Experts' Perceived Patient Burden and Outcomes of Knee-ankle-foot-orthoses (Kafos) Vs. Microprocessor-stance-and-swing-phase-controlled-knee-ankle-foot Orthoses (Mp-sscos)

BACKGROUND

Patients with neuromuscular knee-instability assisted with orthotic devices experience problems including pain, falls, mobility issues and limited engagement in daily activities.

OBJECTIVES

The aim of this study was to analyse current real-life burden, needs and orthotic device outcomes in patients in need for advanced orthotic knee-ankle-foot-orthoses (KAFOs).

METHODOLOGY

An observer-based semi-structured telephone interview with orthotic care experts in Germany was applied. Interviews were transcribed and content-analysed. Quantitative questions were analysed descriptively.

FINDINGS

Clinical experts from eight centres which delivered an average of 49.9 KAFOs per year and 13.3 microprocessor-stance-and-swing-phase-controlled-knee-ankle-foot orthoses (MP-SSCOs) since product availability participated. Reported underlying conditions comprised incomplete paraplegia (18%), peripheral nerve lesions (20%), poliomyelitis (41%), post-traumatic lesions (8%) and other disorders (13%). The leading observed patient burdens were "restriction of mobility" (n=6), followed by "emotional strain" (n=5) and "impaired gait pattern" (n=4). Corresponding results for potential patient benefits were seen in "improved quality-of-life" (n=8) as well as "improved gait pattern" (n=8) followed by "high reliability of the orthosis" (n=7). In total, experts reported falls occurring in 71.5% of patients at a combined annual frequency of 7.0 fall events per year when using KAFOs or stance control orthoses (SCOs). In contrast, falls were observed in only 7.2 % of MPSSCO users.

CONCLUSION

Advanced orthotic technology might contribute to better quality of life of patients, improved gait pattern and perceived reliability of orthosis. In terms of safety a substantial decrease in frequency of falls was observed when comparing KAFO and MP-SSCO users.

[Rehabilitation following the amputation of an extremity]

The rehabilitation of patients with an amputation is challenging and an example of an interdisciplinary team approach. Knowledge of the principal surgical techniques and the needs for a good prosthetic fitting is mandatory for the team members. According to the ideas of International Classification of Functioning, Disabilities and Handicaps the goal of the rehabilitation is to achieve the highest possible participation in private, work and social life of the patient. Within the team a clear definition of responsibilities is necessary, as well as an intensive communication structure. The patient himself plays a major role. This rehabilitation is complex, in terms of both personal and resource use. Depending on the level of amputation, the usual rehabilitation times range between 4 to 12 weeks for the lower extremity; for the arms, the time varies greatly from person to person. Longer rehabilitation times seem to ensure better treatment outcomes in the long term.

[A German Survey of Goal Setting and Goal Agreement in Medical Rehabilitation]

AIM

To describe the current practice of goal setting and goal agreement in the Medical rehabilitation in Germany.

METHODOLOGY

Rehabilitation centers contracted by the German Pension Insurance and covering all indications were approached by a questionnaire survey.

RESULTS

The percentage of questionnaires returned was 48.1% (N=716). 93.3% of the responders replied that the importance placed on "rehab goals" at their institution was "very high" (41.1%) or "quite high" (52.2%). Our findings, however, reveal the potential for improving the quality of setting rehab goals in the fields of "process orientation", "team orientation" and "patient orientation".

CONCLUSION

Rehabilitation centers perceive current practice in goal setting and goal agreement as being on a high level. The rehabilitation centers name many positive aspects as well as barriers to goal setting. Those problems should be more frequently addressed in practice.

[Errors and complications associated with lower limb amputation]

BACKGROUND

The newly launched "German law of patients' rights" strenghthens the rights of patients and places special emphasis on the right to full information. This includes information on errors, mistakes and complications due to surgery.

ASSESSMENT

Surgery complications and mistakes are of main importance especially in the area of amputation because rehabilitation chances are dependent on good surgical quality. Therefore, it is necessary that surgeons know about these problems. Complications may be hematomas, bleeding, dysvascular problems, skin- or muscle-necrosis, and infections and wound healing problems, as well as neuromas or calcification of soft tissues. They are not totally preventable.

