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Aim: Decreases in depth and irregularity are typical changes of the acetabulum in patients with Perthes disease and develop secondary to the femoral head involvement. Optimal timing of therapy plays an important role to prevent these secondary changes. The present study investigates the influence of the amount of femoral head involvement and the patients' age on the acetabulum and the outcome., Methods: 66 patients with 76 affected hip joints were included in the study. 20 hips had a conservative therapy, 22 an operative therapy (IVO). 34 hip joints underwent a conservative therapy at first, followed by an operative intervention. The radiomorphometric analyses at the time of diagnosis, pre- and postoperatively and at follow-up were performed with epiphyseal ratio, acetabular ratio and acetabulum-head ratio. At the time of diagnosis the patients were classified with the Catterall classification, at follow-up with Mose classification., Results: Independent from therapy there was a correlation of the parameters with Catterall classification over the whole course, i.e., the higher the Catterall group the worse the parameter at the time of diagnosis as well as at follow-up. Operatively treated patients with Catterall IV tended towards a worse result of the epiphyseal ratio whereas they achieved better results in the other parameters compared to conservatively treated patients. Catteral I and II patients achieved good results., Conclusion: Operative treatment of the higher Catterall groups seems to be more effective than conservative therapy. Secondary changes of the acetabulum develop in proportion to the amount of femoral head involvement.

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).

Aim of the Study: The results from 56 patients with osteonecrosis of the femoral head who underwent 66 uncemented total hip replacements were analyzed and compared with current reports in the literature on cemented endoprosthesis., Methods: In the retrospective study in 30 of those cases the Zweymüller and in 25 cases the HA-coated ABG prosthesis were used. In addition the results of 11 patients with a polyethylene Endler cup in combination with a Zweymüller stem are presented. The mean age at surgery was 48 years, the mean follow-up was 5.9 years. Clinical examination, registration of the Merle d'Aubigné score and a radiological examination were performed., Results: The clinical results did not show any differences between the used prostheses. A more favourable outcome with regard to the Merle d'Aubigné score was demonstrated for the Zweymüller and ABG prostheses. No loosening of the stem was found. Revision as a consequence of aseptic loosening of the acetabular component was done in 7,5 % (27,3 % of the Endler cups and 8 % of the ABG cups). 20 % of the patients with an ABG prosthesis showed acetabular osteolysis of various degrees. This seems to be correlated with an increased polyethylene wear., Conclusion: Recent reports in the literature about a favourable outcome in uncemented total hip arthroplasty in osteonecrosis of the femoral head can be confirmed. The unsatisfactory results of the Endler cup indicate that established types of endoprostheses should be preferred.

Aim: The objective of the current, prospective study was the evaluation of long-term results after total knee arthroplasty with the PFC-Modular-knee system., Method: A total of 514 total knee arthroplasties were implanted between 1991 and 1994 in 248 female and 55 male patients. Their average age amounted to 62.4 years and 449 of them (87.4%) were re-investigated within the first half-year of 2000. Clinical and radiological data were evaluated according the recommendations of the American Knee Society., Results: Late complications were observed in 6.5% of the cases. They consisted of prosthetic loosening (13 knees), patella problems (11 knees), instability (2 knees), periprosthetic fractures (2 knees), and one prosthesis fracture, 18 patients complained about a therapy-resistant, chronic pain syndrome. These findings lead to revision arthroplasty in 15 cases (3.3%). Preoperative American Knee Society Score values were on average 33, 35 an 17 points and improved to mean values of about 85, 79 and 5 points. Radiological signs of prosthetic loosening were observed in 12 cases (2.7%)., Conclusion: Long-term results after total knee arthroplasty with the PFC-Modular-knee system showed a significant improvement in the patients' complaints and clinical findings at an average of 7.8 years postoperatively. Complication and revision rates of 6.5% and 3.3%, respectively, were low when compared with the international literature and--apart from this--decreased in the course of the observation time.

