Die Behandlung traumatischer Armplexusschäden erfolgt phasenabhängig. Nach Durchführung der Akutbehandlung (Phase I), der neurologischen Diagnostik (Phase II) und neurochirurgischer Operationen sowie deren Nachbehandlung (Phase III/IV) können funktionsverbessernde Eingriffe (Phase V) indiziert sein. Häufig verbleibt ein unzureichender Kraftgrad der Muskeln nach Armplexusläsion. Patienten mit traumatischen Schädigungen des Plexus brachialis sollten innerhalb der ersten 6 Monate nach dem Unfall einer adäquaten neurochirurgischen Behandlung zugeführt werden. Abhängig vom individuellen neuromuskulären Ausfallmuster, der passiven Gelenkfunktion und den knöchernen Voraussetzungen kann danach eine weitere Funktionsverbesserung durch knöcherne oder weichteilige Sekundäroperationen erreicht werden. Die Gesamtbehandlung des Patienten mit Armplexusschaden erfordert eine interdisziplinäre Zusammenarbeit.

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha's technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique.The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6degrees (0 to 45) to 34degrees (5 to 90) at the last review. The mean forward flexion increased from 12degrees (0 to 85) to 30degrees (5 to 90).Abduction (41degrees) and especially forward flexion (43degrees) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42degrees of abduction and 56degrees of forward flexion. Active abduction (28degrees) and forward flexion (19degrees) were much less in completely flail shoulders (n =34).Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished.The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.

Limited function due to paralysis following brachial plexus lesions can be improved by secondary operations of the bony and soft tissue. Between April 1994 and December 2000, 109 patients suffering from arm-plexus lesions underwent a total of 144 reconstructive operations guided by our concept of integrated therapy. The average age at the time of surgery was 32 years (range: 15-59). The following operations were performed: shoulder arthrodesis (23), trapezius transfer (74), rotation osteotomy of humerus (9), triceps to biceps transposition (9), transposition of forearm flexors or extensors (8), latissimus transfer (7), pectoralis transfer (1), teres major transfer (1), transposition of flexor carpi ulnaris to the tendons of extensor digitorum (10), and wrist arthrodesis (2). Prospectively, in all patients, the grade of muscle power of the affected upper extremity was evaluated prior to surgery. The follow-up period for all 144 operations was, on average, 22 months (range: 6-74). By means of operative measures, almost all patients obtained an improvement of shoulder function (100%) and stability (>90%), elbow flexion (85%), and hand, finger, and thumb (100%). When muscles malfunction after brachial plexus lesions, one should take into account the individual neuromuscular defect, passive joint function, and bony deformities; different procedures such as muscle transpositions, arthrodeses, and corrective osteotomies can then be performed to improve function of the upper extremity. Each form of operative treatment presents patients with certain benefits and all are integrated into a total treatment plan for the affected extremity.

The treatment of traumatic brachial plexus lesions follows sequential steps. After acute therapy (phase I), neurological diagnostics (phase II), neurosurgery and postoperative treatment (phase III/IV), reconstructive operations (phase V) can be indicated and performed. Inmost cases an insufficient grade of muscle power remains. Within 6 months 9 after injury, neurosurgery must be performed in patients with brachial plexus palsy. After malfunction of the muscles, taking into account the individual neuromuscular defects, passive joint function and bony deformities, different procedures such as muscle transposition, arthrodesis and corrective osteotomy can be performed to improve the function of the upper extremity. The treatment of patients suffering from brachial plexus lesion requires interdisciplinary teamwork.

Fragestellung: Welche Konsequenzen ergeben sich aus dem Ausfallmuster der Handmuskeln bei traumatischen Arm-Plexus-Läsionen?