CONSEQUENCES

Surgical mistakes may involve insufficient shaping of the bony stump end, incorrect treatment of soft tissue, wrong decisions regarding the amputation level, insufficient treatment of nerves and wound closure under tension of soft tissue. All surgical mistakes negatively influence the end-bearing capability of the stump and, therefore, the prosthetic fit, and with this reduce rehabilitation chances.

PURPOSE

It is necessary that surgeons know about these problems in order to avoid them. Therefore the typical complications and errors are demonstrated with case reports.

[Protect employability: effects of prevention programs offered by the German pension scheme]

A pilot study was carried out in 4 medical rehabilitation centers to examine the practicability and effectiveness of preventive life-style interventions for employees with risk factors. The programs were developed in cooperation with the German pension scheme and employers. Selection criteria were risk factors as lack of physical activity, overweight, dorsal pain or job strain. The results demonstrate that preventive programs, which are conducted in addition to the normal working hours on the job, can be implemented successfully in rehabilitation units. The participation in the multimodal prevention program goes along with a stable reduction of risky health behavior: increased physical activity, stress coping, dietary change und weight reduction. The healthier life-style is reflected in an enhanced state of health and has also positive impact on the occupational field scale: The percentage of employees who believed to be able to work until their old-age pension, could be increased significantly (p<0.001) from 47% to 74%. Work-related risk behaviors like excessive demands on oneself were reduced and protective strategies were -developed.

[Technical orthopedics. Importance in an increasingly operatively oriented faculty]

The foundation of the German Society for Orthopedics in 1901 was due to a separation from the faculty of surgery because a surgical approach alone did not adequately deal with the symptoms. Orthopedists were initially considered as a fringe group. The conservative treatment approach was initially at the forefront and operative measures were a side line. The main aim was the rehabilitation of patients into a normal life as best as possible. In the conservative area treatment with orthopedic technical aids and appliances rapidly came to play an important role and a great multitude of technical appliances were developed with sometimes very different possible applications. Despite the clearly improved operative treatment approaches in orthopedics and trauma surgery, technical orthopedics still plays a substantial role even today. Healing and supportive aids and appliances are of decisive importance for the treatment of a multitude of diseases and handicaps. They stabilize and improve operative treatment results and often result in new approaches. This depends on cooperation between technicians, therapists and physicians in a team, even in the scientific field. Evidence-based studies on the effectiveness of technical aids are currently still uncommon but recently some clear evidence for effectiveness could be shown. Scientifically this is a very varied field of work. The demographic development presents new requirements which must be dealt with. Technical solutions are often very promising especially in this field. Technical orthopedics remains an important component of the specialty of orthopedics and trauma surgery and with an increasing tendency due to more recent research and development.

[DGRW-Update: musculo-skeletal diseases]

BACKGROUND

Orthopedic rehabilitation is a major entity in rehabilitation. Due to coming demographic changes and its challenges concerning mobility of elderly patients it will increase. The criticism on orthopedic rehabilitation in Germany focuses on its missing evidence in therapeutic eff ectiveness especially in chronic low back pain. This overall-criticism is actually no more valid as there are a number of studies showing eff ectiveness of orthopedic treatment in rehabilitation if psychosocial comorbidities are respected and treatment is focussed on occupational training and eintegration.

GOALS

This overview describes the actual situation in orthopedic rehabilitation and its research.

RESULTS

The need for orthopedic rehabilitation will increase over the next years due to demographic changes. Important fi elds in orthopedic rehabilitation research are chronic low back pain, new rehabilitation models with focus on occupational reintegration, rehabilitation in elderly and following joint surgery as well as the analysis of health-care-system changes due to disease related groups.