Purpose: To evaluate the perioperative risks for lumbar disc surgery., Materials and Methods: Over a 10-year period 558 patients (mean age 45, range from 18 to 83 years; 62.7% male, 37.2% female) underwent conventional lumbar disc nucleotomy (69.4% mono-, 27.3 bi-, and 3.3% tri-segmental) for the first (84.4%), second (12.3%), third (2.3%) or more (1.0%) time. Main levels operated were L4/L5 in 56.3% and L5/S1 in 35.3%. In 63.9% there was a preoperative motor deficit. Before the operation and until 3 months after the operation all complications were recorded., Results: In 115 (20.6%) of our patients intra- and/or postoperative complications were observed. Of these 115 patients 33 (5.9%) had slight complications (i.e. urinary tract infection, GI tract disturbance, local irritation of the wound), 57 (10.2%) had moderate complications (i.e. respiratory tract infection, superficial wound infection, dural tear), and 25 (4.4%) suffered from severe complications (i.e. deep vein thrombosis, pulmonary embolism, increase of the neurological dysfunction, additional operation because of a complication). Only in severe complications the hospital stay was prolonged (from a mean of 21 days to a mean of 33 days, p < 0.05). Our analysis showed a doubling of the complication risk in patients older than 75 compared to patients younger than 40 years. Multiple regression analysis revealed significant influence of concomitant diseases like diabetes mellitus and hepatitis (p < 0.01)., Conclusion: 25 or 4.4% of all our patients were confronted with severe complications. The indication for nucleotomy should be weighed especially careful in old patients with diabetes mellitus or hepatitis.

Question: Investigation of the predictive value of the Catterall- as compared to the Herring-classification in patients with Perthes disease., Method: A radiological follow-up study including 53 patients with a total of 59 affected hips was carried out. In the initial diagnosis the Catterall-, Waldenström- and Herring-stages were assessed. The epiphyseal ratio, the head-neck ratio and the lateral subluxation were measured and compared at the time of diagnosis, fragmentation stage and in a follow-up examination, which was carried out 4, 9 years after diagnosis on the average. The results of the follow-up examination were assessed using the Mose-classification and compared as well. In addition the two classifications were compared as to the necessity of an upgrading., Results: Both classifications yielded similar descriptions of the radiomorphometric course. There was a good correlation between the results of Herring A and Catterall I, Herring B and Catterall II and III and Herring C and Catterall IV. Upgradings were necessary in the Herring- and the Catterall-classification in 21 cases, and 18 cases, respectively., Conclusion: The predictive values of both classifications are comparable.

Introduction: This study investigated the influence of concentration and activity of several markers of the collagen and bone metabolism and their impact on ingrowth of non-cemented total hip arthroplasty., Methods: 40 patients underwent an implantation of a ABG-prosthesis. Before surgery and 1, 2, 12 and 24 weeks after it serum concentrations of PICP, ICTP, IGF-1, ON, b-AP, Calcium, Phosphate, GPT and Creatinin were measured and a collagen ratio (CQ) was calculated., Results: PICP decreased until 1st week, increased at 2nd week and decreased again after that time. ICTP increased significantly in 1st week, reached a maximum in 2nd week and decreased after that. b-AP decreased in 1st week but increased after that time. IGF-1 and ON decreased significantly after surgery but increased later. Calcium and Phosphate always showed normal values. CQ decreased in 1st week in males (45%) and females (60%), but increased later on., Conclusion: These markers investigated made it possible to estimate the osteointegration of non-cemented total hip arthroplasty and confirm radiologic and histomorphometric results of the literature.

