M. H. Hackenbroch

Osteoarthritis and recurrences after Putti-Platt and Eden-Hybbinette operations for recurrent dislocation of the shoulder

Summary. Thirty-five patients who had operations for recurrent anterior dislocation of the shoulder were reviewed, with a further 26 answering a questionnaire; the results were not as good as reported by others. The mean follow up was 26.9 years. Ten out of 43 patients had recurrent dislocations after the Putti-Platt and 6 out of 18 after the Eden-Hybbinette operation. Osteoarthritis developed in 15 shoulders of 26 patients who were followed-up after the former procedure and in 8 out of 9 shoulders after the latter. These sequelae depend on the age at the first dislocation rather than the number of dislocations. The overall satisfaction rate was acceptable for both procedures.Résumé. Notre étude à long terme (sur 61 patients, 35 suivis avec une moyenne de 26,9 ans) montre que les résultats des opérations de Putti-Platt et Eden-Hybbinette pour luxation récidivante de l’épaule ne sont pas, en considérant les récidives et le développement de l’arthrose, aussi bons que ceux rapportés dans la littérature [5, 8, 14, 18]. Dans notre série, 10 patients sur 43 ont eu une luxation récidivante après une intervention de Putti-Platt et 6 sur 18 après une opération de Eden-Hybbinette. Une omarthrose était présente chez 8 sur 9 patients du groupe Eden-Hybbinette et chez 15 sur 26 patients du groupe Putti-Platt. Nous pensons que le développement de l’omarthrose dépend plus de l’âge du patient lors de la première luxation que du nombre de luxation avant l’intervention. Cependant, le taux de succès après une période d’observation moyenne de 26,9 ans était acceptable pour les 2 types de traitement.

Prophylactic dynamic screw fixation of the asymptomatic hip in slipped capital femoral epiphysis.

Prophylactic dynamic screw fixation (DSF) of clinically and radiographically unaffected hips of 34 patients with a contralateral slipped capital femoral epiphysis and no evidence of an endocrinopathy or systemic disorder was performed using a single cannulated screw. Follow-up ranged from 2 to 12 years (average, 5.4 years). There was no case of perioperative complication and no avascular necrosis or chondrolysis occurred. No preslip or slip became apparent. In all 34 hips, no tendency toward premature closure of the epiphysis could be observed, no growth disturbance including greater trochanteric overgrowth, coxa brevis, or coxa vara was noted. This study supports the prophylactic treatment of the asymptomatic hip, using a simple and safe fixation method.

A new classification for heterotopic ossifications in total hip arthroplasty considering the surgical approach.

We would like to introduce a new classification for heterotopic ossifications (HO) after total hip arthroplasty which also considers ossifications within the region of the surgical approach. Furthermore, we will point out the influence of the surgical approach on the rate of HO. We analyzed 75 cementless hip arthroplasties with consecutive HO in a prospective study. The operations were performed by three experienced orthopaedic surgeons using an identical stem and a standardized lateral approach. All patients followed an identical rehabilitation procedure. Clinical and radiological data were documented in a standardized way. We found a total of 40 HO. Only 24 could be exactly classified by the known methods. Our classification considers 3 regions and 4 grades and is relevant for all 40 HO. Electrocauterisation to dissect the muscles in the lateral approach reduced the rate of HO: overall 64.3% to 39.4%; clinically relevant ossifications were reduced to 3.0% from 16.7%. Our new classification considers all HO concerned with total hip arthroplasty, especially those localized in the intertrochanteric region. The rate of HO can be reduced by using electrocauterisation for muscle dissection in the lateral approach.

Osteoarthrosis following the Putti-Platt operation

The objective of this study was to search for any degenerative changes in the shoulder joint following the Putti-Platt operation in a long-term follow-up study, as most papers regarding that operation report a redislocation rate and a limitation of external rotation, but only a few mention osteoarthrosis (OA). Patients operated on between 1945 and 1971 answered a questionnnaire and were invited for a clinical examination including standard X-rays of the shoulder. These films were compared with those taken preoperatively. OA was classified according to the Samilson and Prieto grading. Twenty-six patients could be re-examined on average 26 years after the operation. Fifteen had evident radiological signs of OA. According to Samilson and Prieto there were 11 mild, 2 moderate and 2 severe cases of OA. Nine patients had a Hill-Sachs defect and 3, a Bankart lesion. Patients over the age of 25 years at the time of the first dislocation developed OA more often. Following the Putti-Platt operation one has to expect radiological signs of OA in a longterm follow-up. Mainly minor forms are seen. Older patient age at the time of the first dislocation is a predisposing factor for the development of OA.