[REDIA--impacts of DRG introduction in the acute sector on medical rehabilitation]

The REDIA study is the only long-term (2003-2009), prospective, multicentre study analyzing the impact of the DRG system on quality and costs in rehabilitation facilities. In 2004, Diagnosis Related Groups (DRG) were implemented on a mandatory basis in the German healthcare system as a reimbursement scheme for hospitals based on administered prices for procedures. Experiences from other countries revealed that introduction of DRG does not only have a significant impact on hospitals but also on rehabilitation facilities. The study approach ensures a comprehensive analysis as it considers major clinical, therapeutic, psychological and economic aspects. The REDIA study is the only nationwide empirical study that includes all stages of the implementation process: before DRG implementation, during the convergence phase and following implementation. An indication-specific comparison of the phases showed significantly shorter stays in the acute sector as well as shorter transition times between the sectors, resulting in admission of patients into rehabilitative care at an earlier stage of their recovery process. Significant diversions of treatment efforts from the acute sector to the rehabilitative sector have been proven in terms of increased nursing efforts and potential changes in the therapeutic and medical treatments to be provided.

[A comparison of multimodal programmes of patient education in the rehabilitation of chronic low back pain]

There is growing evidence for the effectiveness of multimodal intervention concepts for chronic low back pain in the international literature, and accordingly several German rehabilitation programmes for the treatment of chronic low back pain patients have been developed. Focus of this paper is to describe and compare frequently used German multimodal intervention programmes for in- and outpatient rehabilitation of patients with chronic low back pain. Programmes were chosen by searching the most relevant online resources as well as the online pages of Deutsche Rentenversicherung and Zentrum Patientenschulung during September 2008. Keywords guiding the search were: Patientenschulung, Rückenschmerzen, Manual, psychologische multimodale Interventionskonzepte, Rehabilitationsprogramm, psychology, intervention, low back pain, manual and therapy. By this means, six manually supported multimodal rehabilitation programmes for the in- and outpatient therapy of patients with chronic back pain could be identified: Göttinger Rücken-Intensiv-Programm (GRIP), the psychological programme for chronic head- and low back pain, the Münchner Rücken-Intensiv-Programm (MRIP), Back to Balance, Arbeiten und Leben--Back to Balance (ALEBABA) und Rückenfit: Lebenslust statt Krankheitsfrust. These programmes are depicted and compared with regard to their potentials and limitations in supporting the rehabilitation process of patients with chronic low back pain. While comparing the programmes, a number of similarities between them can be detected, as well as pronounced differences, e. g., regarding settings and complexity. In most programmes, lack of appropriate evaluation studies and lack of aftercare turn out to be critical aspects.

[Rehabilitation and prosthetic fitting in patients suffering from diabetic foot syndrome]

Rehabilitation of patients suffering from diabetic foot syndrome requires a holistic team approach. Besides the treatment of the local problems the treatment of the basic disease with education, correct nutrition and best possible drug treatment is of importance to prevent subsequent complications. A diabetic foot schooling is of importance to prevent secondary ulcers. Correct wound care with broad knowledge of wound healing stages, a variety of wound dressings and skilled knowledge in prosthetic and orthopedic shoe fitting plays a predominant role. The treatment is completed by physiotherapeutic gait training including the correction of gait deviations, psychological support and proper care.

[Preserving amputations or resection techniques on the foot]

The main causes for amputations on the lower extremities are dysvascular disease and/or diabetes mellitus. Especially in diabetics tissue preserving surgical techniques should be performed. Due to multimorbidity and high risk of an amputation on the other extremity, the so called "major amputations" ("transtibial" or "transfemoral") should be reduced. Especially in diabetics tissue preserving amputations on the foot or resection techniques on the foot are of importance to prevent major disabilities or handicaps on the patients. For this the surgeon has to have knowledge on all amputation levels on the foot as well as knowledge about prosthetic fitting or shoe techniques. With this a high percentage of good results will prevent the patient from major amputations.

