The natural alpha angle of the femoral head-neck junction

Aims

Asphericity of the femoral head-neck junction is common in cam-type femoroacetabular impingement (FAI) and usually quantified using the alpha angle on radiographs or MRI. The aim of this study was to determine the natural alpha angle in a large cohort of patients by continuous circumferential analysis with CT.

Methods

CT scans of 1312 femurs of 656 patients were analyzed in this cross-sectional study. There were 362 men and 294 women. Their mean age was 61.2 years (18 to 93). All scans had been performed for reasons other than hip disease. Digital circumferential analysis allowed continuous determination of the alpha angle around the entire head-neck junction. All statistical tests were conducted two-sided; a p-value < 0.05 was considered statistically significant.

Results

The mean maximum alpha angle for the cohort was 59.0° (sd 9.4). The maximum was located anterosuperiorly at 01:36 on the clock face, with two additional maxima of asphericity at the posterior and inferior head-neck junction. The mean alpha angle was significantly larger in men (59.4°, sd 8.0) compared with women (53.5°, sd 7.4°; p = 0.0005), and in Caucasians (60.7°, sd 9.0°) compared with Africans (56.3°, sd 8.0; p = 0.007) and Asians (50.8°, sd 7.2; p = 0.0005). The alpha angle showed a weak positive correlation with age (p < 0.05). If measured at commonly used planes of the radially reconstructed CT or MRI, the alpha angle was largely underestimated; measurement at the 01:30 and 02:00 positions showed a mean underestimation of 4° and 6°, respectively.

Conclusion

This study provides important data on the normal alpha angle dependent on age, gender, and ethnic origin. The normal alpha angle in men is > 55°, and this should be borne in mind when making a diagnosis of cam-type morphology. Cite this article: Bone Joint J 2018;100-B:570–8.

Adult osteochondritis dissecans and focussed ESWT: A successful treatment option

Extracorporeal shockwave therapy (ESWT) has gained acceptance in the medical field and in the treatment of non-unions and delayed bone healing. ESWT has been used effectively for many years as a noninvasive surgical procedure. The idea of treating Osteochondritis dissecans of knee and talus arose in the middle of the 1990's. OCD is known as a pre-arthritic factor in the long-term and still there is no consistent treatment. In the literature there is still only a small number of publications but international societies for shockwave treatment are convinced that ESWT on OCD shows to be an effective and safe method in the treatment of OCD in the early stages. We want to summarize the actual data on the treatment of OCD by ESWT.

Lateral epicondylitis: This is still a main indication for extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) is used in a number of indications in the medical field. A number of tendinopathies show good and excellent results due to evidence based medicine. The treatment of lateral epicondylitis is known to show conflicting results. This overview of the published RCT's on ESWT for lateral epicondylitis tries to show the reasons for this conflicting data-base and point out, why we think that this is still a main indication for extracorporeal shockwave therapy.

[Greater trochanteric pain syndrome]

Greater trochanteric pain is one of the common complaints in orthopedics. Frequent diagnoses include myofascial pain, trochanteric bursitis, tendinosis and rupture of the gluteus medius and minimus tendon, and external snapping hip. Furthermore, nerve entrapment like the piriformis syndrome must be considered in the differential diagnosis. This article summarizes essential diagnostic and therapeutic steps in greater trochanteric pain syndrome. Careful clinical evaluation, complemented with specific imaging studies and diagnostic infiltrations allows determination of the underlying pathology in most cases. Thereafter, specific nonsurgical treatment is indicated, with success rates of more than 90 %. Resistant cases and tendon ruptures may require surgical intervention, which can provide significant pain relief and functional improvement in most cases.

[Calcific tendinitis of the shoulder]

Calcific tendinitis of the shoulder is a process involving crystal calcium deposition in the rotator cuff tendons, which mainly affects patients between 30 and 50 years of age. The etiology is still a matter of dispute. The diagnosis is made by history and physical examination with specific attention to radiologic and sonographic evidence of calcific deposits. Patients usually describe specific radiation of the pain to the lateral proximal forearm, with tenderness even at rest and during the night. Nonoperative management including rest, nonsteroidal anti-inflammatory drugs, subacromial corticosteroid injections, and shock wave therapy is still the treatment of choice. Nonoperative treatment is successful in up to 90% of patients. When nonsurgical measures fail, surgical removal of the calcific deposit may be indicated. Arthroscopic treatment provides excellent results in more than 90% of patients. The recovery process is very time consuming and may take up to several months in some cases.

