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Radio frequency ablation (RFA) represents a new technique for local destruction of liver tumors. Indication and procedure are poorly validated at present.To record the actual nationwide RFA application in Germany, a survey of 2026 hospitals with standardized questionnaires was conducted.With a respond rate of 17.5%, results from 58 hospitals covering 1700 ablated patients were analyzed. In 25.9% of them, RFA is already used in potentially curative resectable tumors, in 22.4% even when incomplete ablation for tumor mass reduction is expected. Of the 58 hospitals, 75% combine resection and RFA to reach a so-called R-0 situation. The maximal tumor sizes they quoted for achieving complete ablation ranged from3 cm to 11 cm. In contraindications for RFA, the tumor size, number of tumors, critical localization of the tumor, and disorders of liver function were mentioned the most.This survey documents significant discrepancies in indication, application, procedure, and results in RFA for liver tumors. The lack of general standards and an overestimation of the method may lead to uncritical application, neglect of standard therapy, or unsatisfying results.

Economic aspects have gained increasing importance in recent years. The operating room (OR) is the most cost-intensive sector and determines the turnover process of a surgical patient within the hospital. Thus, optimisation of workflow processes is of particular interest for health care providers. If the results of surgery are viewed as a product, everything associated with surgery can be evaluated analogously to a manufacturing process. All steps involved in producing the end-result can and should be analysed with the goal of producing an efficient, economical and quality product. The leadership that physicians can provide to manage this process is important and leads to the introduction of a specialised "OR manager". This position must have the authority to issue directives to all other members of the OR team. An OR management subordinates directly to the administration of the hospital. By integrating and improving management of various elements of the surgical process, health care institutions are able to rationally trim costs while maintaining high-quality services. This paper gives a short introduction into the difficulties of organising an OR. Some suggestions are made to overcome common shortcomings in the daily practise. A proposal for an "OR statute" is presented that should be a basis for discussion within the OR team. It must be modified according to individual needs and prerequisites in every hospital. The single best opportunity for dramatic improvement in effective resource use in surgical services lies in the perioperative process. The management strategy must focus on process measurement using information technology and feed-back implementing modern quality management tools.However, no short-term effects can be expected from these changes. Improvements take about a year and continuous feed-back of all measures must accompany the reorganisation process.

Exposure to low-energy ultrasound shock waves (1000 impulses at a frequency of 2/sec and an energy density of 0.08 mj/mm2; peak positive/negative pressure 16/-7 MPa; pulse duration about 10 musec) led to the following alterations in the cells and tissues of stage 35 embryos of Oryzias latipes ranked according to their extent: (1) In various tissues, especially in the trunk musculature, orthodox mitochondria were transformed into condensed (= low energy) mitochondria. (2) Nuclear envelopes and sarcoplasmatic reticulum of muscle fibres as well as endoplasmatic reticulum of epidermal ionocytes were often vesicularly dilated. (3) Muscle fibres in the trunk musculature began to separate from each other. Epidermal intercellular spaces were enlarged and increased in number. (4) Destruction of vessels and haematomas were observed in the circulatory system of the yolk sac. (5) Necroses up to total disintegration were found in various organs of the body cavity (intestine, liver, spleen). The less serious alterations (1 and 2) occurred in organs completely surrounded by other tissues. Major damages (4 and 5), however, affected only organs with free outer and inner surfaces, probably explained by cavitation and jet stream phenomena within the adjacent fluids.