Rehabilitation und Diagnosis Related Groups (REDIA-Studie): Auswirkungen der DRG-Einführung im Akutbereich auf die medizinische Rehabilitation

As experiences from other countries show, introduction and use of Diagnosis Related Groups (DRG), as of January 2004 now also mandatory in Germany, may have a significant impact on associated rehabilitation. The Institute of Hospital Management (IKM) in a multi-centre study promoted by Deutsche Rentenversicherung Bund and Deutsche Rentenversicherung Westfalen is conducting a study regarding potential diversion of healthcare expenditures from acute care towards rehabilitation as a result of DRG introduction in Germany. For documentation of potential short-term changes in patient populations and patient streams, extensive data have been collected in the first two phases in 2003/04 and 2005/06 for a total of 1342 cardiologic and orthopaedic patients. Indication-specific comparison of the two phases showed significantly shorter stays in the acute sector as well as shorter transition times between the sectors, resulting in an intake of patients into rehabilitative care at an earlier stage of their recovery process. Significant diversion of treatment efforts from the acute to the rehabilitative sector, regarding increased nursing effort and potential changes in the therapeutic and medical treatment to be provided, has not been proven as yet. The increase in wound problems expected by practitioners was confirmed in the orthopaedic area by an increasing number of wound healing disturbances and haematomas; in bypass-patients, an increasing number of pericardium and pleura bruises was found. The analyses performed on the data collected revealed no limitations in the patients' ability to participate in rehabilitative measures when the first and the second phase of the study are compared. To be able to depict the further course and interdependencies of changes, continuous systematic observation of developments would be desirable. To ascertain a lasting impact of DRG implementation at least a third study-phase will be necessary, which should be placed at the end of 2008, at the time when the DRG convergence phase will end.

Nachhaltigkeit orthopädischer Rehabilitation bei chronischen Rückenschmerzen - Das Integrierte orthopädisch-psychosomatische Behandlungskonzept (IopKo)

Chronic diseases of the musculoskeletal system rank first as causes of early retirement in Germany. Therefore orthopaedic rehabilitation has to identify patients with work-related problems and to promote return to work through differential treatment and vocational counselling. In the framework of the IopKo-Project such measures were developed and evaluated. These measures encompass: (1) an intensive and multiprofessional diagnostic pathway which allows early detection and treatment of mental disorders and job related problems; (2) homogeneous treatment groups based on multiprofessional diagnostics; (3) differential treatments, among these a multidisciplinary programme for patients with chronic low back pain or high risk of chronification (Rückenfit); (4) interactive training modules which mediate principles of performance and disability expertise, the legal bases of retirement pensioning, and measures to support occupational rehabilitation; and (5) a work hardening training programme.

METHOD

To evaluate the effects of these measures in comparison to a control group with usual care, a prospective longitudinal study was conducted. A total of 307 patients were assigned to the multidisciplinary in-patient treatment programme, whereas 176 patients in the control group had a standard rehabilitation programme.

RESULTS

The results show positive moderate and strong effects in the intervention group concerning function, pain, psychic strains as well as the number of sick days and return to work rates 10 months after discharge. The effects in the intervention group exceeded the effects achieved in the control group. PATIENTS WITH HIGH RISK OF CHRONIFICATION: Beside the full sample, a subgroup of patients with chronic pain or high risk of chronification was analyzed, who had received a multidisciplinary functional restoration treatment. Also for this subgroup we found moderate and strong effects of treatment for function, psychic strains and sick days superior to those in the control group.

CONCLUSION

By this study we were able to show that orthopedic rehabilitation in a multimodal and multidisciplinary setting with a focus on activating and motivating therapy can have sustainable positive effects on pain, function and psychic well-being as well as on economic parameters. We interpret these persistent and superior effects in the treatment group (1) as a result of multiprofessional diagnosis and assignment which helps to subdivide the inhomogeneous group of patients with unspecific back pain into more homogeneous and thus more effective subgroups, (2) as a result of increased motivation by closed treatment groups, (3) as a result of intense and multilevel counselling of work related problems, (4) as a result of work hardening modules, and (5) as a result of direct and efficient treatment of psychic strains. The results also demonstrate the significance of inpatient rehabilitation, which will be efficient if differential treatment - adequate to the problems of the patient - is offered.

