INTRODUCTION Analysis of the quality of different modes of preoperative information management on the example of primary total hip arthroplasty. Comparison between a since 10 years used, computer based system and a conventional procedure with additional hand-written notes. METHODS Retrospective analysis of respectively 50 with conventional and computer based system written preoperative patient information. The completeness of the documentation is examined according to the demands of current judgement. RESULTS The results confirm, independent from the level of education, a complete documentation of all risks by applying the computer based system, whereas the conventional method leads to considerable lacks of documentation. DISCUSSION The computer based system guarantees a high quality of preoperative patient information which cannot be obtained by the conventional method and therefore offers a protection against unjustified claims of liability.

Fragestellung: Lassen sich die guten klinischen, kurzfristigen Ergebnisse der zementfrei implantierten Titan-Schraubpfannen vom Typ Mec-Ring im mittelfristigen Nachuntersuchungszeitraum bestätigen?

Introduction: Nerve lesions after hip arthroplasty are common complications which may imply the reproach of a treatment mistake. Thus, the decisive question to the expert runs: fate or treatment mistake?Methods: Retrospective analysis of all cases dealt with at the medical expert commission of the General Medical Council Nordrhein during 1977-1997 in respect of the damage mechanisms and expert judgments.Results: As long as diagnosis and therapy were set on time, nerve lesions after hip arthroplasty due to extension, pressure or placement of the leg were evaluated as fateful (81%). Delayed treatment as well as incorrect operation technique, -indication, or inadequate documentation were judged as a treatment mistake (19%).Conclusion: Nerve lesions after hip arthroplasty cannot always be avoided and thus do not directly imply a treatment mistake. Immediate therapy and precise documentation are important to minimize the damage.

The treatment of enchondroma in long tubular bones has been the subject of controversial discussions for several years. Whereas secondary malignancy is very rare when the enchondroma is located in a hand, a position near to the trunk represents a high risk of transformation into a chondrosarcoma. For an enchondroma in long tubular bones, authors recommend a whole variety of approaches ranging from regular controls to radical en bloc resection. Between 1989 and 2001 we followed a concept of intralesional resection and cement filling. After an interval without recurrences, the cement was extracted andreplaced by a spongiosaplasty. Of 16 patients 12.5% suffered from an intralesional fracture in the course of the treatment, and 25% complained of persistent pain and loss of function after surgery. These complications led us to change our concept. Though there were two cases of secondary transformation into chondrosarcoma G1, we now prefer to keep the patients under close clinical and radiological control without performing surgery.

Die Therapie des Enchondroms in langen Röhrenknochen wird seit Jahren kontrovers diskutiert. Während bei der Lokalisation an der Hand eine Entartung kaum zu befürchten ist und man allgemein zum Abwarten rät, besteht für Läsionen im Stammbereich Einigkeit über die hohe Gefahr einer malignen Entartung. Die Empfehlungen der Literatur für einen Enchondrombefund in einem langen Röhrenknochen reichen jedoch von der abwartenden Beobachtung bis hin zur radikalen En-bloc-Resektion.

To evaluate the in vivo performance of “duplex” hydroxylapatite top coat/TiO2 bond coat systems, cylindrical Ti6Al4V rods of 130 mm in length and 11–13 mm in diameter were coated by atmospheric plasma spray (APS) technique with both a standard hydroxylapatite (HAp) layer and a HAp+TiO2 bond coat “duplex” layer. In this pilot study coated and uncoated rods serving as controls were implanted into the femur of sheep so that their distal ends were freely suspended in the medulla of the femur. After an observation time of six months it was found that bone apposition and bone ingrowth were considerably increased in the presence of a osteoconductive coating. In particular, in vivo spalling and delamination frequently observed with HAp coatings was virtually absent in duplex coatings owing to the strong adhesion of the bond coat to the HAp top coat that anchored the latter solidly to the metallic surface of the implant. Some tentative mechanisms leading to this improved coating adhesion will be discussed.

AIM:With the introduction of the Australian DRG system in Germany the question arises which current procedures remain reasonable in cost. The present study compares the actual costs with the expected DRG reimbursement.PATIENTS AND METHODS:Prospective analysis of 23 patients with primary hip and 26 with knee arthroplasty was performed to identify all cost factors during the hospitalization period including all applied measures. Retrospective analysis was carried out of the additional costs of relevant concomitant diseases (liver transplantation, haemophilia).RESULTS:Expenses of 6231 euro; for hip and 6453 euro; for knee implants were covered by the DRG reimbursement. Although a special reimbursement was paid, the additional costs of the concomitant diseases resulted in a financial loss.CONCLUSION:To cover the current costs for patients free of complications, an enormous reduction of the length of stay is required. Otherwise complicated cases may result in a loss of quality or selection of patients. The present cost analysis outlines a guideline for an individual calculation and assessment of the necessary DRG reimbursement.

