Posterior glenohumeral instability

The posterior instability of the shoulder is a more difficult diagnostic and therapeutic challenge than the anterior instability. There are many etiologies and causes of posterior instability. Most studies in the literature are retrospective and yield a great variation in therapeutic recommendations. Generally it has to be separated in traumatic and atraumatic instabilities. Most of the traumatic dislocations are impaction fractures of the humeral head against the dorsal glenoid. Therapy is depending on the size of the humeral defect, the duration of dislocation and the functional demand of the patient. Therapeutic possibilities are closed reduction and fixation with a cast, open reduction and the transfer of the lower tubercule (McLaughlin's procedure), lifting of the defect and supporting with cancellous bone, subcapital rotational osteotomy or arthroplasty. The therapy of choice for atraumatic instability is a individualized rehabilitation program with strengthening and balancing of rotatator cuff muscles and scapular stabilizers. Psychologic abnormalities and emotional problems have to be recognized prior to any operative procedure. These patients are no operative candidates. Operative treatment of choice is the posterior capsular shift adressing the causative redundancy or laxity of the postero-inferior capsule. Posterior bony procedures as glenoid osteotomy or bone block transfers are indicated, if the pathologic geometry of the glenoid is primarily responsible for posterior instability. It is strongly recommended to combine them with a capsular shift to adress the secondary capsular redundancy.

[Posterior shoulder joint instability. Classification, pathomechanism,diagnosis, conservative and surgical management]

The posterior instability of the shoulder is a more difficult diagnostic and therapeutic challenge than the anterior instability. There are many etiologies and causes of posterior instability. Most studies in the literature are retrospective and yield a great variation in therapeutic recommendations. Generally it has to be separated in traumatic and atraumatic instabilities. Most of the traumatic dislocations are impaction fractures of the humeral head against the dorsal glenoid. Therapy is depending on the size of the humeral defect, the duration of dislocation and the functional demand of the patient. Therapeutic possibilities are closed reduction and fixation with a cast, open reduction and the transfer of the lower tubercule (McLaughlin's procedure), lifting of the defect and supporting with cancellous bone, subcapital rotational osteotomy or arthroplasty. The therapy of choice for atraumatic instability is a individualized rehabilitation program with strengthening and balancing of rotator cuff muscles and scapular stabilizers. Psychologic abnormalities and emotional problems have to be recognized prior to any operative procedure. These patients are no operative candidates. Operative treatment of choice is the posterior capsular shift addressing the causative redundancy or laxity of the postero-inferior capsule. Posterior bony procedures as glenoid osteotomy or bone block transfers are indicated, if the pathologic geometry of the glenoid is primarily responsible for posterior instability. It is strongly recommended to combine them with a capsular shift to address the secondary capsular redundancy.

[Excessive stress damage of the lower extremity caused by sports. The value of sonographic diagnosis in stress damage of the lower extremity]

150 sportsmen with lesions and diseases of the lower extremity served as basis for demonstrating the possibilities offered by diagnosis via sonography. Main indications were articular and paraarticular diseases of the large joints (hip and knee) to demonstrate effusions, ganglia, bursae and tendon ruptures, diseases and injuries of the musculature at the thigh and lower leg, as well as the Achilles tendon with its various changes such as rupture, achillodynia and peritendinitis. Muscular and tendon ruptures can be differentiated via sonography in respect of extension, type, age and localisation. This makes differentiated treatment possible. Intraarticular lesions of the knee joint remain the domain of arthroscopy. Sonographic findings should always be supplemented by anamnesis, clinical findings and x-ray film so as not to overlook any bony injuries and damage of the capsular ligaments.