Integriertes Orthopädisch-Psychosomatisches Konzept zur medizinischen Rehabilitation von Patienten mit chronischen Schmerzen des Bewegungsapparates - Langfristige Effekte und Nachhaltigkeit eines multimodalen Programmes zur Aktivierung und beruflichen Umorientierung

BACKGROUND

According to a recent review by Hüppe and Raspe effects of multidisciplinary treatment programs for patients with chronic low back pain in Germany seem to be rather weak and not to have persisting effects. Factors which could counteract possible benefits of treatment are, among others, psychic and job-related stresses and strains persisting after treatment. A multidisciplinary, in-patient treatment program for patients with chronic low back pain, therefore, was amended by multidisciplinary diagnosis and assignment and measures to support vocational solutions.

METHOD

To evaluate the effects of the multidisciplinary program in comparison to a control group with the usual care, a prospective longitudinal study was conducted. 307 patients were assigned to the multidisciplinary in-patient treatment program, whereas 176 patients with comparable complaints had the standard rehabilitation program. Besides the full sample, we analyzed a subgroup of patients with chronic low back pain.

RESULTS

We found positive moderate and strong effects in the intervention group concerning function, pain, psychic strains as well as the number of sick days and return to work rates 10 months after discharge. Effects in the intervention group exceeded the effects achieved in the control group. Beside the full sample, we analyzed a subgroup of patients with chronic low back pain, who received an intense activating group treatment. Also in this subgroup we found moderate and strong effects of treatment superior to those in the control group for function, psychic strains and sick days.

CONCLUSION

We attribute these persisting and superior effects in the treatment group to an efficient treatment of occupational and psychic problems as well as to more homogeneous treatment groups attained by a multidisciplinary diagnosis and team-based assignment. They also show the significance of in-patient-treatment which is effective, when -- based on multidisciplinary diagnosis -- differential treatment groups can be formed.

Berufliche Orientierung in der medizinischen Rehabilitation und Leistungen zur Teilhabe am Arbeitsleben

Return-to-work and protection of work-related participation is stated as a primary objective of rehabilitation by the statutory pension insurance institutes. A general continuous management of work-related participation in rehabilitation is a prerequisite for optimal results in view of stay in work and return to work. This means an extended vocational orientation in medical rehabilitation, individualized occupational rehabilitation according to need and capacity in connection with closer linkages between medical and occupational rehabilitation. In the course of the "Rehabilitation Sciences" research funding programme and beyond it, quite a few research projects and scientific activities aimed at development, testing and evaluation of -new screenings and diagnostic instruments with better findings of vocational related needs in medical and occupational rehabilitation, -specific methods of therapy and models for treatment settings with immediate reference to the work related restriction and capacity, as well as -models of the organization and forms of cooperation between medical and occupational rehabilitation. This paper reviews the projects and findings in these research fields in relation to the requirements for an increase of general continuous vocational orientation in rehabilitation.

[Gender-specific aspects in chronic low back pain rehabilitation]

Gender-specific Aspects in Chronic Low Back Pain Rehabilitation. Little is known about gender differences in utilisation, outcomes and evaluation of orthopaedic rehabilitation for chronic low back pain. The purpose of this article is to review and analyse the literature on rehabilitation and recovery of men and women with chronic back pain. In Western societies, chronic back pain is one of the most common causes for utilising medical rehabilitation services. In general no significant gender differences in the prevalences of back pain are found, but men are more sick-listed and early retired due to musculoskeletal diseases. Also, more men than women participate in medical rehabilitation programmes. National and international studies pinpoint the fact that differences exist between women and men with regard to participating in an orthopaedic rehabilitation programme. Additionally there is some evidence that different physical and psychological therapy services have different effects on health status of women and men. Mixed results are available regarding gender differences concerning the outcomes of rehabilitation programmes. Rehabilitation activities after discharge from in-patient programmes and these being performed within the home setting are primary indicators of recovery. Gender differences have been identified regarding various types of activities, apparently because especially family roles interfere with activity. Further research must be conducted so as to increase the understanding of women's and men's experiences relative to orthopaedic diseases and orthopaedic rehabilitation services.