Der Oberflächenersatz am Hüftgelenk

Resurfacing arthroplasty is regarded as an attractive method, especially for the young patient who needs a hip replacement. However, the high expectations regarding this new technique in THR must first be met. Earlier experiences with similar forms of surface replacement have led to high revision rates with early aseptic wear induced component loosening and neck fractures. Technical progresses in production techniques for metal-on-metal articulations with minimized wear have enabled the introduction of new surface replacements for the hip joint. Long-term results of these resurfacing arthroplasties are still due. Femoral neck fractures and femoro-acetabular impingement are possible early complications which require revision. The implantation of these systems requires a high degree of operative skill and experience on the part of the surgeon. Approach dependent trauma to the musculature and endangering of the blood supply to the femoral head is balanced with the positive effect of the preservation of femoral bone stock and better options in case of revision. Whether the younger patient with a higher activity profile and an increased chance of implant loosening actually profits from the resurfacing arthroplasty will be determined in the future.

[Diagnostic strategies in cases of suspected periprosthetic infection of the knee. A review of the literature and current recommendations]

Reliable confirmation of periprosthetic infection after total knee arthroplasty is a diagnostic challenge. The present work reviews published data evaluating the available diagnostic tools. Erythrocyte sedimentation rate and C-reactive protein serum levels are relatively sensitive methods with rather low specificity towards periprosthetic infection and are mainly applied to exclude infection. Studies evaluating scintigraphic methods--especially white cell scans--provide inconsistent data with varying accuracy. Consequently, white cell scans cannot be recommended as standard methods. Immunoscintigraphy with antigranulocyte antibodies and FDG-PET scans demonstrated promising results with particularly high sensitivities, but have to be validated in larger studies. Microbiological evaluation of joint aspirates proved high specificity for periprosthetic infection. However, an average of 20% of infected cases remained undetected. Nevertheless, aspiration is widely recommended for preoperative isolation of the infecting organism. Intraoperative frozen sections demonstrated excellent specificity with good sensitivity. The real accuracy of intraoperative culture and permanent histology cannot be determined due to the missing golden standard; however, a combination of both methods is recommended to define the final diagnosis. Large studies validating both methods and criteria for the final diagnosis of periprosthetic infection are necessary to optimize the diagnostic algorithm.

[The modular MML revision system in knee revision and tumor arthroplasty]

Increasing age and a higher level of mobility lead to an increasing incidence in revision arthroplasty after total knee replacement and tumor surgery. So far, the reconstruction of large defects in bony and soft tissue environments can be accomplished by the modern modular components of revision implants. The consecutive reconstruction of the extensor mechanism in extended revision has its own drawbacks and is often associated with significant functional limitations for the patient. Specially designed implants and methods are required to generate good functional results. The modular knee revision system MML provides specific modifications of the tibial component for reconstruction of the extensor mechanism. Combined with artificial strips, an excellent functional outcome could be achieved. In this study, 70 patients were operated with the MML endoprosthesis in knee revision or tumor surgery. An excellent functional outcome could be determined. At 7 years after surgery, an average of 32+/-13 points was achieved on the Oxford Knee Score. The outcome measurement using the functional scoring system of the American Knee Society (AKS score) showed similarly good results with 71+/-25 points out of 100. A minor deficit of only 2 degrees in active extension could be observed after reconstruction of the extensor mechanism. In conclusion, we have demonstrated that the MML modular revision system is appropriate for reconstruction of segmental bone defects.

Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial

BACKGROUND

Epidural neuroplasty seems to be one of the promising minimally invasive techniques for adhesiolysis in patients with chronic sciatica with or without low back pain. However, because no data exist from randomized studies the aim was to investigate whether this procedure is superior to conservative treatment with physiotherapy.

METHODS

A total of 99 patients with chronic low back pain were enrolled in this study and randomly assigned into either a group with physiotherapy (n = 52) or a second group undergoing epidural neuroplasty (n = 47). Patients were assessed before and 3, 6, and 12 months after treatment by a blinded investigator.

