[[Surgical intra-articular interventions in arthrosis]

The reconstruction of weight-bearing joint surfaces has long been a challenge for the orthopedic surgeon. The statistical rise in life expectancy, the spread of high-risk sports and leisure-time activities combined with high demands for painfree joint function even in older age as a factor for contemporary quality of life are the demographic factors of the bone and joint decade announced by the WHO. Osteoarthritis represents a multifactorial, irreversible, often heterogeneous joint disease with joint destruction as the inevitable consequence. Conventional and innovative intra-articular operative methods for the treatment of osteoarthritis are presented and discussed. Tissue engineering stands for vitalizing tissue modification by modification of cellular and humoral mechanisms. Thus, new therapy options for curing degenerative joint diseases will arise in the future. Autologous chondrocyte transplantation (ACT) represents one of the first clinically established methods. The paradigm of treating osteoarthritis by the orthopedic surgeon will be multimodal in the future. Innovative techniques in the biotechnological sector provide a promising horizon.

[Biomechanical considerations on shoulder joint prosthesis implantation]

The biomechanical goals of prosthetic reconstruction of the shoulder are to restore the normal anatomy and range of motion, and to recreate the normal soft tissue balance of the static and dynamic stabilizers of the glenohumeral joint. An unconstrained prosthesis design best reproduces the physiological articulation and original anatomy of the shoulder. Humeral head components have been recently developed, which are adaptable to the variable anatomy of the proximal humerus (third generation design). A precise reconstruction of the three dimensional structure of the proximal humerus may lead to an improved functional outcome. However, there is still a lack of biomechanical data to support this concept. The optimal design of the glenoid component remains a challenge for future research. Specific issues including the choice of biomaterials, the optimum shape, radius of curvature, surface area of the articulation, component height and stem design remain under investigation. Although the prosthetic design represents an important factor in the success of glenohumeral arthroplasty, the surgical reconstruction of the soft tissues to recreate the normal soft tissue balance as well as postoperative rehabilitation determine the functional outcome.

[Injection therapy in lumbar syndromes]

Injection therapy as part of orthopaedic pain treatment is of major importance in sciatica. It helps to differentiate unclear complaints and allows a break through of the vicious circle of pain and muscle spasm. Pharmacological principles and possible complications have to be observed. The different techniques need experience and manual training. The paper describes the various injection techniques in detail.

[Medical training therapy in lumbar syndromes]

Chronic low back pain can be considered to be one of the most frequently treated and most costly diseases in modern industrial societies. Dysfunctions and imbalances of the spine-supporting muscles increase the risk of low back pain. Consequently preventive treatment and rehabilitation have to aim at preserving and restoring the full capacity of the spine-supporting muscles as well as training coordination and spine-friendly behaviour. In addition to various measures of pain therapy, physiotherapeutic treatment including neuro-physiotherapy, physical treatment (eg electrotherapy), balneotherapy and supportive behavioural training, medical rehabilitation therapy (MRT) ranks among the most effective ways of treating low back pain. MRT applies guidelines and methods of exercise methodology within medically indicated programmes of preventive treatment and rehabilitation. Various objectives of MRT are outlined with special regard to the stages of MRT treatment, emphasizing positive adaptation of the neuro-muscular system in the course of rehabilitation. Physicians are responsible for MRT diagnosis and control. Taking into account the base disorder and the progress of therapy physiotherapists and the physicians in charge determine MRT objectives and treatment strategies.

[Surgical approach in lumbar intervertebral disk displacement. Topographical principles and characteristics]

For the operative procedure in lumbar disc extrusion it is important to expose the prolapsed disc and sequestrum without disintegration of the musculature and branches of r. dorsalis nervi spinalis or provoking lesions in the spinal canal. A classification helps to determine exact description of localization of disc material in craniocaudal and mediolateral directions. It can be correlated with the interlaminar window as a structure seen in the operative procedure. A speculum helps to limit the exposure for an interlaminar as well as a lateral access, thus reaching the structures concerned in the spinal canal with minimal irritation of the surrounding tissues. For interlaminar access partial excision of the lig. flavum is sufficient. The extrusions in the foraminal region that can be exposed laterally from a medial skin incision, as well as from a paramedial are between m. multifidus and m. longissimus. In revision surgery, the upper laminar corner is advantageous for entering the spinal canal.

Topographical principles and peculiarities of operative access in lumbar disc extrusion

For the operative procedure in lumbar disc extrusion it is important to expose the prolapsed disc and sequestrum without disintegration of the musculature and branches of r. dorsalis nervi spinalis or provoking lesions in the spinal canal. A classification helps to determine exact description of localization of disc material in craniocaudal and mediolateral directions. It can be correlated with the interlaminar window as a structure seen in the operative procedure. A speculum helps to limit the exposure for an interlaminar as well as a lateral access, thus reaching the structures concerned in the spinal canal with minimal irritation of the surrounding tissues. For interlaminar access partial excision of the lig. flavum is sufficient. The extrusions in the foraminal region that can be exposed laterally from a medial skin incision, as well as from a paramedial are between m. multifidus and m. longissimus. In revision surgery, the upper laminar corner is advantageous for entering the spinal canal.