Amputation, Handicap, High Subsequent Costs. Lack of "Outpatient Wards for Diseases Involving the Feet" in German hospitals. A Challenge to Prevention: In consequence of diabetic polyneuropathy, about 25% of all diabetics develop neuropathic foot complications often resulting in amputation (about 30,000 cases in Germany per annum). Suffering and handicaps of the patients, as well as the high costs involved (estimated at 800 million Deutsche Mark per annum) systematic prophylaxis and early identification of patients at risk are imperative. According to experts every second amputation could be avoided if treatment of diabetic foot complications is started as early as possible. To prevent expensive in-hospital treatment, an outpatient clinical treatment may be offered on an interdisciplinary basis (internist, neurologist, orthopaedist, surgeon, radiologist). About 50 "outpatient wards for diseases involving the feet" exist up to now in German hospitals. Appropriate fees, subsidy by sick funds (and if necessary by politicians) and co-operation with general practitioners, internists etc. are indispensable. Other important co-operators are the family doctors. With regard to health care, preventive activities and publicity, co-operation of the local Public Health departments would also be feasible.

A case of complete paraplegia due to a giant cell tumor of the dorsal spine following manual therapy without previous x-ray examination is reported. In a malpractice trial the question whether manual therapy is indicated or not had strictly to be denied. The question whether paraplegia due to a giant cell tumor could have been avoided when the tumor would have been detected radiologically was impossible to answer retrospectively. But, it is likely that with immediate surgical therapy after radiological detection of this lesions complete paraplegia should have been avoidable.

In a clinical and radiological follow up 64 Lord-endoprostheses could be controlled after a meantime of 8.5 years. The positive judgement of the patients, which is caused by the reduction of pain, is in contrast to the poor improvement of gait and mobility. Radiological findings are suspicious for a higher rate of loosening of the cup and fractures of the shaft.

Departments of Health can function as important initiators of health promotion on community level. This includes the support of efforts for cooperation ("corporate identity"). A one-day-project for the World Diabetes Day (June 27, 1992) in the Ammerland county (Lower Saxony) gives an insight on possible activities, results and conclusions.

Surgical treatment of pyogenic infections of the sacroiliac joint is indicated in cases of ineffective conservative treatment, abscess formation, septicemia, and neurological deficits. Between 1983 and 1990 in nine patients surgical treatment was performed for pyogenic sacroiliitis under this criteria. The surgical procedure included joint debridement, primary arthrodesis of the sacroiliac joint using a autologous bone graft, antibiotic therapy and postoperative immobilisation. Follow-up examination of 8 patients in average 47 months postoperatively revealed excellent functional and roentgenological results in 6 patients. Two patients suffered only from mild low-back pain, none of the eight patients demonstrated signs of a recurrent infection, one patient died due to complications of a long-lasting preoperative septicemia. Regarding these postoperative follow-up results surgical therapy including primary sacroiliac arthrodesis should be early considered, because this treatment has a low complication rate and the surgical technique is easy to perform and results are excellent or good in most of the patients.

Commercial solaria are not always up to the standards that would be desirable from a Public Health point of view in respect of protection of users against health hazards of exposure to UV radiation, and also with regard to supervision, qualified personal advice given to users by the staff, and qualification of the staff members to give such advice. Hygiene is definitely also a problem, as is evident from bacteriological swabs made from tanning beds. However, the talks conducted by a local Public Health board in Lower Saxony (North Germany) revealed considerable open-mindedness on the part of the entrepreneurs who were quite willing to follow expert health advice and to display a poster with recommendations regarding protective measures. This was combined with a questioning procedure that has proved successful with the proprietors.

In the case of surgically dressed necroses of the hip condyle and coxarthroses a condition was found after fracture of the pelvis or after dislocation of the hip joint in 7.2% of the cases. In 13.2% of the cases a trauma was found anamnestically. It was subdivided into fractures of the acetabulum, fractures of the pelvic girdle, dislocations, and fractures of the pelvic brim on the basis of the system of Judet and Engler as well as Feldkamp. Fractures of the pelvic brim through muscular traction, traction of the ligament, and direct trauma were discussed. The most frequent delayed consequences arising after dislocations of the hip joint and fractures of the acetabulum are: necroses of the head of the femur, coxarthroses, pseudarthroses, and myositis ossificans. The pathogenesis of the delayed injuries resulted from: capsular and vascular lesions, damage to cartilage with fractures in the spongiosa region, incongruence of the surface of the joint, insufficiency of the static structure of the pelvic ring, deposit of calcium salt outside the bone. In some cases the progress of the necrosis could be arrested by means of osteotomy and spongiosa filling. The rate of necrosis increases in proportion to the period between the time of occurrence of the accident and reposition (limit of 6 h). Even though about half the pelvic girdle fractures show good results with conservative treatment, in the case of fractures of the acetabulum a reconstruction as far as possible continuous and without stages is to be aimed at. In many cases the development of a myositis ossificans cannot be prevented.

