[Isolated bilateral Sternocostoclavicular Hyperostosis (SCCH) with a pathological clavicular fracture--a 10-year follow-up]

The presented case demonstrates the clinical and radiological course of a woman suffering from bilateral sternocostoclavicular hyperostosis (SCCH) from early changes to a spontaneous clavicula fracture after 10 years. SCCH is characterised by a chronic recurrent painful swelling of the sternoclavicular region due to an aseptic inflammation and hyperostosis of the clavicula, sternum, upper ribs and the adjacent soft tissues. Frequently the picture is accompanied by cutaneous and other skeletal symptoms. The disease can be part of the SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome. The chronic process is represented by the typical "bull horn sign" in a bone scan. NSAIDS should represent the first line treatment.

[Portable NMR-MOUSE: a new method and its evaluation of the Achilles tendon]

AIM

The increased demands placed on the Achilles tendon in recreational and professional sports have led to a rise in pathological changes in this anatomic region. Magnetic resonance evaluations of the tendon have proven to be a valid but expensive and stationary diagnostic tool. In this study, a new mobile NMR sensor was to be tested in the evaluation of the Achilles tendon.

METHOD

The technical development of the so-called NMR-MOUSE ( Mobile Universal Surface Explorer) represents a novelty with an open and portable sensor. To appraise its diagnostic efficacy, healthy athletes (professional soccer players, track and field, as well as aquatic athletes), healthy controls and patients with Achilles tendon lesions were evaluated. As an accessible, sensitive and reproducible parameter for the study the transverse relaxation time T2 with its angular dependency was chosen. As part of the examination, the relaxation times of the skin, the tendon and the surrounding soft tissue were determined.

RESULTS

During the evaluation with the NMR-MOUSE, the skin and peritendineous tissue exhibited relatively long T2 relaxation times, while the tendon itself had significantly shorter T2 times, allowing for a clear differentiation of the structures. The T2 relaxation time of the Achilles tendon in the control group averaged 5.8 ms. The MRI-MOUSE was able to demonstrate an increase in the T2 relaxation times in patients with pathological lesions of the tendon due to the increased water retention of the tissue.

CONCLUSION

The novel NMR-MOUSE represents a cost efficient and portable sensor, which allows for a reliable evaluation of surface structures, such as the Achilles tendon. The anisotropic structure of the tendon and the surrounding soft tissue can be reliably differentiated with the help of the NMR-MOUSE.

[The value of peripheral quantitative computed tomography (pQCT) in the diagnosis of osteoporosis]

AIM

To evaluate the accuracy of distal radial pQCT in discriminating between osteoporotic fracture and non fracture cases and its efficiency to predict fractures.

METHODS

Densitometric data determined with an XCT 900 Stratec pQCT device at the distal radius of women who had suffered distal radius (57), spinal (87) or femoral neck fractures (21) before or after measurement were compared with densitometric data of age-matched healthy women (265) and were analyzed in regression tests. Women whose fractures occurred before measuring were selectively analyzed.

RESULTS

More significant differences between fracture and non fracture groups were obtained by trabecular bone density (TBD) (r2radius = 0.531, r2spine = 0.528, r2femur = 0.711, p < 0.001) than by total bone density (BD) (r2radius = 0.468, r2spine = 0.495, r2femur = 0.605, p < 0.001). In the radius and spine group TBD data determined before fracture showed less significant differences than those determined afterwards, whereas in the femur group TBD data were almost equal. All femur fractures could be predicted. As TBD decreased, the relative risk of fracture increased by gradients of m radius = 0.017, m spine = 0.013, and m femur = 0.027 in the linear regions of the risk curves.

CONCLUSION

Selective measuring of TBD at the distal radius enables one to detect bone loss at an early stage and to estimate the risk of future fractures not only at the point of measurement.

[Arm motion analysis: a new method and its clinical application]

AIM

An investigation into the objective criteria of shoulder mobility possesses special meaning for diagnostic documentation, the evaluation of therapy and the effects of rehabilitation in the treatment of diseases of the shoulder. In order to ascertain the criteria which characterise shoulder mobility, it is necessary to have a tool available that is objective, comparable and allows the complexity, variability and range of motion to be recorded. Motion analysis represents one such standard procedure used to measure joint movement.