Slipped capital femoral epiphysis: a prospective study of dynamic screw fixation.

Twenty-five consecutive children (29 hips) who had slipped capital femoral epiphysis of a mild degree (slip angle less than 30°) were treated with dynamic screw fixation. The goal of dynamic screw fixation is to achieve physeal stability to prevent additional slippage and to avoid premature physeal closure. Seventeen boys and eight girls were followed up for an average of 7 years (range, 4–13 years). There were 25 chronic slips, three acute slips, and one preslip. The average age at the time of surgery was 11.7 years for the girls (range, 11.1–12.9 years) and 13.9 years for the boys (range, 9.4–16.1 years). The average time to physeal closure was almost the same in both genders (boys, 3.0 years; girls, 3.2 years), ranging from 1.1 years to 6.3 years. No increase in the degree of slippage occurred; there were no perioperative complications, and avascular necrosis and chondrolysis were not apparent. In all 29 hips, no growth disturbance, including greater trochanteric overgrowth, coxa brevis, or coxa vara, was seen. According to the clinical criteria of Heyman and Herndon, 26 hips were rated either excellent or good, and two were rated fair. One was rated poor because of the presence of slight pain after strenuous exercise. The technique of dynamic screw fixation provides sufficient immediate and long-term fixation, does not promote premature physeal closure, and permits normal hip development.

Behandlungsergebnisse nach operativer Versorgung ossärer Mammakarzinommetastasen Prophylaktische Stabilisierung vs. Versorgung nach pathologischer Fraktur

ZusammenfassungFragestellung, Methodik. Den Vorteilen der prophylaktischen Versorgung von frakturgefährdeten, ossären Metastasen des Mammakarzinoms stehen das perioperative Risiko sowie konservative Alternativen gegenüber. Da bei konservativem Vorgehen im Einzelfall eine pathologische Fraktur nicht sicher ausgeschlossen werden kann, wurden in einer retrospektiven Studie die Behandlungsergebnisse nach pathologischer Fraktur (n=35) mit denen nach prophylaktischer Versorgung (n=44) verglichen. Ergebnisse. Bei insgesamt 20,3% (n=16) intraoperativen, kardiopulmonalen Komplikationen waren diese in beiden Gruppen gleichverteilt. Intraoperative, operationstechnische Komplikationen (n=3) traten ausschließlich in der Frakturgruppe auf. Allgemeine, postoperative Komplikationen sahen wir in 20,3% (n=16) aller Fälle, wobei die Patientinnen der Frakturgruppe mit 28,6% (n=11/35) vs. 11,4% (n=5/44, Prophylaxegruppe) vermehrt betroffen waren (p<0,02). Während sich bei den postoperativen operationstechnischen Komplikationsraten keine Unterschiede zwischen beiden Gruppen zeigten, erreichten in der Prophylaxegruppe mit 91,9% (n=40/44) vs. 74,3% (n=26/35) in der Frakturgruppe signifikant mehr Patientinnen die volle postoperative Gebrauchsfähigkeit der operierten Region (p<0,05). Die durchschnittliche Überlebenszeit war in der Prophylaxegruppe tendenziell länger [19,3±15,6 Monate (Prophylaxegruppe) vs. 15,0±16,9 Monate (Frakturgruppe)]. Schlussfolgerungen. Die prophylaktische Versorgung bei frakturgefährdeten, ossären Metastasen des Mammakarzinoms bedeutet also im Vergleich zu den Patientinnen mit pathologischer Fraktur insgesamt eine Verringerung der postoperativen, allgemeinen Komplikationsrate und zudem eine höhere Chance der einzelnen Patientin, postoperativ die volle Mobilität wiederzuerlangen. Angesichts langer Überlebenszeiten nach Auftreten ossärer Metastasen beim Mammakarzinom stellt somit die prophlaktische Versorgung bei drohender Fraktur die Methode der Wahl gegenüber dem konservativem Vorgehen mit persistierendem Frakturrisiko dar.AbstractAim of the study, method. The advantages of a prophylactic care of fracture-endangered, osseous metastasis of the mammary cancer stand opposite to the perioperative risk and to conservative alternatives. As a pathologic fracture cannot surely be excluded while performing a conservative proceeding, a retrospective trial was set up to compare the results of treatment after a pathologic fracture (n=35) with those undergoing a prophylactic attendance (n=44). Results. The intraoperative, cardio-pulmonary complications were distributed in balance totally amounting to 20,3% (n=16). Intraoperative complications concerning surgical procedure (n=3) exclusively occurred within the fracture group. Generally, postoperative complications arose in 20,3% (n=16) of all cases, in which the patients belonging to the fracture group were increasingly afflicted [28,6% (n=11/35) vs. 11,4% (n=5/44); p<0,02]. While there were no differences between both groups concerning the postoperative, surgery-technical complications, significantly more patients (91,8% [n=40/44]) of the prophylactic-care group achieved a complete postoperative usability of the operated area than in the fracture-group [74,3% (n=26/35)] (p<0,05). The average survival time tended to be longer within the prophylactic-care group [19,3±15,6 month (prophylactic-care group) vs. 15,0±16,9 month (fracture group)]. Conclusions. The prophylactic treatment of fracture endangered, osseous metastasis of the mammary cancer leads to reduction of the general, postoperative complications compared to the patients with a pathologic fracture. Further, those patients have a better chance to recover full mobility after surgery. Considering the long survival time after the incidence of osseous metastasis at the mammary cancer a prophylactic treatment represents the method of first choice compared with the conservative treatment which persistently contains the risk of fracturing.