With regard to germ mutation in osteomyelitis, spondylitis, and arthritis it has been established that the frequency of Mycobacterium tuberculosis and the gram-positive pathogens (S. albus, Streptococci) has decreased in the last 20 years. To varying degrees, S. aureus and the gram-negative, aerobic organisms are the most important pathogens of bone and joint infections. Overall, there has been an increase in the frequency of infections with gram-negative, aerobic organisms. In the majority of cases the bone and joint inflammations were caused by exogenous factors, their course was chonic, and the typical localization was the lower extremity. There was a positive trend toward shorter periods of hospitalization and a shorter duration of illness.

In a woman aged 74 fatigue fractures occurred in the anterior part of the pelvic ring following bilateral replacement of the hipjoints with Müller-Charnley prostheses. After increasing pain in the inguinal region radiographs disclosed fractures through the public and ischial bones on the side of the last replacement. There was no concomitant disease. The possible dynamic causes of fatigue fractures after well-placed hip-prostheses are discussed.

Varus or valgus deformities and metabolic alterations of the articular cartilage and synovialis of patients with gonarthrosis (n = 67) had been analysed. The increase of axial deviation went together with a significant change of the LDH-activity of the cartilage. The increasing activity of the LDHH-subunits depending on the axial deviation corresponded exactly with the maximum stress on the articular surface calculated by Maquet. On the other hand alterations of the LDH isoenzyme distribution of the synovialis could be found with increasing activity of the LDHM subunits. A close correlation of the whole joint metabolism and the hypercompression of the cartilage is obvious.

Weber's rotational osteotomy is a surgical treatment of recurrent shoulder dislocation. While eliminating recurrence of the complaint, it attempts to regain full range of movement in the joint. Of the 39 operated patients it was possible to follow up 34 cases. The percentage of recurrent dislocation was 5.7%. The range of movement was reduced in some patients; in one by 10 degrees - 20 degrees. Otherwise there were no significant complications or post-operative complaints. The operative technique, the X-ray procedure and the pathogenesis of the original dislocation are described. Typical accompanying injuries require a particular operative method. The most common accompanying damage was normally the typical defect of the humeral head (incidence 91%). The regular overstretching of the subscapular muscle and the defect of the humeral head are considered by the operational technique introduced by Weber.

The article compares the load capacity of the collateral ligaments of the metacarpo-phalangeal and interphalangeal joints exposed to a laterally applied force. The tests were performed in vivo with 50 each female and male volunteers. It was found that the average load capacity of the metacarpo-phalangeal and interphalangeal joints in women was 5.8 kp and in men 12.3 kp. Furthermore, the bones of the long fingers with the preserved joint capsules and collateral ligaments of ten corpses were also examined, and the collateral ligaments exposed to a load which was increased to the point of their destruction. The average values found in this manner were 26.5 kp for the metacarpo-phalangeal collateral ligaments and 15.4 kp for the interphalangeal collateral ligaments. This means that the pain threshold is usually below the destruction limit, so that generally there will be no spontaneous overloading. It is important for the construction of endoprostheses that their stability level should always be above that of the pain threshold and should attain at least the values of the tear tests, since otherwise these endoprotheses will not function properly. These basic prerequisites enable a comparative study of endoprostheses, the results of which will be presented at a later date.