METHOD

Accordingly, a marker- based motion analysis of the wrist and elbow, a marker-based three-dimensional motion analysis system for the upper extremities was developed. We evaluated 10 healthy subjects without shoulder conditions and 8 patients with impingement syndrome (7 operative, 1 conservative therapy).

RESULTS

The healthy subjects revealed a reproducible motion curve for the specific motion tested. The curves were defined as the normal standard and we used them for comparative purposes. In the treatment group, an improvement of the 3D range of motion could be documented for the affected shoulder following rehabilitation.

CONCLUSION

It can be stated that this newly developed marker-based procedure for the three-dimensional motion analysis is suitable for recording complex unconstrained movements. This was found to be more relevant for the assessment of the ability of patients to manage the physical demands of daily living than traditional clinical tests. Furthermore, the information gained from motion analysis of the upper extremities will play a valuable role in the future for quality control during diagnosis and treatment, as well as for the design of shoulder rehabilitation programs.

Septic arthritis of the knee in adults: treatment by arthroscopy or arthrotomy

Fifty-one patients with septic arthritis of the knee were reviewed retrospectively. Twenty-seven patients had been treated by arthroscopic lavage and debridement, 24 patients by open arthrotomy with subtotal synovectomy. The patients were staged according to the duration of preoperative symptoms and to the intraoperative spread of the inflammatory process. With early onset of therapy (less than 5 days) and without osseous involvement arthroscopic treatment led to an effective resolution of infection with better functional results than open arthrotomy.

Diagnostic and therapeutic management of lumbar and thoracic spondylodiscitis--an evaluation of 59 cases

Fifty-nine patients with spondylodiscitis (SD) of the thoracic and/or lumbar spine were followed-up clinically and radiologically [X-ray, computed tomography (CT), magnetic resonance imaging (MRI)] over a mean time of 2.2 years (1-6.5 years). All patients without abscess formation (n = 35) were treated conservatively. Out of the group with abscess formation (n = 24) 6 patients were also treated conservatively, 11 were drained under CT control and 7 were operated. At time of diagnosis, "signs of florid inflammation" were seen in 60% of the roentgenograms, in 93% of the CTs and in all of the MRls. The sensitivity to differentiate between SD with and without abscess formation was 85% by MRI and 69% by CT. "Signs of regressive inflammation" and "signs of increasing osseous consolidation", essential facts for starting remobilization, could first be seen using CT 6 weeks after onset of therapy. Using MRI these signs were seen with a considerable delay at 12 weeks. Clinically, only 3 of the 59 analyzed patients developed recurrent SD. In conclusion, MRI is the radiological method of choice for establishing the diagnosis of SD, in particular with regard to differentiating between cases with and without abscess formations. In contrast, CT is superior for performing success control after treatment. Therapeutically, conservative, minimal-invasive and operative procedures are not rival but rather complementary.

Interleukin-6: a potential inflammatory marker after total joint replacement

In a prospective study C-reactive protein (CRP) and interleukin-6 (IL-6) measurements were taken serially in 30 patients before and after 20 total hip arthroplasties (THR) and 10 total knee arthroplasties (TKR). There were no peri- and postoperative complications. Postoperatively the IL-6 serum concentration increased rapidly and peaked 6 h postoperatively at maximum levels (399+/-140 pg/ml). There was a mean half-life of 15 h and thereafter a rapid return to normal concentrations. In comparison, the postoperative CRP concentration rose more slowly and reached maximum levels (138+/-54 mg/l) on the second postoperative day. There was thereafter a slow descent with a mean half-life of 62 h. There was no significant difference between the patients with THR and those with TKR (P>0.05). IL-6 is therefore a superior marker for the inflammatory phase after THR and TKR.

[Early diagnosis of isthmic spondylolysis with MRI]

INTRODUCTION

Early diagnosis of isthmic lumbar spondylolysis cannot always be established on plain radiographs and CT scans, only. In the case presented here, magnetic resonance imaging (MRI) showed typical bone marrow changes in T1- and T2-weighted images, even at an early stage.

CASE

A 11-year old female judoka complained of deep lumbar pain with local tenderness to pressure at L3 to S1. Clinically, there was no neurologic deficit. Conventional x-ray showed no abnormalities. In contrast, MRI revealed a locally ill-defined bone marrow oedema in both pars interarticularis of the 5th lumbar vertebra. This was interpreted as the typical MR-tomographic feature of occult stress fracture, which has to be seen as early evidence of isthmic spondylolysis. Complete restitution was achieved after conservative treatment.