Sulbactam/ampicillin versus cefotaxime as initial therapy in serious soft tissue, joint and bone infections

In an open, randomised comparative study, 23 patients with bone, joint or soft tissue infections were treated with ampicillin 2g plus sulbactam 1g 3 times a day or cefotaxime 2g 3 times a day as an initial 2-week therapy. Monoinfections with Staphylococcus aureus were the most common bone or joint infections. Clinical cure or improvement 2 weeks after the end of therapy was observed in all 13 patients treated with sulbactam/ampicillin and in 7 of the 8 patients evaluated for efficacy after treatment with cefotaxime. Most organisms identified before the onset of therapy were susceptible to the antibiotic randomly selected for therapy, although the majority of infections due to beta-lactamase-producing staphylococci could not have been treated with ampicillin without sulbactam. Treatment failed to eradicate S. aureus in 1 patient from each group. In addition, S. aureus infection recurred in 2 patients in the cefotaxime group within 2 weeks after the end of therapy. No serious side effects were observed.

[Scintigraphic findings in fracture of the vertebral body]

The "region-of-interest technique" was applied for taking 85 quantifying skeleton scintigrams in 60 patients suffering from 75 stable impression fractures of the inferior thoracic spine or the lumbar spine. The skeleton scintigrams were made between 3 days and 6 years after the accident, predominantly between the first and twelfth posttraumatic week. The evaluation curves of the scintigraphic quotients following to fractures of the vertebral bodies show a linear increase of the quotient until the fourth week and afterwards an exponential decrease. The quantifying skeleton scintigraphy is not only valuable in diagnostic evaluation but allows also to assess the age of fractures of the vertebral bodies. In the future, quantifying skeleton scintigraphy may thus play an important role in the examination of fractures of the vertebral bodies.

An open, comparative study of sulbactam plus ampicillin vs. cefotaxime as initial therapy for serious soft tissue and bone and joint infections

In an open, randomized, comparative study, patients with bone, joint, or soft-tissue infections were treated with sulbactam sodium plus ampicillin (sulbactam/ampicillin, 1 g of sulbactam and 2 g of ampicillin three times a day) or with cefotaxime (2 g three times a day) for two weeks as initial therapy. Thirteen patients were entered into the sulbactam/ampicillin group and nine into the cefotaxime group. Two weeks after the end of therapy, clinical cure or improvement was observed in all 13 patients treated with sulbactam/ampicillin and in seven of nine patients treated with cefotaxime. Staphylococcus aureus was not eliminated from one patient in each group. Recurrence of S. aureus infection occurred in two patients in the cefotaxime group within two weeks after the end of therapy. No adverse effects warranting discontinuation of antibiotic therapy were observed. The combination of sulbactam sodium plus ampicillin was at least equivalent to cefotaxime for the initial treatment of acute serious soft tissue and bone and joint infections.

[Mineral and trace element determination in human osteosarcoma. Case report]

The concentrations of calcium and magnesium, and of the trace elements iron, copper, manganese and zinc were determined in the amputation specimen of a 25-year-old patient with osteosarcoma and compared with the tumor-free, normal bone tissue. Not only the concentrations of calcium and magnesium, but also those of the trace elements were significantly higher in the osseous portion of the tumor. The periosseous concentrations of trace elements iron, copper and zinc were also significantly higher in the tumor than in the normal bone tissue.

[Schwartz-Jampel syndrome. Orthopedic and neurological problems of chondrodystrophic myotonia]

This report deals with two brothers suffering from chondrodystrophic myotomy (Schwartz-Jampel syndrome), and presents, through the study of these cases, the orthopedic and neurological problems presented by this condition. In the case of our patients there is no confirmation of the stunted growth mentioned in other reports, nor are there any changes in the vertebral column. In contrast to cases reported to date, pathologically high sero-enzyme amounts were found in both children. The congenital changes in the hip joints worsen during the pre-puberty phase, so that in one case bilateral adduction contraction and in the other complete bilateral dislocation of the hip joints resulted. Early orthopedic treatment to prevent later irreparable consequences is recommended.