Aim: With the introduction of the Australian DRG system in Germany the question arises which current procedures remain reasonable in cost. The present study compares the actual costs with the expected DRG reimbursement. Patients and methods: Prospective analysis of 23 patients with primary hip and 26 with knee arthroplasty was performed to identify all cost factors during the hospitalization period including all applied measures. Retrospective analysis was carried out of the additional costs of relevant concomitant diseases (liver transplantation, haemophilia). Results: Expenses of 6231 (sic) for hip and 6453 (sic) for knee implants were covered by the DRG reimbursement. Although a special reimbursement was paid, the additional costs of the concomitant diseases resulted in a financial loss. Conclusion: To cover the current costs for patients free of complications, an enormous reduction of the length of stay is required. Otherwise complicated cases may result in a loss of quality or selection of patients. The present cost analysis outlines a guideline for an individual calculation and assessment of the necessary DRG reimbursement.

INTRODUCTION:The diagnosis-related reimbursement for total hip- and knee arthroplasty is often interpreted as a claim for cost reduction and thus influences increasingly the surgeon's choice of treatment. With regard to further planned budget reductions the following questions arise: Remains quality payable? Where are cost savings possible?PATIENTS AND METHODS:Prospective analysis of 21 patients with primary hip- and 26 with knee arthroplasties to identify all cost factors during the hospitalization period including the implantation technique and quality improvement measures.RESULTS:Expenses of 18,763.26 DM for hip- and 18,649.40 DM for knee implants were covered by the diagnosis-related reimbursement. Compared to cemented implants, the average total costs of cementless prostheses were usually less expensive.CONCLUSION:Although the current costs are covered, a further reduction of the diagnosis-related reimbursement may result in a loss of quality. The present cost analysis outlines a guideline for an individual calculation and assessment of possible saving effects.

Purpose: So far no clinical results concerning the survival rates of cementless pure titanium cups with laser-structured surfaces exist. This study was performed to evaluate our results for the Alphasegment acetabular component (Alphanorm). Method: Retrospective analysis of 50 cups in 45 patients was performed (operations performed between November 1995 and January 1998). The average age at the time of the implantation was 65.1 years. Dysplastic hips and revisions were excluded. The survival rate was calculated according to the Kaplan-Meier analysis with the end point defined as the revision surgery of the cup. Results: The average follow-up period was 2.9 (0.6-4.0) years. Two patients (i.e., two implants) died during the observation period, none were lost for followup. Six of the cups had to be revised due to aseptic loosening. The survival rate at 3.2 years after implantation was 87%. None of the stems had to be revised. Conclusions: Further use of the cementless hemispherical pure titanium cup with laser-structured surface cannot be recommended. The observed prevalence of loosening for the Alphasegment acetabular components was higher than for other cups. Close follow-up of patients with this type of implant is necessary.

Further use of the cementless hemispherical pure titanium cup with laser-structured surface cannot be recommended. The observed prevalence of loosening for the Alphasegment acetabular components was higher than for other cups. Close follow-up of patients with this type of implant is necessary.

Observation of a sacrococcygeal chordoma with exceptional long survival of now 17 years after incomplete surgery with following additional resection and adjuvant radiotherapy. Local recurrence occurred after more than 10 years, metastases after 15 years.

PURPOSE:Clinical and radiographic findings are of little value in the diagnosis of hip endoprothesis loosening. Refined contrast and radionuclide arthrographic techniques are more precise in predicting endoprothesis loosening. Here we compare both techniques with respect to the surgical result.MATERIAL AND METHODS:68 patients with hip pain after various arthroplasty procedure were investigated by clinical examination, X-ray, DSAr and AS. Surgical proof was obtained in 73.5%.RESULTS:An acetabular component loosening was detected in 89% by DSAr and in 86% by AS with a specificity for both methods of 93%. The femoral component loosening was seen with a sensitivity of 89% by DSAr and 100% by AS, respectively. Specificity of DSAr in the femoral compartment was 94%, of AS 88%.CONCLUSIONS:DSAr and AS are useful tools in the diagnosis of hip endoprothesis loosening and in planning surgical treatment. Both methods are comparable concerning the acetabular component, whereas AS is more sensitive in detecting femoral stem loosening. Combination of both methods is not recommended for routine diagnosis.