CONCLUSION

In early spondylolysis--presented here in form of a case report--, changes of MR signal intensity in the pars interarticularis may be detected, even before fracture lines are to be seen on plain radiographs. Further studies are necessary to confirm MRI to be the method of choice for early diagnosis.

[Optimizing the bone cement-implant interface by hydrolysis-resistant conditioning of the metal surface]

PURPOSE

The hydrolytic degradation of the implant-cement interface has to be seen as the main reason for aseptic loosening of cemented total hip replacements. Therefore, a new method of conditioning the metallic surface was developed in order to achieve a hydrolytic-resistant bound stability between the implant and bone cement. Preliminary experimental data on test bodies are presented here.

METHOD

The metallic surface of 6 pairs of cylindrical test bodies each (CoCr-alloy, circular testing surface with O 6 mm) were conditioned by the method of silicoating/silanisation to gain a covalent coupling with the applied bone cement. In order to examine the initial stability and the hydrolytic resistance of the metal-cement compound, these pairs of surface-conditioned test bodies (SCT) as well as a reference series of surface-unconditioned test bodies (SUT) were immersed for 0, 30, 90, 150 days (d) in moisture environment (physiological saline solution, 37 degrees C) after coupling with bone cement. The adhesive strength of the test bodies-(bone cement-compounds) were determined by tensile tests on an universal testing machine (Typ Z030, Zwick, Ulm) with gimbal suspension.

RESULTS

At time 0 d (that was without immersion of the test bodies) the mean maximum tensile bond strength of the SCT-cement-compounds was 39.5 MPa (SD +/- 4.7 MPa) and that of the SUT-cement-compounds 37.1 MPa (SD +/- 7.3 MPa) (p = 0.575). After immersion the tensile bond strength of the SUT-cement-compounds significantly decreased to an average of 13.5 MPa (SD +/- 2.7 MPa) (30 d), 10 MPa (SD +/- 1.7 MPa) (90 d) and 12.3 MPa (SD +/- 1.4 MPa) (150 d) (p < 0.01). In contrast, the SCT-cement-compounds showed a nearly unchanged high mechanical stability with tensile bond strength values of 37.0 MPa (SD +/- 4.9 MPa) after 30 d, 36.1 MPa (SD +/- 5.0 MPa) after 90 d und 30.2 MPa (SD +/- 4.7 MPa) after 150 d (p > 0.01).

CONCLUSIONS

With reservation as to further in vitro and in vivo investigations the increased hydrolytic stability of the metal-cement-bound of surface-conditioned CoCr-alloy test bodies promises an improvement of the long-term stability of cement total joint replacements.

[A new MR-(and CT-) compatible bone biopsy system: first clinical results]

PURPOSE

To describe the development and clinical evaluation of a new, hand-powered or alternatively motor-driven, MRI and CT compatible percutaneous bone biopsy system.

MATERIALS AND METHODS

A new coaxial drill system (Cook Europe A/S) was designed for percutaneous, MR-guided bone biopsies and powered either by hand or an optional motor (10-250 rotations/minute using 6 bar [88.2 PSI] compressed air). The system has been used in 23 patients. Fourteen procedures were performed in a 1.5 T MR scanner (Philips-Gyroscan ACS-NT) which has an attached C-arm (Philips-BV 212-Angio) in case fluoroscopy is required, and 9 procedures in a CT scanner (Siemens-Somatom Plus).

RESULTS

Driven by hand or by the pneumatic motor unit, the system achieved safe and accurate MR-guided access to all of the lesions and was even able to penetrate osteosclerotic lesions. MR- or CT-guided percutaneous biopsy yielded a correct diagnosis in all but 5 cases. No procedural complications occurred.

CONCLUSION

MR-guided percutaneous bone biopsy performed with the new coaxial drill system was found to be safe and reliable, and suitable for obtaining histological specimens from skeletal lesions even when covered with thick cortical or sclerotic bone.

[Percutaneous CT-controlled puncture and drainage of spondylodiscitis--a minimally invasive method]

PURPOSE

Is there an absolute operative indication for the abscess-forming spondylodiscitis or is a curing also possible with minimal invasive procedures?