Problem: The success rate of high-energy extracorporal shock wave therapy in the treatment of non-unions in comparison to the "golden standard" surgery is still unclear., Method: In a prospective study, 3000 impulses with an energy density of 0.6 mJ/mm2 were applied with an experimental device to the pseudarthrosis in 52 patients., Results: The mean duration of pseudarthrosis was 13 months. A mean of 2.5 surgical interventions had already been performed. Bony union was achieved in 52% of our patients after an average of 3.3 months. Failures especially were found in the atrophic type of pseudarthrosis as well as in congenital bone disorders like fibrous dysplasia or osteogenesis imperfecta. No serious complications were observed., Conclusions: Even after numerous surgical interventions high-energy extracorporal shock wave therapy as a noninvasive method for the treatment of bony non-unions showed a fair success rate. A higher success rate can be expected by strict selection criteria.

We report on 48 patients with a mean postoperative follow-up of 7.7 years. 9 patients underwent simple anterior derotation spondylodesis (VDS), 31 patients were additionally fused with posterior Harrington spondylodesis. In 7 of 8 patients the Dwyer compression spondylodesis (DCS) was completed with the Harrington instrumentation. 2 of 3 scoliosis were idiopathic, the residual cases were mainly neuromuscular. The primary curve (preoperative mean: 69.9 degrees) was initially corrected by 62.8% and sustained a loss of correction of 7.6 degrees resp. 10.9% during long-term follow-up. The long-term loss of correction was maximal after DCS showing 10.4 degrees (14.4%), on the average, and minimal after combined VDS and Harrington spondylodesis showing 6.9 degrees (9.3%). After simple VDS the long-term progression of the curve was 7.0 degrees (12.9%). In this group the initial correction was above-average high showing 76.4%. The main loss of correction occurred during the first 2 years after surgery. The long-term correction stability did not show significant differences between simple VDS and combined antero-posterior instrumentation. After anterior instrumentation of the primary curve the secondary cranial nerve spontaneously straightened up by 30%, on the average, and remained stable in the long-term. The anterior instrumentation of the spine lead to a mean loss of lordosis of 13.6 degrees which in the long-term additionally increased by 6.4 degrees due to the anterior epiphyseodesis effect. In 17 patients (42.5%) 24 fractures of the 3 mm-threaded VDS-compression rod occurred. In case of single rod fractures no higher loss of correction or differences in incidence of pain were observed in comparison to intact implants.

Between 1972 and 1992 91 patients with tuberculous spondylitis were treated in the orthopaedic departments of the Universities of Münster and Mainz. The age of the patients at the time of operation was 41 years and 7 months on the average. The tuberculous spondylitis was mostly located in the lower dorsal and upper lumbar spine. Indications for a surgical treatment were the acute spondylitis, the deformation of the spine and imminent or already existing neurological deficiencies. The number of removed vertebrae averaged between 2 and 7. For the ventral spondylodesis we mostly used iliac or tibial bone-grafts. The own results are discussed in relation to the literature, especially the different therapeutic regimes are regarded.

70 patients older than 50 years (mean age: 60.2 years) underwent a CD-spondylodesis from 1987 to 1991 for degenerative changes of the lumbar spine, and were followed for 2 years. 88.2% improved, but only 47.1% showed a good-to-excellent result. Patients with fair and poor outcomes had had significantly more operations on the lumbar spine (p < 0.001), had a greater extent of preoperative lumbar kyphosis (p < 0.05), motor weakness (p < 0.05), had less vertebral slips (p < 0.01), had less posterior distraction postoperatively (p < 0.001), and had a greater extent of postoperative motor weakness compared to patients with good-to-excellent outcomes. Age, sex, duration of back/leg pain, taking of analgetic drugs, preoperative pain status, profession, range of walking, time of operation, number of fused segments, blood loss, blood transfusion, postoperative profile of the spine did not show any significant influence upon clinical results. Already at 6-months-follow-up there was significant difference of the clinical outcome (p < 0.001), making improvement of a then fair or poor result unlikely.

At the Orthopaedic University Hospital of Mainz more than 150 patients were treated surgically according to Cotrel and Dubousset procedure. By means of this operation average corrections of the curves of 54.8% to 64.6% could be achieved in the first 150 patients, depending of the localization of the curve. Operative procedure, duration of operation and blood loss are adequate to known procedures, the stability of the method is better than in other known methods. The change of the postoperative sagittal profile demonstrates the influence of the operation in cases of hypokyphosis in the thoracic and hypolordosis in the lumbar spine.