["Zest for life instead of strain of illness" - implementation and evaluation of a programme activating chronic back pain patients in a rehabilitation clinic]

"Zest for Life Instead of Strain of Illness" - Implementation and Evaluation of a Programme Activating Chronic Back Pain Patients in a Rehabilitation Clinic.A group training was developed for chronic back pain patients in a rehabilitation clinic to enhance coping, to activate internal and external resources, and to make transfer to everyday life easier. The training consists of 12 either physiotherapeutic or psychologically oriented sessions. The training was evaluated in a longitudinal, quasi-experimental control-group design. Patients of the intervention group (n = 144) and control group (n = 157) rated the usefulness of the rehabilitation for private and working life at the end of the in-patient phase (t1) and three month later (t2). They also evaluated selected elements of the rehabilitation (t2). Results show that the anticipated usefulness of the rehabilitation was rated higher at the end of the stay than three months later. This indicates frustration after returning to everyday life. Patients of the intervention group rated the transfer possibilities to working life higher than the control group. They also are more satisfied with the psychological parts of the rehabilitation. After minor revisions, such as strengthening the topic of employment, the training now is implemented in the clinic for all patients with chronic back pain.

[Ambulatory diagnosis and therapy of gonarthrosis]

AIM OF STUDY

To develop recommendations for appropriate diagnostic procedures and conservative treatment of knee osteoarthritis in outpatients.

MATERIAL AND METHODS

Following a consensus conference and expert reviews basic recommendations were developed.

RESULTS

While standardized radiographic assessment is mandatory, MRI investigation should be restricted to problems apart from osteoarthritis. Indications for physical therapy, bracing and pharmaco-treatment depend on the severity of the disease. Guidelines for intraarticular injections are presented.

CONCLUSION

Effective treatment of knee osteoarthritis must be based on available recommendations and guidelines.

[Asymmetry of posture and truncal musculature following unilateral arm amputation--a clinical, electromyographic, posture analytical and photogrammetric study]

Unilateral upper limb amputation causes changes in statics of the spine. As a result asymmetrical posture of the spine, muscular asymmetries follow. In this study a population of upper limb amputees (above and below elbow amputees) is examined by clinical, electromyographical analysis and gait analysis. Upper limb amputations cause in correlation to weight loss a shift of the trunk to the side of the amputation, a scoliosis with a bowing to the side of the amputation, an elevation of the shoulder on the amputation side and a torsion of the trunk. Muscular asymmetries result from loss of function (muscles of the arm, M. latissimus, M. trapezius) and by shifting of the center of gravity. In order to get the center of gravity over the legs, the amputee compensates the loss of weight by shifting the upper trunk to the side of the amputation. As a result the shift of the segmental center of gravity at the lumber height to the side of the normal arm with muscular asymmetry in the erector trunci lumbalis results. As well we saw an overactivity of musculus glutaeus medius and resulting stress of the amputation sided hip joint. There was a remarkable difference between above and below elbow amputees caused by differences in weight loss. Muscular and static asymmetries in amputees who lost their arm only a short period before could be reduced by compensating the weight loss. Results for technical orthopaedic fitting and stress on gymnastic procedures to compensate these statistical problems are discussed.

[Special case report: Gangrene of all 4 extremities caused by disseminated intravascular coagulation in pneumococcal sepsis]

The rare case of a child with gangrene of all extremities following intravascular coagulation in pneumococcus septicaemia is described. The two years old spanish girl showed a gangrene of all four extremities and accompanying celloid scars. The operative treatment, the orthopaedic technical fitting as well as the problems are discussed.

[The diabetic foot]

Foot disease in patients with diabetes mellitus is multifactorial and results from a combination of peripheral neuropathy, vascular compromise and superimposed infection. Foot complications in diabetic patients are common and account for more hospital days than any other aspects of their disease. Therefore, familiarity with the spectrum of findings in the different imaging modalities appears essential. Radiographically, significant changes include Charcot joints of the tarsus (destructive type) and bone absorption of the forefoot (mutilating type). In diabetic foot problems, magnetic resonance imaging and leukocyte scintigraphy appear to be the most effective tools for detection of osteomyelitis, and a negative study makes osteomyelitis unlikely. However, the findings of both techniques in active, noninfected neuropathic osteoarthropathy may be indistinguishable from those of osteomyelitis.