METHOD

In a retrospective study over a period from 1986 to 1993, 40 patients with a spondylodiscitis of the thoracic and lumbar spine were treated and then followed up over two years in our Department of Orthopedic Surgery. Using a CT-controlled method of minimal invasive punction and drainage of the abscessed forms of spondylodiscitis, it was to be settled whether these therapeutic procedures result in a normalization of the biochemical inflammatory parameters (CRP) and in a normalization of the CT--as well as MRI-findings.

RESULTS

7 of the 40 patients had a spondylodiscitis with a local abscess, further 7 patients had a gravidation abscess. 92.5% of the cases were treated conservatively and minimal invasively, respectively. In 11 patients the minimal invasive procedure was used in addition to conservative therapy. 3 cases had to be operated on. A recurrence of the spondylodiscitis was seen in 1 patient; complications (n = 2; 1 x pneumonia, 1 x venous thrombosis) occurred in 5% of all patients.

CONCLUSION

Minimal invasive therapy with CT-controlled punction or drainage may be a good alternative to the operative intervention in the predominantly old and multimorbid patients with abscessed forms of spondylodiscitis. The risk is minimized, the immobilizing period was 8.7 weeks on average.

[MRI-controlled outcome after core decompression of the femur head in aseptic osteonecrosis and transient bone marrow edema]

PURPOSE

We evaluated the signal changes of avascular necrosis and transient bone marrow oedema before and after core decompression of the femoral head to deduce prognostic factors for this operative procedure.

METHOD

38 to 40 cases with core decompression (35 patients, medium age 44 years) were analysed with a mean follow-up time of 26 months. Preoperatively patients were staged by the ARCO classification. MR-images were judged in accordance to the criteria of Mitchell and Steinberg. The clinical outcome was analysed according to the hip index of Merle D'Aubigne.

RESULTS

All hips with transient bone marrow oedema showed normal signal patterns at an average of 3 months after core decompression. In stage I and II, all patients with a preoperative necrosis area less than 30% of the femoral head showed a reduction of the necrotic zone and good clinical results. An unchanged or progressive appearance was observed in necrotic lesions with more than 30% head involvement. Because of failure a renewed operation had to be done in all patients with stage III and IV.

CONCLUSION

In the case of transient bone marrow oedema, a restitutio ad integrum can be achieved with core decompression. In stage I and II of avascular necrosis, the successful outcome depends on the lesion size of the femoral head. Necrotic lesions less than 30% seem to have the best prognosis. In stage III and IV, core decompression cannot be recommended.

MRI-guided biopsy of bone in a hybrid system

This is a report of our experience with percutaneous, MRI-guided biopsies in 25 patients with skeletal lesions using a 1.5-T MR hybrid system. Twenty-five consecutive patients with skeletal lesions were referred for MRI-guided biopsy. Biopsies were performed with a 1.5-T Philips Gyroscan (Philips Medical Systems, Best, The Netherlands) combined with a c-arm fluoroscopy. Specimens were obtained percutaneously either with a 14- or 18-gauge "side-slit" type of biopsy needle (n = 10 skeletal lesions that had penetrated through the cortex), or using a prototype coaxial drill system powered either by hand or an optional motor (n = 15 skeletal lesions still covered with cortical bone). All but two biopsies could be completed within the MR unit. For one patient, who required a transpedicular approach to a lumbar vertebra, and for one child, who required general anesthesia, we decided to switch to CT guidance. In 19 of the 25 cases (17 of the 23 cases performed in MR), the sample was sufficient and the histopathologic diagnosis was confirmed. Three patients had an inadequate sample, and three others had adequate samples but inaccurate results. No procedural complications occurred. Percutaneous biopsy of skeletal lesions performed under MRI-guidance was found to be safe and reasonably accurate. There were no procedural complications in our small series. MRI may be used as an alternative to CT, but its role vis-à-vis CT has yet to be ascertained.