[Guidelines in orthopedics. Alliance of German Orthopedists. University Clinic of Orthopedics, Heidelberg]

Guidelines are systematically developed statements of the actual knowledge in order to assist doctors and patients by the decision of appropriate health care. Since 1998 the DGOT has published 22 well structured guidelines, 20 guidelines are under construction. The AWMF as the coordinator of guideline constructing of all scientific medical societies has published 629 guidelines since 1995. The publication of guidelines of the DGOT and the BVO is the first step for dissemination, next steps should be implementation und evaluation. Then it will be evident whether change in medical practice will occur.

[Biomechanics of injury of the cervical spine]

Whiplash injuries of the cervical spine are of special medical and socio-economic importance. Biomechanical studies of the injury have proven, that a hypertranslation of the capito-cervical region takes place first, leading to ligamentous hyperdistension and ruptures, when exceeding elastic deformation, thus possibly resulting in mechanical disturbance and rotatory malpositioning. Diagnosis of so called "functional disorders" bears difficulties concerning objective tests for structural lesions. This demands the definition of diagnostic parameters and clinical signs, which also consider vegetative phenomena. This paper aims at a systematic clinical and radiological check. Adequate therapeutic means have to be concordant to prognosis. Therefore functional parameters should already determine differential diagnosis. This is based on technical feasibilities and needs future scientific efforts.

[Motion analysis in whiplash injuries]

Motion analysis of the cervical spine is a sensitive tool in the fields of preventive and clinical biomechanics of whiplash. In the field of preventive biomechanics motion analysis contributes to validation and optimisation of dummy based crash test experiments and simulations. In the clinical field motion analysis up to now is of restricted value. Data exist about restrictions and pathologies of movement and motion of the cervical spine, coordinative disturbances, postural control, TMJ-function and oculomotor disturbances after whiplash. The standardisation of technical and clinical set-ups is necessary to establish a well proven biomechanical model of whiplash and whiplash related biomechanical dysfunction. Without this model the value of motion analysis for clinical use will be restricted due to lack of comparable data on sensitivity and specificity although motion analysis of the cervical spine is neither cost- nor time consuming and free of adverse effects. Within a prospective series of 28 patients (14 m/14 f) with a follow-up to six weeks we were lucky to describe numerically two different types of reaction to low energy (delta v < 20 km/h) rear end collision: Type I with disturbances in complex movements only, Type II with overall restriction of movement. Control of angular velocity during cyclic movements of the head was disturbed by oscillations of higher frequency in all patients. Recovery from whiplash within 6 weeks could be monitored.

[Analysis of orthopedic specialty knowledge and comparison of 2 written test methods]

QUESTION

What about the knowledge of specific orthopaedic subjects in medical education as tested with mc-questions and open-ended questions?

METHOD

524 medical students were evaluated by a questionnaire survey to determine the state of orthopaedic knowledge in different periods of medical education. With the same questionnaire the use of two different types of written tests of knowledge (multiple choice questions and open-ended questions) has been tested and the results have been compared. The students participating in the orthopaedical practical (6th clinical semester) have been tested before and after the practical, given as pretest and posttest.

RESULTS

The results show that the orthopaedic knowledge corresponds to the educational level so that during medical formation, there is a gradual knowledge gain. Comparison of the results of the pretest and the posttest reveals that the highest knowledge gain occurred during the orthopaedic practical. For all groups candidates performed better in mc-questions than in open-ended questions. Likewise in all groups, open-ended questions were found to be more difficult than the mc-questions.

CONCLUSIONS

To summarize it may be concluded that there is a gradual orthopaedical knowledge gain during medical formation. It was found that students gain a considerable part of their technical knowledge during the practicals. Both mc-questions and open-ended questions are useful to measure this knowledge gain where there are hints that open-ended questions give a more accurate assessment of the actual knowledge. The pre- and posttest setting can provide both teachers and students with feedback regarding the realization and acquisition of instructional contents.