Long term results of uncemented Judet hip endoprostheses

We reviewed 94 patients in whom 113 Judet uncemented total hip endoprostheses had been inserted; 83 had a mean follow up of 10.8 years (range 6 to 13 years). The Merle dAubigne and Harris hip scores were used for clinical evaluation. In the long term follow up, severe or moderate pain was present in 38.6% of hips. Radiographs were studied and radiolucent lines, and other evidence of loosening, were recorded. Twenty hips (24.1%) showed radiological signs of loosening of the acetabular cup and a displacement of more than 5 mm in 37.3%. The loosening rate of femoral stems was 32.5%, but only 8.4% showed subsidence. The cumulative survival rate at 6 years was 84.1%, decreasing to 55.1% after the eleventh year. Complications and other aspects of the outcome are discussed. Our results were on the whole not satisfactory and we cannot recommend this type of uncemented endoprosthesis for routine total hip replacement.

[Technical surgical possibilities for preserving an end-bearing knee exarticulation stump in skin necrosis]

Disarticulation of the knee results in an excellent end-bearing stump. Operative technique is easy, fast and gentle. The muscular balance in the femur is not disturbed. The shape of the stump provides excellent rotation control in the prosthesis. New socket designs and prosthetic knee mechanisms have eliminated the former cosmetic problems concerning this amputation level. Nevertheless--because of external rotation of the femur, poor skin quality or wound closure under tension skin necrosis can occur, most of the times concerning the lateral condyle region. Several operative possibilities to get a satisfactory wound closure while preserving the advantages of this stump are presented.

[Walking ability in bilateral leg amputees following prosthetic rehabilitation]

Between January 1989 and March 1993 117 patients were treated after acquired bilateral amputation of the lower extremities at the "Klinik und Poliklinik für Technische Orthopädie und Rehabilitation der Westfälischen Wilhelms-Universität Münster", Germany. Information from patients files and telephone interviews were collected to assess the degree of use of prostheses. All patients with levels of amputation not higher than above-knee on one side and hind-foot on the other side used their prostheses for daily walking. None of the patients with bilateral knee-disarticulation or higher levels of amputation used prosthetic devices for regular walking. In patients with amputation levels between these extremes the result of rehabilitation with prostheses is determined mainly by the cause of the amputation.

[Amputation in geriatric patients]

The incidence of amputation rises dramatically in old age. Trauma and tumors are uncommon reasons in this age group, however; 90% of amputations in such patients are performed for occlusive disease. These patients are distinguished from all other amputees by their multiple morbidity, which must be borne in mind at all stages, from the decision to operate to rehabilitation. This paper briefly indicates the points that are important for an optimal result of rehabilitation, starting with selection of the amputation level and extending through to provision of the prosthesis and mobilization. The paper ends with a presentation and discussion of the results of rehabilitation in 90 patients aged over 70.

[Long-term results of Judet's cementless total endoprosthesis of the hip joint]

AIM

Control of the long term results of the Judet-TEP.

METHODS

From 1980-1985 124 Pat. have been operated. The follow up was done in the same collective of 83 patients after 2-6 years and > 6 years.

RESULTS

The intraoperative complications have been fractures of the femur (19.3%) and the trochanter major (3.6%) and luxation (1.9%). In the follow up time the clinical results declined. The patients complained increasing pain in the thigh (26.5%) and the groin (13.2%). Radiological loosening of the acetabulum occurred especially in the medio-caudal area (61.5%) and in the proximal femur (32.5%). Cranial movement of the cup (31.3%) and varus deviation in the femur (40.9%) predominated. 28 prostheses were revised. After 11 years the cumulative success rate was 55.1%.