Dyamic screw fixation for slipped capital femoral epiphysis. Treatment results

ZusammenfassungDie Behandlung der Epiphyseolysis capitis femoris juvenilis ist in allen Stadien grundsätzlich operativ. Die Operationsart hängt vom Dislokationsgrad und -modus (Epiphyseolysis capitis femoris lenta oder acuta) ab. Bis zu einem Dislokationswinkel von mindestens 30° erfolgt nach übereinstimmender Meinung eine In-situ-Fixation. Dabei wird eine dauerhafte Stabilisierung der Lagebeziehung zwischen Epiphyse und Schenkelhals bis zum endgültigen Fugenverschluss angestrebt, ohne dass eine Beeinträchtigung des weiteren Femurwachstums in Kauf genommen werden muss. Hierfür bietet sich das Verfahren der dynamischen Schraubenfixation (DSF) mit einer kanülierten nach lateral überstehenden Gleitschraube mit Kurzgewinde an.Die Methode ist einfach in der Handhabung, führt zu einer sicheren und dauerhaften Stabilisierung der Kopfepiphyse, fördert nicht den vorzeitigen Verschluss der Wachstumsfuge und ist komplikationsarm. Sie ist daher auch für die prophylaktische Fixation der gegenseitigen “gesunden” Hüfte geeignet, die bei uns grundsätzlich durchgeführt wird. Wir berichten über unsere Ergebnisse mit der dynamischen Schraubenfixation anhand von 63 Hüften; von diesen waren 29 therapeutisch und 34 prophylaktisch stabilisiert worden. Die DSF bewirkte regelmäßig eine zuverlässige Stabilisierung ohne erkennbare Wachstumshemmung am Schenkelhals.AbstractSlipped capital femoral epiphysis always requires surgical treatment. The operative technique depends on the degree of dislocation and the type of the slip. The goal of treatment is to achieve physeal stability until the epiphyseal plate closes without harming the further femoral growth. In situ fixation is generally recommended for slipped capital femoral epiphyses of a mild degree. For this purpose the technique of dynamic screw fixation (DSF) is applicable using a long cannulated screw with a short thread.DSF is easy to handle, provides sufficient long-term fixation of the epiphysis, does not promote premature closure of the epiphysis, and engenders few complications. Therefore, this technique is also applicable for the prophylactic treatment of the contralateral unaffected hip, which we always perform. Moreover, DSF can be used following gentle reduction of acute epiphysiolysis, if the amount of eventual residual dislocation does not exceed 30°. We report our results with dynamic screw fixation of 29 slipped capital femoral epiphyses of a mild degree, and the prophylactic dynamic screw fixation of 34 unaffected hips. The fixation technique achieved a reliable stabilization with no visible growth disturbance of the femoral neck in all cases.