RESULTS

After 3 months, the visual analog scale (VAS) score for back and leg pain was significantly reduced in the epidural neuroplasty group, and the need for pain medication was reduced in both groups. Furthermore, the VAS for back and leg pain as well as the Oswestry disability score were significantly reduced until 12 months after the procedure in contrast to the group that received conservative treatment.

CONCLUSIONS

Epidural neuroplasty results in significant alleviation of pain and functional disability in patients with chronic low back pain and sciatica based on disc protrusion/prolapse or failed back surgery on a short-term basis as well as at 12 months of follow-up.

[Reconstruction of the extensor tendons in revision total knee arthroplasty and tumor surgery]

Reconstruction of the extensor mechanism in extended revision after total knee replacement and tumor surgery remains a clinically relevant problem. Due to large tibial bone defects with resection of the extensor insertion area, the specific problem of patella ligament refixation frequently arises. Several biological approaches and augmentation techniques have been published. Most of these are associated with a high rate of revision surgery because of failed replacement of the extensor mechanism and unsatisfactory functional outcome. Surgical reconstruction of these tendon defects is complicated by the difficulty of completely neutralizing tensional force across the repair. To overcome this problem, methods have been developed to reinforce the reconstruction with overlapping flaps; in addition, artificial materials are being increasingly used for tension neutralization. These artificial strips need special fixation mechanisms on the tibial component and specific technical modifications of the prosthesis. The present study gives an overview of reconstruction modalities of the extensor mechanism and provides an improved technology for better reconstruction by using artificial strips combined with specific modifications of the tibial component.

Schwerwiegende Risiken und Komplikationen der epiduralen Neurolyse nach Racz

Racz's minimal invasive epidural catheter procedure, also known as "epidural neuroplasty" is not only utilized in patients suffering from failed spine surgery ("failed back surgery syndrome") but also increasingly applied to non-surgical back pain patients to prevent chronification or deterioration. Its hypothesized principle of action is local epidural lysis of adhesions, neurolysis of vertebral nerve roots and local lavage of proinflammatory mediators by repeated injection of local anesthetics, corticosteroids, hyaluronidase and hypertonic saline solution. However adverse events are well known to occur in epidural neuroplasty. Complications of epidural neuroplasty are due to the procedure itself or due to specific drugs-related side effects. Unintended dural puncture, administration of the drugs to the subarachnoid or subdural space, catheter shearing, infection and severe hemodynamic instability during application are most commonly observed adverse events. Complications related to the procedure itself occur immediately, while complications relating to drug administration show later onset. Within this context, we report a case of severe meningitis with neurologic sequelae in a patient who received Racz catheter-treatment for unspecific low-back pain and provide an overview of the literature on other potential severe complications. As a consequence, we recommend that the Racz catheter procedure as yet should be restricted to controlled clinical trials with rigorous inclusion- and exclusion criteria.

Retrograde intramedullary nailing in tibiotalocalcaneal arthrodesis: a short-term, prospective study

In this prospective study, tibiotalocalcaneal arthrodesis was performed in 29 patients with a retrograde femur nail (Interlocking Compression Nail; Stryker Trauma, Schönkirchen, Germany) inserted through a plantar approach. Patients were evaluated by a standardized follow-up examination using the American Foot and Ankle Society ankle-hindfoot scale and the main criteria of the short-form health survey (36 items). Special emphasis was placed on surgical approach, bony consolidation, and postoperative quality of life. Solid fusion was achieved in 90% of the patients after a mean follow-up of 25 months. Twenty-two patients (76%) showed primary bone healing after an average of 5.2 months; a delayed union was observed in 7 patients. In 79% of the patients, pain was reduced effectively and quality of life substantially improved with the intramedullary nail arthrodesis. The average ankle-hindfoot score improved from 46 (range, 41-53) to 71 (range, 49-83) points. Complications occurred in 6 patients (21%), including 2 deep infections, 3 nonunions, and 1 case of postoperative flexion deformity. The authors found retrograde intramedullary nailing in tibiotalocalcaneal arthrodesis to be an effective technique in obtaining solid fusion, an effective relief from pain, and an improvement of quality of life.