CONCLUSIONS

The long term results are disappointing.

Treatment of congenital elevation of the scapula. 10 (2-18) year follow-up of 37 cases of Sprengel's deformity

We studied retrospectively and partially prospectively all 37 cases of Sprengel's disease who were treated between 1970 and 1990, 23 of whom were operated on. Many of the patients were severely handicapped by abnormal shoulder abduction and elevation. Neurological deficits were not found. 34 of our cases had other congenital malformations. Several operative techniques were used. In cases with only cosmetic problems we now prefer resection of part of the superior angle. In cases with impaired function we prefer the Woodward-procedure.

[Charcot's elbow joint in syringomyelia]

Neuropathic arthropathy is a rare case in daily orthopedic practice. The case of a 43 year old technician is reported, who developed severe destruction of both elbow joints as a result of syringomyelia. The diagnostical problems as well as the therapeutical considerations are discussed.

White blood cell scintigraphy with monoclonal antibodies in the study of the infected endoprosthesis

Forty-three patients with suspected infection of a hip or a knee prosthesis were studied with white blood cell scintigraphy (WBC), using technetium-99m (n = 37) or iodine-123 (n = 6) labelled monoclonal mouse antibody (MoAb). Previously, all patients had undergone skeletal scintigraphy, which was performed as a three-phase study in 33 cases. The final diagnosis was established by open surgery, histology and culture in 37 cases, by puncture and culture in 3 cases, and by clinical follow-up of at least 6 months in 3 cases. Eighteen prostheses were infected, 25 uninfected. The delayed phase of skeletal scintigraphy had a sensitivity of 92%, a specificity of 24% and an accuracy of 48% in the detection of infection. The perfusion and blood pool activity of the three-phase bone scan had a sensitivity of 67%, a specificity of 71% and an accuracy of 70%. The diagnostic value of WBC was sensitivity 89%, specificity 84% and accuracy 86%. WBC with 99m-Tc-MoAb is easy to perform and always available. Its diagnostic accuracy is similar to conventional WBC scintigraphy with either indium-111 or technetium-99m.

Inflammatory reactions in primary osteoarthritis of the hip and total hip prosthesis loosening

In 14 patients [9 with loosened total hip arthroplasty (THA), 5 with primary osteoarthritis], the inflammatory cell infiltrate was characterized in cryostat tissue sections using antibodies against subsets of macrophages and lymphocytes. In all patients the abundance of a mature type macrophage (25F9+) was observed, whereas 27E10+ macrophages, characteristic of acute inflammatory reactions, were not seen in primary osteoarthritis but were found in 4 out of 9 patients with THA loosening. The RM3/1 + macrophage phenotype was seen in some of both sets of patients (osteoarthritis 4/5; THA loosening 4/9). The markers MRP8 and MRP14 typical of immature macrophages, were found in all patients with osteoarthritis and in some (4/9 and 8/9 respectively) of those with THA loosening. IOT4+ T-helper cells were only present in 1/5 5 patients with osteoarthritis and in 2/9 patients with THA loosening. IOT8+ T-suppressor lymphocytes were more frequently present (in 4/5 and 5/9 respectively). The data reveal remarkable differences between the two groups of patients. While the inflammatory infiltrate in patients with osteoarthritis lacks the characteristics of acute inflammation, in patients THA loosening the inflammatory process seems to be determined by periods of acute reactions. The occasional presence particularly of T-helper cells suggests that the inflammatory process is less T-cell but rather macrophage-driven.

[Intra- and postoperative blood loss]

The first results of the DGOT-study "wound-heeling" are presented. In a population of nearly 3700 patients data of intra- and postoperative blood-loss, transfusion-volumes and postoperative drainage were examined. There were remarkable high rates of blood-loss, followed by high rates of infusion-, transfusion- and drainage-volumes. The drainage-volumes were in general half as high as the blood-loss. In joint operations there were even higher drainage-volumes. Operations with the highest blood-loss were operations of the back and total hip arthroplasties. The problems resulting for the patients as well as recommendations for reducing transfusion rates are discussed.