Anatomic study of femoral vein occlusion during simulated hip arthroplasty

An anatomic study was undertaken to establish whether positioning of the leg and surgical approaches for total hip replacement (THR) cause changes in the femoral v. which may contribute to the development of deep vein thrombosis (DVT). The patency of 32 femoral vv. of 18 cadavers was inspected at different levels during simulated THR. Before and after removal of the femoral head through a transgluteal or posterior approach, a wide-angle endoscope was inserted into the femoral v. via the external iliac v. Blood flow was simulated by proximal irrigation with saline through the popliteal v. After removal of the femoral head distinct changes were observed in both approaches. In the transgluteal approach the changes were dependent on the degree of adduction and the body build of the cadaver. Initially, an oval form was seen in a constricted lumen with an increasingly oblique oval deformation and a final facet-like closure, usually at about 5 to 7.5 cm below the inguinal ligament. In total adduction this stenosis occurred regardless of build. Using a posterior approach, the necessary internal rotation caused a closure of the vein in 50% of cases. In combination with flexion and adduction there was stenosis in all cadavers regardless of body build. Our results indicate that the duration of the adducted position of the thigh during THR via a transgluteal approach should be minimised, as there is a reduction in blood flow with even minor degrees of adduction. In the posterior approach the stenosis occurs earlier, and is independent of the build of the cadaver.

Does the anchorage form and depth influence the pull-out strength of screws from bone cement? An experimental study

The pull-out strengths of cortical screws inserted into soft, unpolymerised Refobacin Palacos bone cement (procedure S) and into hardened polymerised cement into which a hole had been drilled and tapped (procedure P) were compared. Cortical screws 58 mm in length, outer diameter 4.5 mm and inner diameter 2.95 mm were used. Screws were inserted into cement cylinders at 5 mm incremental depths between 10 and 30 mm. At a screw depth of less than 25 mm, the screws pulled out, and at a depth of greater than 25 mm, the screws broke in both procedures. There was no statistically significant difference in pull-out strength leading to burst or break between the two procedures for screws inserted to comparable depths, but there was a statistically significant difference regarding the screwing depth regardless of the procedure of screw insertion chosen. The average material stability (sigma) of the cortical screws used was calculated to be 1191 N/mm2, and the elasticity limit was 5137 N. This study demonstrated that the material stability and not the depth of screw insertion was the limiting parameter in screw anchorage in bone cement while static testing. To avoid screw breakage due to fatigue during continuous alternate loading, the screws should not be loaded above this value.

Compound osteosynthesis of pathological fractures of the proximal femoral shaft. Experimental studies on the biomechanical effects of additional intramedullary splinting

The biomechanical stability of two compound osteosynthesis techniques with and without intramedullary splinting were compared in 20 paired cadaver femora. Group A was stabilised using a contoured 12-hole DC plate and polymethylmethacrylate cement. In group B an additional intramedullary semi-diameter osteosynthesis plate was inserted parallel to the outer plate and transfixed with the same screws. The specimens were tested in a universal testing machine using a force applied to the specimen at 45 degrees to the load to provoke the most unfavourable condition, consisting of a bending moment and torsion. Both force and extension were recorded. The compound osteosynthesis with an additional intramedullary plate (group B) reached an average higher load stability. This increase of stability was not significant statistically.

Reactivation of a tuberculous coxitis due to loosening of a total hip endoprosthesis

A 45-year-old woman who suffered from juvenile tuberculous coxitis at the age of 4 is presented. Her hip joint replacement lasted for 18 years and then needed replacing. Intraoperatively removed caseous soft tissue and an opalescent secretion histologically resembled a tuberculous focus, and bacteriological culture grew a Mycobacterium tuberculosis strain. Four months after the replacement, the patient suffered from a tuberculosis-induced septic loosening of the newly replaced hip joint endoprosthesis. The tuberculosis relapse was probably due to aseptic loosening of the first hip joint endoprosthesis.

Neopterin Determinations in Tuberculous Bone Infections

In patients with tuberculous chest infections caused by intracellular Mycobacteria elevated serum neopterin levels could be found. In the present study neopterin levels were elevated in 5/6 patients with proven tuberculous bone infections as well. Neopterin determinations in serum were especially helpful for the drug monitoring of these patients. After a sufficient antituberculous therapy initially elevated neopterin levels decreased and remained within normal range. Persistent elevation of neopterin may be a hint for a resistance of the Mycobacteria.