Perioperative Schmerztherapie in der Kniegelenkendoprothetik

Total knee arthroplasty (TKA) is associated with significant postoperative pain. Adequate analgesics and techniques are required for early mobilization, continuous passive motion and intensified physical therapy as well as for high-quality postoperative analgesia.However, in the immediate postoperative setting the excessive nociceptive input can be blocked by using doses which are most frequently associated with adverse effects like dizziness, nausea and vomiting, sedation and risk of respiratory depression. The use of peripheral nerve blocks is recommended after orthopaedic surgery. After TKA, the continuous "3 in 1 nerve block" has been proven to be more effective than conventional patient controlled intravenous opioid therapy as well as than epidural analgesia accompanied by side effects. Postoperative analgesic techniques influence surgical outcome, duration of hospitalization and re-convalescence. The use of regional analgesia after TKA may initially lead to higher costs but it is counterbalanced by a reduction in morbidity and mortality, decrease in hospitalization, improved re-convalescence and a better functional outcome.

Biomechanische Aspekte von Wechselkomponenten für den Kniegelenkersatz

Total knee arthroplasty (TKA) is one of the most frequent orthopaedic surgical procedures. Despite continuous improvements in the endoprostheses, instruments, and operative techniques, revision TKA has a rate of about 10% of overall TKA. In addition to the restoration of the periprosthetic bone stock and a precise alignment, the choice of an adequate implant, which meets the patient's specific requirements, has high impact on the outcome. The most significant differences between implants involve the degree of reconstructed joint area (uni-, bi-, tri-compartimental) and the order of the constraining forces between the femoral and tibial component. Implants for revision TKA commonly range from un- or semiconstrained resurfacing implants to fully constrained hinged endoprostheses. In case of severe osseous, ligamentous, and/or muscular defects, special tumor endoprostheses or implants for arthrodesis might be an alternative option.

[Chronic radiculopathy. Use of minimally invasive percutaneous epidural neurolysis according to Racz]

Treatment of chronic low back pain exhibiting radicular symptoms poses a clinical problem that has not yet been solved. The technique of percutaneous minimally invasive neurolysis described by Racz is being performed increasingly to treat chronic radiculopathy. A total of 61 patients with corresponding symptomatology after screening for inclusion and exclusion criteria in the region of the lumbar spinal nerve were treated with the Racz catheter technique. Distinct clinical improvement was observed at the 3- and 6-month follow-ups after percutaneous minimally invasive epidural neurolysis. Subjective pain perception, quantified by the McNab score, clearly improved after 3 as well as 6 months. With the exception of partial catheter shearing in two cases and one occurrence of infection, no relevant side effects were noted. The Racz catheter technique for treatment of chronic radiculopathy following disk surgery is suitable with minimal side effects.

[Diagnosis specific differences in knee joint geometry. A challenge for the correct axial implantation of long stems in total knee arthroplasty]

BACKGROUND

Arthrotic deformities with changes in knee geometry can produce difficulties in implanting long stem knee prosthesis systems using intramedullary alignment. They can result in incorrect lower limb axis and prosthesis positioning. The aim of the presented study was to measure knee geometry in patients with varus and valgus gonarthrosis in order to define diagnosis related differences.

METHODS

A total of 75 patients with indication for total knee arthroplasty were divided in two groups using the weight bearing lower limb axis: patients with varus gonarthrosis (n=43) and with valgus gonarthrosis (n=32). Angles and extensions, important for knee prosthesis implantation, were measured, digitalized and analyzed. The results were investigated for diagnosis specific differences.

RESULTS

After regulation of the measured extension in mean femur/tibia lengths, significant diagnosis specific differences were found: femur condyles were widened towards pathologic weight bearing (P<0.044), and the mechanical tibia axis of the varus gonarthrosis group is transferred to the lateral side (P<0.046) and in projection over the lateral internal cortical substance.

CONCLUSION

The significant differences in deformed arthrotic knees indicate that for an optimal postoperative result the use of standard implants is not always sufficient. Modular knee prosthesis systems can provide adequately for individual demands.

[Plantar pressure measurement in children and youths during sports activities]

The aim of this study was to consider whether changes occur in the foot area while under repeated physical stress and if they are age related. In addition it interests what consequences this might have in regard to proper shoe wear. The subjects for this study consisted of 15 children and youths aged between 4 and 16 years. The plantar pressure distribution and vertical ground reaction forces were measured before and after physical exercise. The subjects first ran a given distance wearing sport shoes, had a rest and then ran the same distance barefoot. The results showed marked age related differences after exercise. The pressure values were increased in all of the youths in the middle foot region. In comparison young children always exhibited an unbound gait pattern without any dynamic foot roll during heel strike or toe-off. The forefoot had ground contact from the beginning of the stance phase. To compensate for the lack of dynamic foot roll it is recommended that children wear a shoe with a soft sole and with sufficient space for toe movement. The sports shoe for youths should grip the heel and support the longitudinal arch to prevent an incorrect weight distribution.