Total hip arthroplasty was performed with PMMA-augmented tumor prostheses in 42 individuals suffering from metastatic destruction of the proximal end of the femur at the Orthopedic University Hospital Mainz from 1980 to 1992. Neoplastic lesions had been triggered by carcinomas of the breast in 25 female patients. 24 of our patients presented with pathologic fractures. In all patients capable of walking preoperatively early mobilization could be attained by total hip arthroplasty. Pain relief was achieved in each patient. Resection of the major trochanter and, partially, of the pelvitrochanteric muscle sleeve entailed luxation of the prosthesis six times in 5 individuals during the first postoperative two months; closed reduction was practicable in all of them. Postoperative survival time amounted to an average of 10.5 months. Leg length and hip function were successfully re-established by implanting tumor prostheses after resection of the proximal part of the femur.

The results of the operative treatment of 44 patients suffering from a neuromuscular scoliosis are presented. Only multisegmental procedures - also in combination with anterior methods - should be used to avoid a postoperative care with cast or brace. By means of the operation an average correction of the curves of 50.7% was achieved. The preoperative mean angle was 75.1 degrees, postoperatively a mean angle of 37.0 degrees (mean correction of 38.1 degrees) was determined. The preoperative angle, the duration of the operations, the blood loss and the quantity of the complications are higher than in idiopathic scolioses. As a result of the known tendency of deterioration in neuromuscular scolioses, the members of the Arbeitskreis Skoliose of the German Orthopaedic Society (DGOT) recommend an early operation (in progressing curves over 20 degrees) in patients suffering from a muscular dystrophy Duchenne.

From 1986 to 1990 50 patients with increasing spinal instability due to pathologic fractures of one or more vertebrae were operated in the Orthopedic Department of Mainz University Hospital. In the course of 57 operations anterior decompression and stabilization were performed 3 times, whereas dorsal spondylodesis was done with Cotrel-Dubousset's instrumentation (CDI) 32 times, with Luque's 7 times and with Harrington's 1 time; a combination of CDI and Luque was chosen in 2 cases, a combination of Harrington and Luque in 1 case. 3 times a single-stage combination and 4 times a two-stage combination of ventral and dorsal stabilization was used. The application of the CDI required no postoperative external support. 35 patients suffered from major neurologic deficits preoperatively--among them 11 from a complete and 6 from an incomplete paraparesis--which made spinal cord decompression necessary in advance of the dorsal stabilization. Of these, 16 improved significantly; however, deterioration of the neurologic status occurred in 4 cases with a paraparesis in 3 of them. Survival time postoperatively was approximately 13 months in 27 patients. 9 of these died within half a year after the operative intervention. Failure of fixation as a result of tumor lesion was found in 2 cases of CDI procedure and in 1 case of the Harrington instrumentation. All required a revisional operation. 3 patients developed a radiologic lysis of methylmethacrylate implants fixed by an anterior procedure. Posterior decompression and stabilization render possible resolution of spine pain as well as restoration of mobility until a few days before exitus letalis without restricting adjuvant radio- or chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Presented is the recommendation of the "Arbeitskreis Skoliose" of the DGOT concerning the sporting activities for juvenile patients suffering from an idiopathic scoliosis. The main points of this concept are the desirable active participation in school sport activities and the ascertainment that restrictions are not necessary in scolioses up to 21 degrees. A special recommendation for operated patients predicates the begin of sport activities after ohne year postoperatively. The kind of sport must be recommended by the surgeon, high-performance sports cannot be tolerated in those patients. Precondition for these recommendations are regularly physical examinations by the orthopedic physician and standardized x-rays in standing position.