The Cenos hollow stem in total hip arthroplasty: first experiences in a prospective study

Due to its hollow construction, which gives it elasticity, the Cenos hollow stem (Artos) reduces stress shielding in the intertrochanteric region and reduces bone remodelling at the distal tip after implantation of a cementless stem in the femoral canal. This should contribute to a longer implant survival time and reduce the number of revision procedures required for implant loosening. Its anatomical shape means that it fits well in the femoral canal and additionally improves load distribution. We prospectively studied patients in whom the Cenos hollow stem was implanted in our clinic. The clinical results after 1 year and 40 implantations are very satisfactory. No thigh pain has been reported so far, which is probably due to the effectiveness of the increased elasticity and the better fit of the stem. Preoperative planning with a special template is very accurate, and in combination with the anatomical shape of the stem makes the surgical procedure easy. The relatively high number of ectopic ossifications found in our series is obviously not related to the stem itself. In our opinion it is a result of the lateral approach. However, no clinical disadvantage resulted from these ossifications.

Thyroid function in Legg-Calvé-Perthes disease: cross-sectional and longitudinal study.

Thyroid function was studied in 59 consecutive children with Legg-Calvé-Perthes disease (LCPD) and 239 controls. The subjects of both groups were generally euthyroid. In the Perthes group, however, plasma concentrations of free thyroxin (FT4) were increased by 16% (p < 10(-8)) and those of free triiodothyronine (FT3) were increased by 10% (p < 0.001) as compared with controls. There was a tendency toward higher FT4 levels in children with necrosis of more than one half of the femoral head (p < 0.015), as compared with those with lesser involvement. The observed moderate hormonal changes were already evident at the time of diagnosis of LCPD and were not appreciably influenced by stage of disease or mode of treatment, as determined by longitudinal evaluation of 38 children. Our data may support the assumption of other investigators that systemic abnormalities exist in children with LCPD, but the relation between these findings and the femoral head necrosis is not known.

Nosocomial methicillin-resistant Staphylococcus aureus (MRSA) and epidermidis (MRSE) infections in orthopaedic surgery. Importance, prophylaxis and therapy

SummaryMRSA/MRSE infections are a major problem in hospitals and although in orthopaedic units the incidence is low awareness of this problem is necessary. Once a MRSA strain has been isolated the strict use of the hygiene precautions has to be applied to avoid epidemic spread of the strain. The patient has to be isolated. The staff has to use gloves and gowns whilst treating the patient. A antimicrobiel hand wash solution has to be used after taking off the gloves and before leaving the isolation room. Patient and staff have to be informed about the pathogenity and the way of infection spread so that infection precaution rules are fulfilled. Antibiotics should only be used in clinically well defined cases and the overall use of antibiotics should be reduced to lower the incidence of MRSA/E isolates. The problems of an MRSA case and its successful treatment are demonstrated.ZusammenfassungMRSA/MRSE-Infektionen im Krankenhaus stellen, obwohl derzeit in orthopädischen Abteilungen eher selten, ein großes Problem dar. Um einen epidemieartigen Ausbruch einer MRSA-Infektion zu verhindern, ist die Einhaltung spezieller Hygienemaßnahmen unbedingt anzuraten. Neben der sofortigen Isolierung des Patienten ist die Verwendung von Handschuhen bei der Patientenpflege, das Tragen von am Patientenbett verbleibenden Kitteln und die Benutzung eines antimikrobiellen Handwaschmittels nach Ablegen von Handschuhen und Kittel unabdingbar. Zur Durchsetzung dieser Maßnahmen ist die Aufklärung des Patienten und der Mitarbeiter über die Pathogenese dieser Infektion äußerst wichtig. Nur der gezielte Einsatz von Antibiotika und die Reduktion des Antibiotikaverbrauchs kann die Inzidenz der MRSA/MRSE-Isolate reduzieren. Die Problematik und erfolgreiche Behandlung einer MRSA-Infektion wird an einem repräsentativen klinischen Beispiel demonstriert.