Osteocalcin levels in chronic osteomyelitis

Osteocalcin is a vitamin K-dependent bone protein synthesized by osteoblasts. In generalized bone disorders serum osteocalcin correlates with osteoblast activity. Bone resorption and new bone formation occur in chronic osteomyelitis, dependent on the level of inflammatory activity. In 17 patients with active chronic osteomyelitis undergoing surgery, the serum levels of osteocalcin, alkaline phosphatase and C-reactive protein were measured before and after treatment. The osteocalcin levels were within the normal range preoperatively (10.8 +/- 11.0 micrograms/l), in the early postoperative period, and at discharge. It is therefore not a helpful marker in the clinical management of this condition.

Pattern of macrophage subpopulations in post-traumatic bone infections after combined operative/antibiotic treatment

Macrophage subpopulations were detected immunohistochemically with the aid of monoclonal antibodies in tissue sections of 15 patients with posttraumatic osteomyelitis at the beginning of therapy and after combined operative/antibiotic treatment. Macrophages represent the majority of the immunocompetent cells in osteomyelitis tissue. Before the start of therapy, the acute inflammatory macrophage subtype 27E10 was absent or rarely found in 8/13 evaluable biopsies from the osteomyelitis focus, and a further decrease in the expression of these macrophage antigens was observed after treatment. The RM3/1-positive macrophage associated with the down-regulation of inflammation was detectable to a low extent in 4/13 evaluable biopsies from the osteomyelitis focus before the start of therapy. After treatment of the infection, an increase in this subtype was found in the cellular inflammatory infiltrates in the tissue samples examined. In 8/15 biopsies a marked expression of the RM3/1 antigen was observed. At the start of treatment, the macrophage 25F9, which dominates in the late phase of inflammation, was missing in 3/13 tissue samples. After combined operative/antibiotic treatment the 25F9-positive macrophage was found in all patients, having increased in 7/14 biopsies studied. These data suggest that treatment of posttraumatic osteomyelitis leads to a local macrophage subtype distribution in the osteomyelitis focus resembling the pattern of a late inflammatory reaction.

[Lymphocyte defects in chronic osteomyelitis. A prospective study]

In patients with chronic post-traumatic osteomyelitis, several deficits in immunological response were demonstrated. In a prospective trial of 20 patients with proven osteomyelitis, histological analysis of lymphocyte subsets in peripheral blood and in the infected bone tissue was performed. The effects of chronic osteomyelitis on lymphocyte subsets in the peripheral blood and in inflamed tissue were only slight. The T4/T8 ratio was diminished in only two patients and had no relationship to the clinical course. Interleukin 2 receptor determination was negative in 83% of biopsies of infected tissue. Osteomyelitis may possibly cause a defect in lymphocyte/macrophage cooperation.

[Suppression of macrophage subpopulations in post-traumatic osteomyelitis]

Similar to other chronic inflammatory diseases such as rheumatoid arthritis the distribution of macrophage subtypes seems to be disturbed in post-traumatic osteomyelitis. This atypical distribution is clearly locally restricted in osteomyelitis. 27E10-positive macrophages found only during the acute phase of inflammation were reduced in 39%, the 25F9-positive subtype, predominating in the late stage of inflammation, was missing in 33%. The antiinflammatory macrophage RM3/1 was decreased in 40% of the osteomyelitis biopsies. Local suppression of macrophage subsets has to be discussed as one of the reasons for the persistence of chronic inflammatory processes in osteomyelitis.

[PMN-elastase as a marker in diagnosis and follow-up of bone and joint infections]

PMN elastase, a proteolytic enzyme, is a biochemical marker for pathologic granulocyte stimulation. In the presence of sepsis, excessive neutrophil stimulation occurs and significant amounts of PMN elastase are released into the plasma and serve as an indicator for the severity of the disease and the prognosis. PMN elastase is also a useful parameter for preoperative diagnostic management and postoperative follow-up of bone and joint infections. In patients with osteomyelitis and joint empyema (n = 48) PMN elastase had a sensitivity of 77%, which was only exceeded by that of the unspecific erythrocyte sedimentation rate (sensitivity 89%). Sensitivities of other inflammation parameters were lower: C-reactive protein (CRP) 67%, fibrinogen 50%, neopterin 32% and leukocyte count 21%. Determination of PMN elastase levels was also helpful in postoperative follow-up of patients with bone and joint infections. In the early postoperative period PMN elastase levels normalized more quickly than the other parameters unless patients actually developed complications. At the first postoperative determination (day 2-4 after surgery) 38% of the patients (n = 24) already had PMN elastase levels within the normal range (less than or equal to 40 micrograms/l) (CRP 13%). After 10 days PMN elastase was normal in 57% and CRP in 30% of the patients. Later on both parameters reacted similarly: by the time of discharge from hospital levels of PMN elastase were normal in 70% and CRP levels in 74%.