[Value of the "region of interest" technique in the scintigraphic diagnosis of primary bone tumors (author's transl)]

Employing ROI-technique, a ratio Q was obtained from relating accumulation of 99mTc-MDP at the site of the bone lesion (n = 150) with that of contralateral non-involved osseous areas. Values of Q were correlated with histologic tumor diagnosis, its dignity and frequency. Values of Q of greater than 3.0 were found in 95% of all sarcomas, in 100% of the osteosarcomas but in only 3.8% of all benign bone tumors. Values ranging from 1.0 to 1.2 were exclusively measured in benign tumors (e.g., in 52% of juvenile bone cysts and in 67% of non-ossifying fibromas). Since the threshold--separating benign from malignant lesions--at Q = 3.0 was blurred by tumorlike lesions, metastases and especially by Paget's disease, this method does not precisely predict dignity. However, this method may complement radiographic evaluation with low values supporting the diagnosis of a benign lesion. The combined findings of radiography and these rations gained by nuclear imaging may help determine the pathway of a patient through further diagnosis and treatment.

[How dangerous is squash? Results of an investigation on injury risk (author's transl)]

Injury risk for squash lies above the international average of total sport injuries. According to a nation-wide assessment, 7 accidents occur yearly in 100 squash-players. Only half of these injuries, however, require treatment. A temporary sports- and work incapacity results relatively frequently. With the exception of eye injuries, the rate of severe injuries leading to permanent damage is low. If appropriate preventive measures are taken, particularly with respect to eye injuries, squashplaying does not entail significantly higher dangers than other racket-games.

Osteosarcoma: histological evaluation and grading

With 60 cases of osteosarcomas a histological evaluation from + to +++ carried out for mitoses, osteoid formation, presence of multinucleated giant cells, and tumor necrosis. A subclassification in osteoblastic, chondroblastic, and fibroblastic type of osteosarcoma (according to Dahlin) and a histological grading from + to +++ based on degree of cellular atypism was also done. In our material no relations between these three types of osteosarcoma and chance for survival became evident. There was, however, a significant correlation between grade of atypism and rate of mitoses. Grading of oestosarcomas from + to +++ showed that cases with grade III osteosarcoma remained only seldomly without metastases during the course of the disease. Grade I osteosarcomas and also grade II tumors showed a higher number of patients with 2-year survival. However, neither correlation between tumor grade and incidence of metastases, nor with chances for survival were statistically significant. Nevertheless, characterization of osteosarcomas, by a histological grading from + to +++ based on cellular atypism and mitotic count is advisable, in addition to the TNM stages. This histological grading appeared to be more practicable than subclassifications of osteosarcoma by type which had been tested by us in a previous study (Konrad et al., in press).

[Sport injuries due to squash. Epidemiology and prevention (author's transl)]

A statistical collection of squash injuries in 8000 players from 30 squash centers in the Federal Republic of Germany over a 12 months period is presented and evaluated. The comparison with other types of sport shows squash to be sooner likely to cause injuries than tennis, but to entail essentially less injuries than e.g. football or handball. With a view to prevention, certain demands must be made on the player as regards his manner of playing and equipment, but also as regards the ground conditions of squash halls.

[Treatment and prognosis of osteosarcoma in childhood (author's transl)]

126 osteosarcoma under the age of 15 years are followed up in an interclinical study. There is a steady increase of tumor incidence towards the 15th year with a slight male preponderance. The main sites of the tumor are the distal femur followed by the proximal tibia and humerus. Evidence of multiple metastases is most often present in the lungs, less often in the skeleton. Nearly always metastases became evident within 2 1/2 years after diagnosis (98%). Therefore the 2 1/2-year disease--free survival rate seems to be sufficient for prognostic evaluation. The over all 2 1/2-year survival rate was 17,5%. Though the different methods of treatment are not statistically valid, the best results can be expected after early amputation. By radiotherapy alone no cure has been achieved. Survivals were seen at any age and at any site of long bones (distal femur, proximal tibia, humerus, femur, distal radius). Prognosis of osteosarcoma in the childhood is similar to that of the adult group.