Surgical therapy had become necessary in 166 patients who had been referred to hospital with the diagnosis of necrosis of the femoral head or osteoarthrosis of hip. In these patients, the osteoarthroses of hip and necroses of the femoral head were observed separately. The secondary osteoarthroses based on a necrosis of the femoral head were classified among the latter group. We also differentiated between the following age groups: 0-20 years, 20-50 years, 50-70 years and over 70 years; the form of therapy also served as a means of distinction.

The article reports on the performance of the proximal femoral epiphysis after isolated screw fixation, Imhäuser-Weber's operation and open repositioning with subcapital osteotomy. The indication for the choice of the operation is explained. Results of the three operative treatment methods are discussed in respect of postoperative mobility, osseous fusion period and complications. Detailed attention is paid to the localisation of the first signs of ossification.

The results of 106 patients with osteoarthritis secondary to severe congenital hip dysplasia and dislocations of the hip operated at the Endo-Klinik were evaluated after an average follow up of 21 months. 142 "St. Georg-Mini" total hips were implanted employing Refobacin-Palacos R. The clinical results were graded as "combined performance" which considered hip pain, walking distance, hip mobility and walking aids. In 93% of the cases "combined performance" was improved at follow up and 91.7% of the patients were satisfied with the result. The early (during hospitalization) and late (after discharge from hospital) complication rate which had an influence on the result at follow up was 2.1% (n = 3) and 3.5% (n = 4) respectively. There were no deep infections. An extended indication for total hip arthroplasty also for younger patients with severe osteoarthritis secondary to hip dysplasia is discussed and can be advocated.

Not only for giving the diagnosis "Perthes' disease" but also with regard to prognostic statements the knowledge of the radiological stages of Perthes' disease is essential. The present treatise demonstrates the radiological course of Perthes' disease, how it results from the evaluation of the courses of illness of 116 patients, which were treated in the period from 1965 to 1980 at the Orthopedic University Hospital Hamburg-Eppendorf because of a genuine Perthes' disease. The following schema turned out to be appropriate to the assessment: I. Initial stage, I a Early period, I b Late period. II. Florid stage, II a Sclerosing period, II b Fragmental period, II c Osteolytic period. III. Stage of regeneration. IV. Final stage.

In the framework of a personal investigation seven blind hand amputees (survivors of world war II, and of the Portuguese colonial war) had been interviewed to study the influence of myoelectric prosthetic fitting on their social and vocational rehabilitation. Five of them use their prostheses from eight to fifteen hours a day, primarily in the office; at home they prefer their Krukenberg stump. For the clients' self-esteem, the cosmetic factors seems to be decisive. Yet all of the clients engaged in (desk) work emphasize that they could do their jobs without using the myoelectric prostheses, without however wishing to be provided with some other type of prosthesis.

Free bodies are supposed to induce degenerative joint disease. The etiological mechanism, as far as known, of the most important and frequent diseases with corpora libera osteochondrosis dissecans, osteochondral and chondral fracture, chondromatosis and osteoarthrosis are discussed. The diagnostic and therapeutic methods are described. The need for surgical therapy is obvious in cases with chronical synovial irritation. The opportunity to reimplant a loose body into the joint surface should be taken. The technique and the results of sticking the fragments to reconstruct the joint surface are demonstrated.

In cases of extensive destructive osteolytic processes in the pelvis and hip region, alloplastic replacement of a part of the pelvis with a total hip replacement and, if necessary, partial replacement of the femur, can represent a therapeutic alternative to hemipelvectomy for preserving the limb in the presence of malignancies; it offers the same degree of radicality in removing the affected bone and soft tissue while preserving the bone. This applies with regard both to primary malignant growths as well as extensive isolated metastases and aseptic osteolysis following multiple total replacement procedures. The partial pelvic prostheses, produced individually on the basis of roentgenograms, are adapted to a great degree intraoperatively and fixed with screws, locknuts, and Palacos, and if possible lined with autogenous bone. Where the defects are extensive the pubic bone of the unaffected side is incorporated in the stabilization. Experience gathered so far and follow-up examinations show that all patients regain full mobility and weight-bearing ability, with almost complete lack of complaints and adequate to good motility. This is demonstrated by examples.