Antibakterieller Effekt hochenergetischer extrakorporaler Stoßwellen: Ein in vitro Nachweis

AIM

Extracorporeal shock wave therapy (ESWT) is used for a multitude of different indications in modern orthopedics. Local bacterial infections, like infected pseudarthrosis, are still considered as contraindications. The goal of the present study was to determine the effect of ESWT on the growth of clinically relevant bacteria in orthopedic and trauma surgery.

METHODS

Standardized suspensions of five bacterial strains of bone and implant-associated infections were treated with 4 000 impulses of high-energy shock waves with an energy flux density (ED) of 0.96 mJ/mm (2) and a frequency of 2 Hz. Subsequently, viable bacteria were quantified and compared with an untreated control.

RESULTS

A highly significant antibacterial effect of the ESWT was demonstrated for all bacterial strains with a reduction of growth to values between 1.1 % and 29.7 % (p < 0.01). Reference strains of Staphylococcus aureus and Staphylococcus epidermidis reacted with the highest sensitivity whereas Enterococcus faecium demonstrated the highest resistance towards high-energy shock waves.

CONCLUSION

ESWT proved to exert a significant antibacterial effect on clinically relevant pathogens. Further investigations on energy flux density and impulse rates might contribute to an optimization of the bactericidal effectiveness. Infections as possible indications of the ESWT should therefore be assessed in further studies and the clinical relevance should be verified in an animal model.

BISS: concept and biomechanical investigations of a new screw system for electromagnetically induced internal osteostimulation

INTRODUCTION

The aim of an intraosseous application of electromagnetic alternating fields is to speed up both the regeneration of osteonecroses and bone regeneration. In clinical studies, the efficiency of the technique could be successfully proven by using a transducer coil. The advantage of the traditional technique was the variety of its applications in connection with various osteosynthesis systems; the disadvantage was a possible failure of the contacting leads and the resulting functional breakdown.

MATERIALS AND METHODS

A newly developed BISS screw (bipolar induction screw system) with integrated coil and electrodes was compared to a standard cannulated screw used in the traditional technique. The strength of BISS screws ( n=6) and of cannulated screws ( n=6) was evaluated in comparative biomechanical tests. Examinations consisted of torsional and static and dynamic cantilever tests. All screws were made of the same material (TiAl(6)V(4)) and had identical outer dimensions.

RESULTS

No significantly lower strengths could be observed when we compared BISS screws with cannulated screws. The BISS screws even showed significantly higher mechanical values due to a reinforcing effect by the attached electrode.

CONCLUSION

In the modified concept of the new BISS screw, both coil and electrodes are housed in only one cannulated screw. No negative effects concerning mechanical strength and durability were associated with the new screw concept. This provides for a simpler implantation and makes removal easier, while the risk of a cable tear is avoided.

Einsatz des Ganglabors bei klinisch-orthopädischen Fragestellungen in der Kinderorthopädie

AIM OF THE STUDY

We point out multiple applications of a gait laboratory in solving different problems in the children's orthopaedic field. With typical examples we show how biometrical data of the gait laboratory can be helpful to solve problems in orthopaedic examinations.

MATERIAL AND METHOD

The range of questions to be solved in the gait laboratory differs from individual diagnostic examinations of a patient up to the control of devices in the functional use at the patient. As a typical example for the individual examination we show the gait analysis in a 14-year-old girl with idiopathic chondrolysis of the hip joint. The functional use of orthopaedic devices will be shown in youths with neuroorthopaedic diseases. As a very special question to the gait lab we describe the supply of children and youths with optimal sport shoes for running.

RESULTS

The biometrical measurement techniques generate exact data to solve individual diagnostic and therapeutic questions. Orthopaedic devices can be tested in their functional efficiency and quality. Special questions can be answered very flexible.

CONCLUSION

Diagnosis and therapy in orthopaedics and children's orthopaedics rely on exact data. However, details of the dynamics during movement are neither visible to the most experienced orthopaedic surgeon nor can they be documented by conventional diagnostic imaging procedures. The present technical potential of biometric assessment methods allow to precise and correct some empirical knowledge, they open a wide field of new applications in diagnostic and therapeutic examinations.