Zusammenfassung Operationsziel Wiederherstellung der Extension des Handgelenks und der Langfingergrundgelenke sowie der Abduktion des Daumens bei Paralysen des Nervus radialis zur Verbesserung der Gebrauchsfähigkeit der Hand. Indikationen Irreparable Lähmung des Ramus profundus nervi radialis. Zusätzlich bei langstreckigem Nerventransplantat mit fraglicher Prognose. Wunsch nach rascher Wiederherstellung der Funktion. Ausfall der durch den Nervus radialis innervierten Muskeln im Rahmen einer Läsion des Plexus brachialis nach erfolgloser konservativer oder neurochirurgischer Therapie. Kontraindikationen Unvollständige Rehabilitation nach konservativer Behandlung oder neurochirurgischem Eingriff. Unzureichende freie passive Beweglichkeit von Hand- und Fingergelenken. Nicht vollständiger Kraftgrad der durch den Nervus medianus versorgten Muskulatur. Mangelhafte Mitarbeit und Zuverlässigkeit des Patienten. Operationstechnik Die Sehne des Musculus flexor carpi ulnaris wird am Os pisiforme abgesetzt und subkutan getunnelt auf die Sehnen des Musculus extensor digitorum communis transponiert. Die Sehne des Musculus palmaris longus wird auf die Sehne des Musculus extensor pollicis longus verlagert. Ergebnisse Von Oktober 1997 bis Dezember 2001 operierten wir zwölf Patienten mit der beschriebenen Methode. In der von Haas vorgeschlagenen Einteilung erreichten je sechs Patienten ein sehr gutes und gutes Ergebnis. Die mögliche Handgelenkextension lag zwischen 0° und 70° (Median 20°). Die Nachuntersuchungszeit betrug 3–48 Monate (Median 14 Monate).

Contraindicaciones No haber realizado un tratamiento rehabilitador suficiente despues de un tratamiento conservador o neuroquirurgico. Movilidad articular pasiva inadecuada de muneca y dedos. Deficit de fuerza de la musculatura inervada por el nervio mediano. Pacientes poco colaboradores. Tecnica quirurgica Desinsercion del musculo flexor cubital del carpo del hueso pisiforme, transferencia subcutanea sobre el extensor comun de los dedos y sutura sobre este. Obtencion del tendon del m. palmar menor que se sutura sobre el extensor largo del pulgar.

Fragestellung: 3D-Ultraschall gewinnt in vielen medizinischen Disziplinen immer mehr an Bedeutung. Softwarebasierte Systeme, die Freihand-Scanning erlauben, konkurrieren mit 3D-fähigen volldigitalen Geräten. Ziel dieser Studie war der Vergleich der Aussagefähigkeit zwischen konventionellen 2D-Verfahren und der neuen 3D-Technik bei Fragestellungen am Bewegungsapparat.

AIM:Dysplastic hips or dislocated hips lead to loss of muscle strength claudication, and finally to coxarthrosis. This study analytically compares the hip joint forces in normal, dysplastic hips and hips after implantation of a hip prosthesis for several positions.METHOD:The results of 173 total hip replacements in 153 cases of either severe congenital dysplasia or dislocation were analyzed. A 2 dimensional mathematical model of the hip was developed to evaluate the effects of surgically achievable mechanical alterations such as acetabular placement, femoral shaft-prosthetic neck angle, and neck length of the femoral prosthesis.RESULTS:63 % of the hip prosthesis were implanted on the right, 72 % on the left. Before implantation, the femoral shaft-prosthetic neck angle in mean was 146 degrees +/- 10 degrees, after implantation it was 135 degrees. The hip centre was displaced on in average 10 mm distally. Postoperatively hip joint force was increased 21 %.CONCLUSION:Minimum joint contact forces occurred when the femoral shaft prosthetic neck angles were small. The loads on the hip were lowered significantly by placing the centre of the acetabulum as far inferiorly and medially as possible. Another important finding is that displacement of the hip centre distally has a great effect on muscle performance and hip joint force.

Dysplastic hips or dislocated hips lead to loss of muscle strength claudication, and finally to coxarthrosis. This study analytically compares the hip joint forces in normal, dysplastic hips and hips after implantation of a hip prosthesis for several positions.The results of 173 total hip replacements in 153 cases of either severe congenital dysplasia or dislocation were analyzed. A 2 dimensional mathematical model of the hip was developed to evaluate the effects of surgically achievable mechanical alterations such as acetabular placement, femoral shaft-prosthetic neck angle, and neck length of the femoral prosthesis.63 % of the hip prosthesis were implanted on the right, 72 % on the left. Before implantation, the femoral shaft-prosthetic neck angle in mean was 146 degrees +/- 10 degrees, after implantation it was 135 degrees. The hip centre was displaced on in average 10 mm distally. Postoperatively hip joint force was increased 21 %.Minimum joint contact forces occurred when the femoral shaft prosthetic neck angles were small. The loads on the hip were lowered significantly by placing the centre of the acetabulum as far inferiorly and medially as possible. Another important finding is that displacement of the hip centre distally has a great effect on muscle performance and hip joint force.