[The lumbar ligamentum flavum. Anatomic characteristics with reference to microdiscotomy]

One important step in lumbar discotomy is the safe penetration and exact partial removal of the Lig. flavum. This is a crucial prerequisite for the selective and gentle removal of prolapsed and sequestrated intervertebral disc tissue. Extensive lancing of the Lig. flavum should be avoided, to minimize intraoperative and postoperative complications, such as injuries to the nerves and the Dura mater, instabilities, bleeding and scarring. As there has up to now been insufficient information on the anatomy of the Lig. flavum especially regarding microdiscotomy, an analysis of the Ligg. flava L2/L3 to L5/S1, guided by this aim, was carried out on 36 corpses kept in formaline (16 f, 20 m; 52-78 y). Preparations showed the lumbar Ligg. flava to be embodied in the Foramina interarcualia in a characteristic configuration. There also proved to be defined insertion areas on the laminae of the vertebral arches, which must be taken into consideration during the operative exposure. The Lig. flavum rises from the cranial vertebral arch from the ventral surface of the lamina (6.8 mm) whilst the insertion area on the caudal lamina covers the dorsal and the ventral surface. The extent at the ventral surface is 2.2 mm in average. Taking the insertion proportions into account we would suggest the Lig. flavum to be divided as follows: Pars interspinalis, which clearly differs from the Lig. interspinale (and from the M. interspinalis), and which houses venous anastomoses in its dorsal, ridge-shaped extension. Pars interlaminaris, which starts at the laminae and constitutes the target area for flavotomy in its lateral section, and Pars capsularis, which merges into the capsular structures of the facets. In all levels examined, there proved to be dorso-ventrally a typical change in the direction of the course of the fibres in the Pars interlaminaris. Whilst the direction of the fibres dorsally is oriented cranio-medially to caudo-laterally at an angle between 15 degrees and 30 degrees to the median line, the ventral fibres of the Lig. flavum are strictly aligned cranio-caudally. The changes in the directions of the fibres are continuous with the fibres being very closely intertwined, without there being any spatium at all. The texture of the Lig. flavum is, therefore, a mirror image of that of the autochthonuous muscular system of the back, even if the overlapping angle area is considerably smaller. The different segment levels show a segment-specific thickness profile. The analysis has provided anatomic information about the Ligg. flava L2/L3 to L5/S1. These data represent important prerequisites for a selective, gentle and safe intraoperative procedure for discotomy.

[Epiduroscopy with access via the sacral canal. Some constructional equipment requirements from the anatomic and biomechanical viewpoint]

To ensure optimal mechanical functioning of the vertebral column, intact symmetry of its bony and muscular elements is mandatory. With this in mind, the need to reduce the invasiveness of spinal surgery is even greater than that applying to surgery in general. To avoid bony or muscular damage during surgery, in particular in the case of the segments L4/L5 and L5/S1-which are particularly prone to intervertebral disc rupture-laser discotomy procedures, with introduction of instruments via the sacral canal during epiduroscopy are presently being developed. Preliminary experiments on human corpses have demonstrated the practicability of the technique, but specially designed instruments have yet to be developed for use in patients. In an attempt to define the conditions of important for the design of the instrument, we have carried out a morphometric analysis of 100 sacral bones (56 females; 44 males). The configuration of the sacral canal is described in quantitative terms, and the results used to determine the diameters and curvatures of the instruments needed for laser discotomy.

[The effect of lumbar relief orthoses with abdominal compression on esophago-gastrointestinal motility]

OBJECTIVE

To investigate the effect of lumbar ortheses with abdominal compression on gastro-oesophageal reflux and gastrointestinal transit.

PATIENTS AND METHODS

In a prospective study 20 consecutive patients with lumbar syndrome treated with lumbar orthesis (10 female, 10 male, median age 54.6 years) were investigated for gastro-oesophageal reflux, mouth-to-cecum transit time (MCT), and whole-gut transit time. Gastro-oesophageal reflux was assessed performing an ambulatory pH metering of the distal oesophagus over a period of 10 h with and without ortheses on two separate study days. After positioning of the pH catheter patients ingested a liquid-solid test meal labelled with 10 g lactulose and 750 g indigocarmine to determine MCT with the hydrogen breath test and whole-gut transit by the first appearance of indigocarmine in the stool. Dyspepsia was assessed by using a standardized questionnaire.

RESULTS

Lumbar ortheses induced a significant increase in reflux time (pH < 4) (8.1 vs 4.1%), total number of reflux episodes (102.5 vs 69.5) and duration of longest reflux episode (6.0 vs 3.7 min) (P < 0.05). 12 patients with ortheses revealed an increase in relative reflux time (2.1-24.5%, median: 8.2%) more than two standard deviations compared to previously obtained normal values. In these patients during ortheses dyspeptic symptoms correlated significantly with reflux time (r = 0.6; P < 0.05). In contrast, MCT and whole-gut transit time in patients with and without ortheses did not differ significantly (85 vs 85 min; 10.2 vs 9.6 h).

CONCLUSION

Lumbar ortheses with abdominal compression, nowadays frequently used in the lumbar syndrome, produce gastro-oesophageal reflux associated with dyspepsia. Gastrointestinal transit time is not affected, though.