Zusammenfassung Fragestellung. Anhand von 3290 analysierten Hüftendoprothesen bei primärer Koxarthrose wird der Einfluss der Weiterbildung auf die Komplikationsdichte und die dadurch bedingten Kostendifferenzen ermittelt. Methodik. Retrospektive Untersuchung der Parameter stationäre Behandlungsdauer ab Operation, Blutverlust, Konservenbedarf, Narkosedauer und perioperative Komplikationen in Abhängigkeit vom Operateur (Facharzt gegenüber Weiterbildungsassistent) bei 3290 Hüftendoprothesen von 1974–1997. Ökonomische Bewertung durch zusätzliche Kosten pro Minute Operationszeit und Materialkosten. Ergebnisse. In beiden Gruppen fanden sich kaum Unterschiede bezüglich des stationären Aufenthaltes, des Konservenbedarfes, der Nervenläsionen und Embolien. Bei Pfannenperforationen, Schaft- und Trochanterfrakturen und Prothesenluxationen ergaben sich bei insgesamt niederer Komplikationsdichte geringfügig nicht signifikant höhere Raten bei den Weiterbildungsassistenten, mit deutlichem Rückgang in den letzten 14 Jahren. Eine anfänglich signifikant höhere Zahl tiefer Infektionen ist in den letzten 9 Jahren auf Werte den Fachärzten entsprechend abgefallen. Die Kostenanalyse ergibt aus den geringfügig erhöhten Operationszeiten einen finanziellen Mehraufwand von DM 85 pro Fall entsprechend 0,6% der FP 17.061 (A-Teil). Schlussfolgerungen. Die Untersuchung belegt, dass die Weiterbildung unter fachärztlicher Aufsicht mit einem kaum messbaren Unterschied zur Facharztoperation bei den Komplikationsdichten einhergeht. Es verbleiben dennoch Mehraufwendungen, die in die Budgets eingerechnet werden müssen.

We studied the effect of surgical experience with regard to complications and costs after 3290 primary total hip arthroplasties (diagnosis: osteoarthritis).We retrospectively analysed duration of clinical treatment and anaesthesia, blood loss, number of banked blood and perioperative complications (fractures of the shaft and acetabulum, dislocations, peripheral nerve injuries, thrombosis of the deep veins, embolism and deep wound infections) related to the experience of the surgeon (junior surgeons in comparison to the consultant) after 3290 primary THA's from 1974 to 1997. Cost analysis was performed by measurement of time and material expenditure.39.2% of all operations were performed by junior surgeons. This number emphasizes the realisation of the order of education in our clinic. Both groups showed just few differences in number of duration of clinical treatment, banked blood, nerve leasions and embolism. We found statistically not significant increased rates of fractures and dislocations in the THA's performed by an unexperienced surgeon, however the rates decreased the last 14 years. Significantly higher rates of deep wound infection at the beginning decreased in the last 9 years to the level of experienced surgeons. Due to longer operation times, we calculated higher expenses of DM 85 per case in the group of junior surgeons.Using an educational program, carried out with an experienced surgeon, there is nearly no additional risk for the patient regarding the complication rates in THA's. However, there are higher financial expenses that have to be calculated.

We report about an exceptional complication after internal hemipelvectomy and replacement of the defect with a custom-made endoprosthesis. A complete luxation of the PE-inlay out of the metal cup occurred. Radiologically we assumed a luxation of the femoral head in dorsal direction. Revision after a failed attempt of closed reposition showed a complete luxation of the inlay, which was caused by deficient fixation in the acetabular component. The absence of a contrast wire in the PE-inlay delayed the right diagnosis and made it difficult to find the dislocated inlay in the large wound.

Up to now there are no facts concerning the loosening rate of the cemented titanium stem (Trios). The central guiding canula and the longitudinal drilled stem shall ensure a symmetric cement mantle. In order to estimate the risk of aseptic loosening all Trios prostheses implanted in our clinic (n = 67; operations 1/95-11/96; max. follow-up: 3.1 years) were examined in a retrospective study and compared with a conventional femoral component (n = 141; Müller special; CoCr; operations 1977-1982). We used survivorship analysis to assess the results (Kaplan-Meier method; end point: revision). Compared to the conventional femoral stem the survival rate of the Trios prostheses was significantly worse (p = 0.0001). The probability of no revision after 3 years was 72% (conventional femoral component: 96%). Preoperative x-rays showed radiolucent lines surrounding the cement mantle. These findings as well as the loosening at the cement metal interface were confirmed intraoperatively. The explanted stems showed corresponding signs of abrasion on the surface. Our results prove that the application of cemented titanium stems might be problematic. With regard to the Trios prosthesis we recommend close routine check-ups to keep the chance of an early revision.

We report about an exceptional complication after internal hemipelvectomy and replacement of the defect with a custom-made endoprosthesis.:A complete luxation of the PE-inlay out of the metal cup occurred. Radiologically we assumed a luxation of the femoral head in dorsal direction. Revision after a failed attempt of closed reposition showed a complete luxation of the inlay, which was caused by deficient fixation in the acetabular component. The absence of a contrast wire in the PE-inlay delayed the right diagnosis and made it difficult to find the dislocated inlay in the large wound.