruous grafts will lead to degeneration of the articular surface but still have a chondroprotective effect.

INTRODUCTION:In a retrospective study a treatment concept for Perthes' disease dependent on the containment was applied. PATIENTS/METHODS:49 hips of 41 children (9 female, 32 male) were treated between 01. 01. 1990 and 31. 12. 1995. In our concept of treatment a varus femoral osteotomy was performed in 28 cases with not contained hips or less than 4/5 coverage of the femoral head (X-ray/MRI). The other 21 well contained hips with 4/5 coverage or more were treated conservatively with physiotherapy and in case of joint effusion and pain additionally with the use of crutches (partial weight bearing) and anti-inflammatory medication. The average age in the non-operative group at the time of first investigation was 4 years and 9 months (3 y./1 m. to 7 y./1 m.) and 6 years and 3 months (4 y/2 m. to 10 y/0 m.) at our last examination (mean follow up 17.7 months, range of 6 to 72 months). At the time of indication for a varus femoral osteotomy the patients had an average age 6 years and 1 month (3 y./6 m. to 10 y./2 m.), the mean age at the last postoperative examination was 7 years and 11 months (4 y./8 m. to 12 y./5 m.) with an average follow up of 21.5 months (6 to 77 months). RESULTS:For the conservatively treated children we achieved good results (still well contained hips with 4/5 coverage, no decrease of function, no increase of pain) in 85.7% (18 of 21 cases). In 85.7% (24 of 28 cases) we found good results (well contained hips, increase of coverage, no decrease of function, no increase of pain) in the operation group. CONCLUSIONS:The presented concept of therapy in Perthes' disease was practicable for all patients and included the possibility of decision for operative or non-operative treatment. In both groups we achieved good results in 85.7% of the cases.

PURPOSE:What is the clinical and radiographic outcome of arthrodeses at the hindfoot and at the ankle more than 10 years postoperatively?METHODS:Between 1968 and 1988, 155 arthrodeses (ankle joint, triple arthrodeses, subtalar, pantalar and talonavicular arthrodeses) were performed on 147 patients. Indications for arthrodesis were posttraumatic arthritis, congenital deformity, idiopathic degenerative arthritis and rheumatoid arthritis. A variety of internal fixation devices or no internal fixation were used. 79 patients with 82 arthrodeses were reexamined clinically and radiographically, after 11.1 years on average. Static and dynamic foot print measurements were recorded with a capacitive sensor system. Another 26 patients with 27 arthrodeses replied to a questionnaire.RESULTS:Subjectively, the average pain score improved significantly. The overall function score improved only slightly. Results were inferior in the talonavicular arthrodesis. Radiographic evaluation revealed bony union in only 59 percent of the arthrodeses, one third at the talonavicular joint. Secondary degenerative arthritis of the foot and ankle occurred in 107 joints of the 82 feet. Evaluation of dynamic foot pressure measurements revealed an overall prolonged weightbearing on the midfoot region.CONCLUSION:An unacceptably low rate of bony union in some locations, a high incidence of secondary degenerative changes at neighboring joints, and a persistent abnormality of the plantar weightbearing pattern in the operated feet demonstrate unsatisfactory results with the techniques used more than 10 years ago. We now recommend stable internal fixation with optimum adaptation of the bone surfaces of the arthrodesis.