Ermittlung von Hallux-Biegemomenten aus der plantaren Druckverteilungsmessung

PURPOSE

The following study aims to demonstrate the bending stress on a hallux valgus during normal gait. The bending axis was related to the position of an open wedge osteotomy. The moments were calculated from plantar pressure measurements.

METHOD

In the gait analysis laboratory plantar pressure distribution measurement was done with healthy adult volunteers during barefoot gait. From the plantar pressure distribution the vertical forces were derived just for the region hallux metatarsal I. The following calculation of the bending stress regarding to the hypothetic region of the osteotomy was done by integrating the pressure distribution multiplicated with the distance to the osteotomy. The measurements are compared with theoretical values derived from the anatomy of the foot under some plausible assumptions.

RESULTS

The results of the mean values of the bending stress were 15.8 +/- 4.8 Nm for the female subjects and 21.6 +/- 5.6 Nm for the male subjects. The amount of the bending moments depended with low significance on the weight. More important is the individual type of gait.

CONCLUSION

The measurements show the size of bending stress the plate stabilizing the osteosynthesis has to resist under unfavorable circumstances (for example if the plantar foot muscles are not adequately activated) and if no external stabilization (for example, cast) is used.

Die minimal-invasive perkutane epidurale Neurolyse beim chronischen Nervenwurzelreizsyndrom

The treatment of chronic back pain with sciatica is still an unsolved therapeutic challenge. Percutaneous minimally invasive neurolysis according to the Racz technique is increasingly applied and discussed controversially. So far there is no prospective randomized controlled study for evaluation of a possible treatment effect. In a prospective pilot study, 25 patients with monosegmental radiculopathy of the lumbar spine were treated with minimally invasive percutaneous epidural neurolysis according to Racz's technique. They all suffered from chronic disc herniations or failed back syndromes after surgery, all with radiculopathy. The average age of the patients was 51+/-16 years, the average duration of the symptoms was 28 months. Twelve weeks after the procedure patients had significant clinical improvement. The Oswestry score increased from 64+/-17 to 22+/-12 points. Subjective pain sensation according to the McNab score showed improvement too. None of the patients had worsening of the situation compared to preoperative findings. No clinically relevant complications were observed. The results are being used to design a clinical trial in accordance with good clinical practice guidelines to analyze the therapeutic efficacy of the procedure. The described technique is still a clinically experimental procedure. However, due to a low probability of side effects and due to the good results reported so far by most authors, the Racz catheter technique may be applied in certain patients with chronic radiculopathy refractory to conservative treatment.

[Leading symptom elbow pain. Differential diagnosis]

Pain affecting the elbow joint may be caused by a number of different pathologies. In principle, these can be grouped by causality criteria into degenerative causes, inflammatory causes, tumor disease, congenital disease and the sequelae of trauma. The majority of these latter are associated with typical clinical symptoms that can be established with the aid of a systematic clinical examination, history-taking, inspection, palpation, an examination of joint mobility, and finally radiography. In this way, the diagnosis can rapidly be established.

[Intramedullary nailing in tibiotalocalcaneal arthrodesis]

Tibiotalcalcaneal arthrodesis is still the treatment of choice for disabling arthrosis of the upper and lower ankle joint, although replacement of the upper ankle joint is widely accepted. Numerous techniques have been described, with increasing use of internal fixation and compression. In 20 patients tibiotalocalcaneal arthrodesis was performed using a retrograde femur nail inserted through the heel, whereas in 20 patients combined arthrodesis of the upper and lower ankle joint was performed using a distal tibia nail through an anterograde approach. Patients were evaluated in a standardized examination using criteria of SF 36 focussing on approach, osseous consolidation, and quality of life.Both techniques demonstrated good results: bony consolidation was achieved after follow-up time of 19 months in 85% of the anterograde group and 95% of the retrograde group. In 78% pain was reduced effectively using the intramedullary nail arthrodesis and quality of life improved drastically. In four cases pseudarthrosis occurred, two implant failures were reported, and there were two infections. Using the anterograde as well as the plantar approach, tibiotalocalcaneal intramedullary nail arthrodesis is an appropriate technique. In this study both groups demonstrated good results regarding bony consolidation, reduction of pain, and improved quality of life. Advantage of the retrograde technique is the noninvasiveness of the proximal tibia. Heel pain or plantar infections were not observed. We see limits of the presented technique in severe malalignment and septic history of the patient.