[Immune reactions in chronic post-traumatic osteomyelitis. Current status determination]

Investigations in patients with chronic post-traumatic osteomyelitis could demonstrate several deficits in immunologic response: Phagocytic activity of phagocytes is lowered accompanied by a functional deminution of leukocyte receptors for C3. Intracellular killing is diminished. Investigations concerning T lymphocyte subpopulations verified a decrease in total T cells and helper/inducer T cells. Dysfunctions in specific humoral immune response are still debatable.

Influence of bone and soft-tissue operations on serum concentrations of growth hormone, somatomedin C and alkaline phosphatase

After animal experiments suggested there was an interaction between growth hormone and bone healing, our aim in this paper was to ascertain whether there were any changes or possible interaction between the serum level of growth hormone, somatomedin C and alkaline phosphatase while a fractured bone was healing. To this end, the serum concentrations of growth hormone, somatomedin C, alkaline phosphatase and calcium were ascertained both pre- and post-operatively in two groups of patients--one with bone operations, the other with soft-tissue operations--and the results were compared. Comparing the groups, we found that after bone operations there was no increase in the serum level of growth hormone, nor of somatomedin C. An increase would have implied that these two hormones are directly involved in bone regeneration. There was no change in the serum level of alkaline phosphatase or calcium after either bone or soft-tissue operations.

Treatment of an old infection in a total hip replacement with an interim spacer prosthesis

When treating a septic hip-joint prosthesis with bone loss of the proximal femur secondary to osteomyelitis, we implanted a specially designed prosthesis to act as a local antibiotic and spacer between the acetabulum and femur until the infection abated. Arthroplasty could then be carried out with no trouble and there was no recurrence of infection.

[Treatment of infected total hip endoprostheses]

In total hip arthroplasty the most serious complication besides aseptic loosening is infection. The results observed in 42 cases of infected hip arthroplasties are presented. In contrast to early superficial infection, deep infection following total hip replacement is difficult to treat. Depending on the general condition of the patient, a well-defined, adequate treatment is required. In patients at vital risk the provocation of a permanent fistula can be recommended as an alternative method in preference to revision arthroplasty.

Nuclear imaging in loosening of hip-joint endoprostheses

In 28 patients with surgically proved loosening of hip-joint endoprostheses and 42 patients without loosening between 2 and 12 years after implantation and without clinical or radiological signs of loosening we performed clinical evaluation, and radiographs, a three-phase bone scan, and a 111indium-labeled leukocyte scan (ILLS). The sensitivity of radiographs in the group with loosening of hip-joint endoprostheses in the femoral as well as in the acetabular component was only about 50%, while the specificity was almost 100%. With a combination of radiographs and ILLS we reached a sensitivity in the acetabular component of 100% and in the femoral component of 88%, but specificities of only 57% in the acetabular component and 40% in the femoral component were found. We found that the ILLS is a very helpful method of examination to detect loosening of hip-joint arthroplasties in doubtful cases.

[Apophyseal avulsion fractures in adolescents--a typical sports injury]

Pelvic apophyseal avulsion fractures in 22 adolescents were followed up for a longer period. Etiology, main localisation, diagnosis and differential diagnostic aspects in the pelvic and hip region, the usual treatment and complications of these stable pelvic fractures are discussed. Characteristic radiographs are demonstrated.

The importance of anaerobic infections in abdominal surgery

The clinical significance of anaerobic bacteria in infective complications occurring in intestinal surgery is discussed. For high-risk patients the authors recommend parenteral prophylactic administration of clindamycin and gentamicin.

[Heitis terminalis promoting cancer (author's transl)]

The increasing number of publications about the incidence of cancer in small intestine with Crohn's disease shows Ileitis terminalis as an affection promoting cancer. Main problems are early diagnosis and differential diagnosis concerning intestinal stenosis caused by Crohn's recidivation or blind loop after resection. Regular scrutiny of patients with Crohn's disease is of special significance; because of the few present case reports early resection as prophylaxis is not justified.