The comparison of the results obtained by conservative or operative treatment of hip dysplasia shows that the consideration of absolute roentgenologic hip parameters is of little use. Classification principles for numerous hip parameters have been developed for this reason by Tönnis. In the Angloamerican and Scandinavian countries, on the other hand, it is predominantly the Severin classification that is employed for an evaluation of the methods of treatment. We examined in our study the differences in the evaluation of the results obtained in 117 hip joints treated by pelvic osteotomy according to Salter by application of the AKH and the Severin classification scheme. There were evident differences in all groups of these classifications. In the application of the Severin scheme the groups I, II and III contained 9.5% less, 24.8% more, and 18.8% less hip joints, respectively than in the respective groups of the Tönnis classification. In the groups IV, V and VI of the Severin classification there were altogether 3.5% less hip joints than in the respective groups of the Tönnis classification. Our study thus showed that a comparison of the operative results of hip dysplasia as presented in the Angloamerican and Scandinavian literature and those presented in the German literature is not possible. We conclude from this result that an evaluation according to a unified classification scheme would be most desirable.

Magnetic resonance (MR) imaging may distinguish transient osteoporosis of the hip from more severe hip diseases. 12 patients with transient osteoporosis of the hip underwent MR imaging. The initial and follow-up studies included T1- and T2-weighted images in coronal, transverse or sagittal planes. There were revealed 3 stages: diffuse-, focal-, and residual stage. This syndrome is characterized by hip pain, limping, and osteoporosis of the femoral head with preservation of the joint space. The clinical symptoms and abnormalities on MR images disappeared completely within 6-10 months.

Mass radiography in juveniles between 10 and 19 years of age in Westphalia pointed to a probable incidence of thoracal scoliosis of more than 10 degrees in about 4 per cent of the girls and 1.0--1.5 per cent among boys. In both girls and boys the convexity of the scoliosis is chiefly in the right direction, especially if the apex of the curvature is positioned in cranial direction or if the findings are very pronounced. In a few exceptional cases only the apex of curvature is above Th7. Hence, most of the patients can be adequately treated by means of one of the more recent methods of orthesis.

In a 32-year-old man with Frederiksen's Type II beta-hyperlipoproteinemia, a total and a subtotal resection of the Achilles tendons were performed. The follow-up examination six years later confirmed the very good prospects of success of total resection and reconstruction of the Achilles tendon; this is the only long term result reported in the literature. Following subtotal resection residual complaints are likely to occur.

In this paper the results of Salter's innominate osteotomy combined with an open reduction are shown on the basis of radiographic and clinical investigations. From 1969-1976 43 hips up to the age of 3.11 years had been treated after Salter's method. At the follow-up 65.6% of the hips were found to have normal or slightly pathological AC angles. 63.4% of the hips show good and fair results concerning the ACM angle. The results of the CE angle and the 'hip value' are disappointing: only just 34.1% of the hips can be considered good or fair. This is a consequence of the high rate of preoperative avascular necrosis on the one hand, on the other hand it is based on the fact that most of the cases had had a previous non-operative or operative treatment.

Only rarely is a surgical intervention necessary for increased kyphosis in Scheuermann's disease. However, effective erection of fixed kyphoses is only possible with an incision of the anterior spinal ligament, removal of the discs at the vertex of the curvature, resection of the vertebral arch joints, narrowing of the considerably widened vertebral arches and stabilizing with Harrington's instrumentation. The present authors have treated 11 patients in this way. With this procedure it proved possible to erect the kyphosis on average by 53.4%. In the first postoperative year there was an average loss of correction of 1.7 degrees, though subsequent deterioration was only 0.7 degrees up to the time of the last follow-up examination. The residual correction gain was 50.4 per cent. The results in 4 other patients, in whom Schöllner's erector rods were implanted, were less favorable. The permanent correction was only 50.4 in these cases. The best postoperative results are likely to be obtained by a unilateral ventral and dorsal procedure.