Osteosarcoma in children. A study of 125 cases

A study is presented of the aetiology and results of treatment in a group of 125 proven osteosarcomas present in children under fifteen years of age. These cases have been collected from the records of one English and six European treatment centres. There is a slight male preponderance, but the striking aetiological feature is the very high proportion of tumours of the long bones of the limbs (96 per cent). The two and a half and five year disease-free survival rates were respectively 15 and 12 per cent, with a further 9 per cent still living, but under observation for less than two and a half years. Evidence of metastasis after two and a half years is very unusual, but no child with a tumour of an axial or girdle bone lived this length of time. Although the differences in the results of the different methods of treatment employed are not statistically valid, the largest number of long survivors had been treated by early amputation, which method also provided the lowest rate of local tumour recurrences. Reasons are discussed which indicate that prompt ablation is the treatment of choice, perhaps with certain advantages in the light of recent advances in adjuvant treatment. The past situation in connection with childhood osteosarcoma certainly provides strong support for immediate carefully designed clinical trials of the new adjuvant methods cited.

OSTEOSARCOMA IN CHILDREN

A study is presented of the aetiology and results of treatment in a group of 125 proven osteosarcomas present in children under fifteen years of age. These cases have been collected from the records of one English and six European treatment centres. There is a slight male preponderance, but the striking aetiological feature is the very high proportion of tumours of the long bones of the limbs (96 per cent).

The two and a half and five year disease-free survival rates were respectively 15 and 12 per cent, with a further 9 per cent still living, but under observation for less than two and a half years. Evidence of metastasis after two and a half years is very unusual, but no child with a tumour of an axial or girdle bone lived this length of time.

Although the differences in the results of the different methods of treatment employed are not statistically valid, the largest number of long survivors had been treated by early amputation, which method also provided the lowest rate of local tumour recurrences. Reasons are discussed which indicate that prompt ablation is the treatment of choice, perhaps with certain advantages in the light of recent advances in adjuvant treatment. The past situation in connection with childhood osteosarcoma certainly provides strong support for immediate carefully designed clinical trials of the new adjuvant methods cited.

[Thermography in sport injuries and lesions of the locomotor system due to sport]

Using the infrared-thermography a exact picture of the body surface can be obtained. Injuries are recognized by a local hyperthermy, if the impaired structures do not lie too deep under the body surface. In combination with anamnesis and clinical and radiological examination the infrared-thermography plays an important role in the diagnosis, management and control of therapy. The results of examinations of 82 patients with distorsions, ruptures of tendons or ligaments, injuries of the meniscus and tendo- and chondropathias as well as of 50 athletes are described. In all cases a hyperthermy was found in the area of injury. In those cases, in which an injury was not the cause of the hyperthermy, other processes could be found (furunculosis, phlebitis, tumor).

Ergebnisvergleich der 99mTc-Polyphosphat-Kamera-(Sequenz, Funktionsszintigraphie, der 85Sr-, 87mSr-Scanner-Szintigraphie und radiologischer Methoden in der Orthopädie

Vergleichende Studien zwischen Radiologie (= R; Röntgen, Thermographie, Angiographie) und Nuklearmedizin (= NM; Scanner-, Szintillationskamera - Sequenzszintigraphie) anhand von 339 Patienten mit Knochenerkrankungen erbrachten folgende Ergebnisse:

Die Thermographie erwies sich zur Aufdeckung von Knochenerkrankungen weniger geeignet als der Scan.

Die Angiographie wurde vorzugsweise zur Diagnose maligner Tumoren verwendet.

Die Sequenzszintigraphie mittels Anger-HP-Szintillations-Kamera und Intertechnique-Cine-System erlaubt die Feststellung des kinetischen Verhaltens des Tumors: Früh gesteigerte TcPoP-Akkumulation wurde bei Tumoren mit hoher Perfusion festgestellt (Sarkom), späte Akkumulation in jenen mit niedriger Perfusion (Osteom).