The aim of this study was to evaluate persistent patterns of paralysis after traumatic brachial plexus lesions. As a result, consecutive reconstructive operations according to our differential therapy concept are presented. Between 04/1994 and 12/2000 in 104 patients with brachial plexus palsy, the grade of muscle power of the affected upper extremities was evaluated prospectively. The neuromuscular patterns of defect showed, in most cases, insufficient muscle power grades of 0-2 for the deltoid muscle (90%), supraspinatus muscle (82%), infraspinatus muscle (93%), elbow flexors (67% to 77%), hand and finger extensors (69% to 71%), and the abductor and extensors of the thumb (67% to 70%). In corresponding frequency, the following operations were performed between 04/1994 and 06/2002: shoulder arthrodesis (n 26), trapezius transfer (n 80), rotation osteotomy of humerus (n 10), triceps to biceps transposition (n 11), transposition of forearm flexors or extensors/Steindler operation (n 12), latissimus transfer (n 7), pectoralis transfer (n 1), teres major transfer (n 1), transposition of forearm flexors to the tendons of extensor digitorum (n 19) and of the extensor pollicis longus (n 9), and wrist arthrodesis (n 5). On malfunction of muscles following brachial plexus lesions, taking into account the individual neuromuscular defect, passive joint function, and bony deformities, different procedures such as muscle transposition, arthrodesis, and corrective osteotomy can be performed to improve function of the upper extremity.

Aim: Shoulder arthrodesis following prosthesis explantation or resection of the acromion has not often been described in the literature. The presented article analyses the special features and problems of these preoperative circumstances in 4 cases and discusses them within the entire group. Patients and Method: Between 06/1987 and 02/2001, a total of 30 shoulder arthrodeses using plate fixation were performed in our clinic and then analysed after an average of 2.7 (0.5 - 8.7) years. Surgery was carried out on 5 (17%) females and 25 (83%) males with a mean age of 37 (17 - 82) years. Two patients underwent shoulder arthrodesis as a salvage operation following unsatisfactory arthroplasty, or after trapezius transfer with corresponding reduced bony conditions, respectively. Results: The active extent of movement following arthrodesis was 56degrees (20degrees-90degrees) abduction, and 60degrees (20degrees - 105degrees) anteversion. The most frequent complications following arthrodesis included pseudarthroses (3/10%), infections (4/13%), and fractures of the humerus (4/13%). The rate of complications was especially high in the cases after explantation of a shoulder prosthesis and resection of the acromion. In two of the four patients, three or five revision operations, respectively, were necessary. Two of the three pseudarthroses of the entire group occurred in these two cases. Conclusion: Complications of shoulder arthrodesis after resection of the acromion or the proximal humerus are especially frequent. To avoid pseudarthrosis in such cases, primary spongiosaplasty is advantageous. A fixation with plates is superior to a simple screw arthrodesis. For postoperative immobilization a plaster cast instead of an orthotic device should be taken into consideration.

Zusammenfassung Ziel der Untersuchung war es, das persistierende Lähmungsmuster nach traumatischen Arm-Plexus-Schäden festzustellen und daraus resultierende funktionsverbessernde Operationen im Rahmen eines Gesamtkonzepts darzustellen.Dazu wurden von 04/1994 bis 12/2000 bei 104 Patienten mit Plexusläsion prospektiv die Kraftgrade sämtlicher Muskeln der betroffenen Extremität erhoben.Das neurologisch-muskuläre Ausfallmuster zeigt, dass häufig ein unzureichender Kraftgrad 0–2 für den M. deltoideus (90%), den M.supraspinatus (82%),M.infraspinatus (93%), die Ellbogenflexoren (67–77%), die Hand- und Fingerextensoren (69–71%) sowie die Daumenabduktoren und -extensoren (67–70%) besteht. In entsprechender Häufigkeit wurden deshalb von 04/1994 bis 06/2002 folgende Sekundäroperationen durchgeführt (Anzahl): Schulterarthrodese (26),Trapeziustransfer (80), Rotationsosteotomie Humerus (10),Trizeps-Bizeps-Transfer (11),Verlagerung Unterarmflexoren-bzw.extensoren/Steindler-OP (12), Latissimustransfer (7),Pektoralistransfer (1), Teres-major-Transfer (1),Verlagerung Unterarmflexoren auf M.extensor digitorum (19) sowie auf M.extensor pollicis longus (9) und Handgelenksarthrodese (5).Bei Plexus-brachialis-Läsionen, kann bei differenziertem Vorgehen in Abhängigkeit vom individuellen neuromuskulären Ausfallmuster, der passiven Gelenkfunktion und den knöchernen Voraussetzungen durch knöcherne oder weichteilige Sekundäroperationen eine Funktionsverbesserung erreicht werden.