At present, we survey 52 patients who had been fitted with Chêneau braces in the years 1978 to 1980. The average primary correction of the single curved thoracic, single curved lumbar, and double curved scolioses amounted to 41%. The best late results are to be expected in the single curved thoracic and single curved lumbar scolioses that presented corrections of 14.2% and 9.2%. In the double curved scoliosis we found a correction of 5.5% of the thoracic and 5.6% of the lumbar curves. The Chêneau orthosis was well accepted by the patients. A final valuation, however, will not be possible till some years have passed.

At the Orthopaedic University Hospital Muenster 50 patients were surgically treated according to the Cotrel and Dubousset technique from June 1985 to October 1986. An outstanding characteristic of this method is the three-dimensional correction of the curve without exclusive application of distraction or transverse forces, bringing about excellent stability. By means of this operation an average preoperative angle of 63.4 degrees could be diminished to 33.9 degrees, meaning a gain of correction of 46.5%. Complications occurred essentially due to insufficient experience with this technique in the first patients operated on. After sufficient training this procedure is as practicable as the Harrington technique.

Further to an earlier paper on progression of untreated idiopathic scoliosis 37 patients with scoliosis following poliomyelitis are reported on. 16 of them could be observed for 2 years or more having had no treatment. Their progression is clearly more extensive than that of idiopathic scoliosis. But like them it is at a peak during the prepubertal spurt of growth. It also is more obvious the earlier it is recognized. The prognosis of post-poliomyelitic scoliosis is particularly bad when it starts shortly after onset of the paralysis.

110 patients with idiopathic scoliosis are reported on, who had no treatment for 2 years or more before growth stopped. Another 36 patients untreated for 1 year could be observed. The changes in the scoliotic angle were followed up radiologically and entered into a diagram. The average progression of these scolioses during one year were calculated. Progression was always most pronounced between the 10th and 15th year and coincided with the prepubertal increase in growth. This has to be expected 2 years later in boys than in girls. The degree of progression definitely depended on the site of the primary curve. Thoracic and S scoliosis showed most pronounced progression, followed by thoracolumbar and lumbar scoliosis. Progression was worse the earlier scoliosis was diagnosed.

Up to now, 106 patients were treated by the muscle stimulation method for scoliosis after Axelgaard at the Orthopaedic University Hospital. We introduced this procedure in 1979. 43 curves could be improved whereas 19 deteriorated also under this treatment. 44 curves did not show any change. At the start of treatment, the average age was 11.3 years, the average angle 21 degrees. It appeared that thoracolumbar curves were best to be influenced. Furthermore, there were better results in angles below 30 degrees than above 30 degrees, and in patients below 13 years than above 13 years. Accordingly, the muscle stimulation therapy is indicated as an early treatment in mild scolioses.

In 1977, for the first time, a recommendation for the expert evaluation of scoliosis-sufferers was given out. On the basis of this a new classification followed, which takes into consideration modern orthetics and new operative procedures. Unchanged are the classifications of incapacity to work with regard to decreasing lung capacity. The levels of vital capacity are still the main factor for determining lung capacity.

At present, we survey the final results of 62 patients having been treated by a Milwaukee brace. The average curve amounted initially to 35 degrees. There succeeded a primary correction to 32 degrees. At start of weaning the initial angle of 35 degrees was reached again. During the weaning period an evident deterioration of 39 degrees occurred, and at the follow-up control 6 years after the end of weaning the curve was 42 degrees on the average. Thus, our own results are somewhat more unfavourable than those of Mellenkamp et al. In 1977, they reported the results of 47 patients who could be submitted to a follow-up control. The mean scoliotic curve of these 47 patients amounted to 44 degrees at start of treatment, at the last control, on the average 5 years after weaning from the Milwaukee brace, the mean angle was about 40 degrees. Essentially, we could prevent the progression of the curvature, too. If there occurred deteriorations in comparison with the initial angle, they were usually caused by a few patients who developed a drastic deterioration of their scoliosis.