[Congenital clubfoot]

Owing to the relatively high incidence of this condition (2 in 1,000 neonates) and the poor functional outcome of inadequate treatment, clubfoot represents a major clinical problem. Although its etiology is not fully known, modern three-dimensional analyses have led to a better understanding of the pathomorphology and provide a new basis for a differentiated therapeutic strategy. Of central importance is early diagnosis and immediate postpartum initiation of primarily conservative treatment taking the form of intensive redressment measures. Depending on the residual deformity, an appropriate surgical procedure aimed at achieving complete correction should be done between the age of 4 to 6 months. To ensure a lasting positive outcome, rigorous follow-up physiotherapeutic treatment and close surveillance are essential.

[Tissue-induced changes of the extracorporeal shockwave]

Extracorporeal shock wave therapy has been applied very frequently for more than 2 decades. Excellent results in clinical application and research led to widespread use of this noninvasive procedure. Until now the actual mode of action and biochemical pathways after extracorporeal shock wave therapy (ESWT) remain unknown. A small number of technical parameters could be determined after improved technical methods and sensor devices had been designed. It is also still unclear how these technical findings apply to the clinical setting. Therefore, we investigated the influence of musculocutaneous tissue on shock wave focus. A tissue thickness of 15 mm significantly influenced focus characteristics. We found distinct spreading and slight lateral deviation of the focus. In the same way, the peak positive pressure was significantly reduced after the shock waves had passed the musculocutaneous model. The study demonstrates that in vitro results could not be transferred directly to clinical or in vivo conditions. The clinical application of extracorporeal shock waves should be modified in intensity and number of shock waves depending on individual anatomic conditions, indication, and location.

[Mineral analysis of roentgenologically defined calcifications in patients with chronic calcifying tendinitis of the rotator cuff]

AIM

Extracorporeal shockwave application (ESWA) is in clinical use to promote disintegration of symptomatic calcifications of the rotator cuff of the shoulder. However, disintegration of roentgenologically comparable calcifications of the rotator cuff is not always successfull. It is known from urologic stone lithotripsy that the susceptibility for disintegration of stone-like concrements depends on their mineral content. Therefore, in the present investigation the relative contents of calcium and phosphorus in rotator cuff calcifications were determined.

METHOD

39 surgically removed rotator cuff calcifications were analyzed by means of atomic emission spectrometry.

RESULTS

The relative content of calcium of the rotator cuff calcifications was found to be 22.3 % +/- 5.7 % (mean +/- SD; 6.8 % - 32.4 %), that of phosphorus as 10.5 % +/- 2.4 % (2.7 % - 14.4 %). The data neither depend on the gender of the patients nor on their age at the time point of surgical removal of the rotator cuff calcifications.

CONCLUSION

Roentgenologically comparable calcifications of the rotator cuff demonstrated distinct individual differences concerning the relative contents of calcium and phosphorus. The present results may serve as the first indication that the susceptibility of rotator cuff calcifications for disintegration may depend on their relative contents of calcium and phosphorus.

[Physical-technical principles of extracorporeal shockwave therapy (ESWT)]

Extracorporeal shock waves in orthopaedics are currently applied in the treatment of chronic enthesiopathies such as lateral epicondylitis, plantar heel spur, as well as in calcifying tendinitis of the shoulder or in bony nonunions. Detailed knowledge of physical parameters and properties of shock waves appear to be necessary to determine clinically relevant dose-effect relations and to make shock wave devices, clinical results, and basic science in shock wave therapy more comparable. This study gives an overview of physical parameters and properties in shock wave therapy. Measurement technologies, types of shock wave devices, and mechanisms of shock waves are also described.