AIM:Shoulder arthrodesis following prosthesis explantation or resection of the acromion has not often been described in the literature. The presented article analyses the special features and problems of these preoperative circumstances in 4 cases and discusses them within the entire group.PATIENTS AND METHOD:Between 06/1987 and 02/2001, a total of 30 shoulder arthrodeses using plate fixation were performed in our clinic and then analysed after an average of 2.7 (0.5 - 8.7) years. Surgery was carried out on 5 (17 %) females and 25 (83 %) males with a mean age of 37 (17 - 82) years. Two patients underwent shoulder arthrodesis as a salvage operation following unsatisfactory arthroplasty, or after trapezius transfer with corresponding reduced bony conditions, respectively.RESULTS:The active extent of movement following arthrodesis was 56 degrees (20 degrees - 90 degrees ) abduction, and 60 degrees (20 degrees - 105 degrees ) anteversion. The most frequent complications following arthrodesis included pseudarthroses (3/10 %), infections (4/13 %), and fractures of the humerus (4/13 %). The rate of complications was especially high in the cases after explantation of a shoulder prosthesis and resection of the acromion. In two of the four patients, three or five revision operations, respectively, were necessary. Two of the three pseudarthroses of the entire group occurred in these two cases.CONCLUSION:Complications of shoulder arthrodesis after resection of the acromion or the proximal humerus are especially frequent. To avoid pseudarthrosis in such cases, primary spongioplasty is advantageous. A fixation with plates is superior to a simple screw arthrodesis. For postoperative immobilization a plaster cast instead of an orthotic device should be taken into consideration.

AIM:The surgical reconstruction of the dorsiflexion of the wrist and the abduction of the thumb in paralyzed radial nerve for the improvement of the useability of the hand is described. Likewise, the early functional subsequent treatment is described. Indications and contraindications are represented in detail. METHOD:Between October 1997 and May 2000 we treated 10 patients by the following method: The musculus flexor carpi ulnaris tendon is cut near the pisiform bone, transferred subcutaneously and fixed on the tendons of the extensor communis digitorum communis muscle. The tendon of the palmaris longus muscle is fixed on the tendon of the extensor pollicis longus muscle. After the swelling in the hand has subsided, the patients are supplied with a dynamic splint in order to avoid adhesions. RESULTS:According to the score suggested by Haas, 9 patients achieved a very good result (median: 30 degrees dorsiflexion), one patient had a good result (0 degree dorsiflexion). CONCLUSION:Adhesions could be avoided and the time of rehabilitation could be shortened by the operation method described. The operations result in an improvement of hand function and as well as patient satisfaction.

Zusammenfassung Sehnennähte gehören zu den grundsätzlichen operativen Tätigkeiten. Die Geschichte der Sehnennähte reicht deshalb weit zurück. In den letzten Jahrzehnten haben sich aber erhebliche Verbesserungen in der Nahttechnik und der Nahtverankerung ergeben insbesondere durch die Einführung neuer Nahtmaterialien. Ziel jeder Sehnennaht ist die Wiederherstellung der Sehnenfunktion. Um dieses Ziel zu erreichen, bedarf es detaillierter Kenntnisse der Sehnenheilung, der Nahtmaterialien, spezifischer Nahttechniken sowie der Nachbehandlung.

Tendon sutures belong to the bases of surgical activity. Particularly in the last decades these sutures experienced a substantial up-swing by the introduction of new techniques and materials. Target is to reestablish the tendon function. In order to achieve this target, it requires knowledge of tendon healing. An outline of suture materials, in particular specific suture techniques as well as the subsequent treatment is given. With different localizations of the tendon lesions one deals.

The load limit of a tendon is expressed by the not linear force/lenghtening behavior. It is determined by the interrelation between load and load-bearing capacity. The load of a tendon results from exogenous, endogenous and temporal factors. The property factors and the aging influence the load-bearing capacity of a tendon. Partial ruptures show necrosis, calcification and fiber swelling. The attachment area shows a mineralization of the cartilage zone, a loss of the collagen fibrils and calcifications. The tendon ruptur knows extrinsic and intrinsic causes. Primary are micro and macrovascular tendon alterations, usually favour the rupture of tendons.