In a comparative study the value of castless immobilisation methods for stabilising the lateral ankle instability was examined. For this the dimension of the lateral talar tilt as a sign for chronic lateral ankle instability in 32 sportsmen with chronic ankle instability was checked initially. Afterwards the reduction of this instability due to the application of the tape-bandage and the "ankle-brace" was tested under the same standardised conditions. In regard to the reduction of the lateral talar tilt a reduction of this instability of the ankle joint is possible significantly. But compared to the normal talar tilt showing a stable ankle joint, it is not possible to reach this in all cases of ankle instability. So for treatment of the lateral ligament rupture it is necessary to use the usual cast for stabilising the joint after ligament suture before reduction of the time of immobilisation is possible. The use in cases of chronic instability or as a precaution method is not restricted when a sufficient active stabilisation is possible.

The compression characteristics of 25 fresh cadaveric vertebrae of different height had been analysed in static compression tests and related to CAT densitometry values. A relationship between fracture load and CAT densitometry values of the vertebral body (spongiosa and corticalis) had been found, which can be described as a logarithmical function (r2 = 0.91). Separated CAT measurements of spongiosa also showed a logarithmical function (r2 = 0.89). Consequently, the thin corticalis of vertebral waist is of subordinate importance in correlation to fracture load. An analogously explored average CAT densitometry value showed no definite dependence on corticalis capacity. The graphic description of analysed spongiosa areas in absorption profile (CAT histogram) almost resulted in a Gauss distribution.

Candida caused osteomyelitis of the spine is a rare entity. In the literature are only 15 cases reported. An own case of Candida-osteomyelitis of the spine is demonstrated and a overview of the literature is given.

Within the scape of a comparative long-term study between conservative and operative therapy of Perthes'-disease the effort was made to estimate the dimension of the psychic and social detraction in addiction to the method of treatment by a detailed inquiry of 116 patients as well as of their accompanying parents. This happened because of the opinion, that not only the formal result should decide on the choice of therapy, but also in a justifiable dimension the way of treatment should be orientated on patients. The analysis of the anamnestic particulars showed, that also under psycho-social aspects the immediate surgical procedure has the advantage over conservative methods of treatment at Perthes' disease.

With regard to the very common disease of sprained ankles the combined tear with ruptures of ligaments of the subtalar joint are possible. Even an isolated instability is known as the reason of long lasting post-traumatic complaints. Using the apparatus of Scheuba, well-known in diagnosing instabilities of the knee and ankle joint, a new standardized method controlling instabilities of the subtalar talo-calcanear joint is introduced. In an experimental investigation this radiological technique has been tested out in cadaveric ankle joints (nine joints) with artificial ligamentous lesions. The results show that in all cases an instability is recognizable radiologically using this technique. For clinical use the bilateral examination is recommended failing standardized values for unilateral use.

Additional ligament ruptures or fractures of the medial side of the ankle joint accompanying the lateral ligament rupture are rare. These injuries are more often in traumas with pronation-eversion movements of the foot. In cases of lateral ligaments ruptures we only found in 2.8% and in 5.9% additional medial injuries. This is confirmed by different biomechanical experiments. Experimentally the delta ligament rupture could mostly be caused by pronation-eversion movements or by forced plantar flexion of the foot. The diagnosis of bony lesions of the medial malleolus might be easy by X-ray, but ligament lesions of the medial ankle joint can be diagnosed easily too be using the stress X-ray controlling the medial talar tilt as a sign of medial instability. Because the necessity of surgical treatment is less important than of the lateral ligaments we recommend this procedure in cases of bilateral instability or if dislocation is obvious.