[Extracorporeal shockwave therapy (ESWT) in epicondylitis humeri radialis. A review of the literature]

This review article evaluates therapeutic procedures and clinical findings of extracorporeal shock wave therapy (ESWT) when used for lateral epicondylitis (LE) based on systematic research of the literature. A total of 20 studies were identified, 2 of which had been carried out as prospective, randomized, and controlled studies; the biometric quality of the remaining is clearly inferior. The inclusion and exclusion criteria used in the studies tallied well. In the more recent literature, important ESWT parameters such as energy used, number of impulses and treatment sessions, and locating methods also tallied in part. The studies reported only occasional side effects that could be evaluated as harmless. When evaluating the clinical success of ESWT, it was stated that about 40-80% of the patients achieved a good or very good result at follow-up examinations after 3-12 months. However, in the single placebo-controlled and blinded study with an independent observer, the same therapy results were achieved in the control group where a local anesthetic was used as in the ESWT group. For this reason, it has been concluded that up to now no clinically relevant efficacy has been proven for the use of ESWT for LE. It should no longer be applied clinically as a matter of course, but only as part of high-quality studies with an adequate control group and blinding of patients and follow-up examiners. Due to the pain incurred when applying ESWT and the risk of uncovering the masking, the blinding of the patients must be checked in each further controlled ESWT study.

Side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of tennis elbow

Apart from a few observational reports, there are no studies on the side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of insertion tendopathies. Within the framework of a randomised, placebo-controlled, single-blind, multicentre study to test the effectiveness of ESWT in the case of lateral epicondylitis (LE), side-effects were systematically recorded. A total of 272 patients from 15 centres was allocated at random to active ESWT (3 x 2000 pulses, energy flux density ED(+) 0.04 to 0.22 mJ/mm(2) under local anaesthesia) or placebo ESWT. In all, 399 ESWT and 402 placebo treatments were analysed. More side-effects were documented in the ESWT group (OR = 4.3, CI = [2.9; 6.3]) than in the placebo group. Most frequently, transitory reddening of the skin (21.1%), pain (4.8%) and small haematomas (3.0%) were found. Migraine was registered in four and syncopes in three instances after ESWT. ESWT for LE with an energy flux density of ED(+) 0.04 to 0.22 mJ/mm(2) is a treatment method which has very few side-effects. The possibility of migraine being triggered by ESWT and the risk of a syncope should be taken into account in the future. No physical shock wave parameters could be definitely identified as the cause of the side-effects observed.

[Musculoskeletal shock wave therapy--current database of clinical research]

During the past decade application of extracorporal shock waves became an established procedure for the treatment of various musculoskeletal diseases in Germany. Up to now the positive results of prospective randomised controlled trials have been published for the treatment of plantar fasciitis, lateral elbow epicondylitis (tennis elbow), and of calcifying tendinitis of the rotator cuff. Most recently, contradicting results of prospective randomised placebo-controlled trials with adequate sample size calculation have been reported. The goal of this review is to present information about the current clinical database on extracorporeal shock wave treatment (ESWT).

[Additive effects of milrinone and dobutamine in severe heart failure]

The hemodynamic effects of dobutamine, milrinone, and a combination of both drugs were compared intra-individually in 14 patients with severe heart failure (NYHA III: n = 9; NYHA IV: n = 5). Dobutamine (maximum dose: 9 micrograms/kg/min) and milrinone (0.5 micrograms/kg/min) each induced a comparable increase in stroke volume index (21 to 29 resp. 21 to 30 ml/m2; mean values; p less than 0.001) and reduction in pulmonary capillary wedge pressure (29 to 22 resp. 28 to 21 mm Hg; p less than 0.001), as well as in systemic (1846 to 1218 resp. 1858 to 1276 dyn s/cm5; p less than 0.001) and pulmonary vascular (301 to 195 resp. 293 to 216 dyn s/cm5; p less than 0.001) resistances. The heart rate rose significantly after dobutamine (92 to 107 min-1; p less than 0.05), but did not change after milrinone (94 to 95 min-1; ns). Neither drug had a significant effect on systemic arterial pressures. The combination of milrinone and dobutamine induced a further significant rise in stroke volume index (37 ml/m2; p less than 0.01) when compared to either drug alone. The combination also caused an additional fall in pulmonary capillary wedge pressure (14 mm Hg; p less than 0.01), as well as in systemic (799 dyn s/cm5; p less than 0.001) and pulmonary (133 dyn s/cm5; p less than 0.001) vascular resistances. When compared to dobutamine alone, the combined therapy did not significantly change the heart rate and systemic arterial pressures. The combined administration of a beta-adrenergic agonist and a phosphodiesterase inhibitor induces beneficial hemodynamic effects.(ABSTRACT TRUNCATED AT 250 WORDS)