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It is often not easy to classify a rotator cuff tear into traumatic or non-traumatic. For individual medical examinations the classification depends basically on the following four criteria: Case history, analysis of the accident, analysis of the complaints after the accident (or even before) and the pathomorphological findings. The aim of this study was to identify findings in the magnetic resonance imaging of the shoulder joints of patients with rotator cuff tears that could help in the differentiation of traumatic versus non-traumatic. As a result it could be shown that infraspinatus and subscapularis tears, Hill-Sachs lesions and fractures of the tuberculum majus are significantly more detectable among those patients reporting a trauma. In contrast degeneration of the supraspinatus tendon, calcific tendinitis of the supraspinatus tendon, ac-joint degeneration and an absence of the subacromial fat pad are more verifiable in the non-traumatic group. These results can be used as additional important information in the individual medical examination of patients with rotator cuff tears.

In the case of SLAP-lesions the upper part of the labrum glenoidale is affected and the long tendon of the biceps muscle can be involved. In literature different types of the lesions are classified. In the case of an individual medical examination, it should be kept in mind that variations of normal anatomy exist and for that reason the examiner should analyse if there is a real pathological condition. He should also discuss the pathogenesis with special regard to the mechanisms of trauma as published in literature. With SLAP-lesions there should be a functional disabling symptomatology of the affected shoulder that occurs directly or at least shortly after the accident. Also the imaging modalities and, when available the findings of an operative treatment, should be analysed to see if other trauma-lesions exist. These aspects will be discussed in the following paper.

It is not scientifically proven that problems in the neck, shoulder, arm and hand which patients complain of after repetitive activities at work, are due to structural damage caused by physical stress at the workplace. As a consequence, from the orthopedic point of view, RSI cannot be accepted as a work-related disease.

A review of the literature revealed that there are no new scientific data which can rule out the existence of an isolated traumatic meniscus tear. However, the large number of publications on the subject of meniscus pathology do suggest that the traumatic tear of a "healthy" meniscus without ligamental or osseous concomitant lesions is indeed very rare. In order to perform an individual medical examination, therefore, medical experts need every available information to assess such a case.

Unlabelled: We assessed the interindividual diagnostic variance of 39 experienced arthroscopists by the Kappa Cohen interobserver variation analysis using videotapes of eight different patients with different diagnoses. Arthroscopically normal findings showed a relatively acceptable interobserver correlation. Pathological changes, in contrast, often showed very little correlation, especially in the synovial membrane of the suprapatellar recess, in the cartilage of the femoropatellar groove and the posterior cruciate ligament. In patellar alignment there was also great interobserver variation., Clinical Relevance: When comparing arthroscopic findings with other imaging techniques the above results should be taken into account. Furthermore, these results will affect the significance of medical expertise based only on pictures. In addition, medical cost billing, which is based on arthroscopic findings, has to take into account that a wrong diagnosis is possible and therefore charges will be wrong.

Treatment of spondylolisthesis is discussed differently even nowadays. In addition to that long term results of surgical reduction and stabilization by internal fixation are rare. Therefore the evaluation of the data of 61 patients treated operatively with the sacral plate by Schöllner with a mean follow-up of more than 10 years seemed to be justified. Additionally 48 out of 61 patients could be reexamined at follow-up and answered a questionnaire to measure their subjective status. Mean age at the time of surgery averaged almost 18 years. 14 male and 47 female patients were treated. Sagittal translation averaged 66% and was corrected to a mean 31%. Sagittal rotation was corrected approximately 70%. Preoperative neurological deficits could be treated successfully in most of the cases. However, in 5 cases irreversible neurological lesions of the L5 nerve root occurred. Early revision surgery was indicated three times each in cases of implant loosening and distal plate pull-out. 4 of 5 patients underwent additional surgery due to pseudoarthrosis. At follow-up 75% of the patients were pain free, another 22.9% experienced improvement of at least 80%. 47 out of 48 patients were very satisfied or satisfied with the result of the operation. In our mind the long term results justify operative reduction and stabilization of spondylolisthesis by internal fixation for improvement of static, function and symptoms. Possibilities to reduce complications are discussed.

In 6.26% of 846 patients with lumbar disc surgery a reoperation was necessary. A total of 93 patient had undergone a revision surgery inclusive a patient group with primary surgery performed elsewhere. 68 patient had 1 reoperation, 22 patients 2, 2 patients 3, and one patient had even 4 revisions. Follow-up ranged between 19 and 42 years with an average of 31 years. 53 patients were clinically examined at a time of follow up and another 15 patients answered a questionnaire. An excellent result with no complaints and patients able to work could be achieved in only 16%. A good result with no radicular pain, but some minor back pain and some loss of sensibility and ability to work was found in 24%. In 40% of the patients the result was only fair with some radicular pain and limited capability for work. 20% of the patients had only a poor result with unchanged symptoms and continued therapy. Those patients were not able to work. Young and female patients had a better prognosis. Another positive predictor was a short period of preoperative pain. Negative predictors were multiple prior operation as well as scar tissue at time of revision. Also spondylodesis according to Cloward correlated also with a negative clinical outcome.

Based on results of anatomical studies, we established an arthroscopic procedure to resect all degenerative changes within the joint without endangering the stabilizing structures. Since November 1989 we operated on 26 patients with this technique. There were no major complications. The mean score significantly increased from 64.9 (+/- 12.8) to 86.8 (+/- 11.5). Analysis of postoperative x rays revealed an average length of resection of 21.3 mm at the inferior border of the clavicle, of 15.4 mm in the middle, and of 10.2 mm at the superior border of the clavicle. 21 out of 26 patients were completely satisfied and would undergo the same procedure again. In two of the five unsatisfied patients the resected length of the clavicle was insufficient and these patients required open surgery for resection of the remaining bone. Our first experiences are encouraging. The surgical technique is standardized and reproducible. The short time results score not worse compared to the open conventional technique. With the 2 to 4 year long term follow up we have to prove, whether maintaining the passive stabilizers of the joint improves the long term results better than the open technique.

Especially in idiopathic thoracolumbar scoliosis the approach and sort of instrumentation have controversially been discussed over the past years. Since 1986 32 patients with adolescent thoracolumbar scoliosis underwent operative treatment, 20 patients were treated with Cotrel-Dubousset Instrumentation (CDI), 10 patients underwent Ventral Derotation Spondylodesis (VDS). In 2 cases a combined two-stage VDS and CDI were performed. The follow-up was 38 months in the CDI-group and 19 months in the VDS-group. Length of the curve and the fusion were identical in the VDS-group. In the CDI-group, however, length of the fusion exceeded curve length by 4 segments on average. With CDI the fusion was carried down to L4 in most cases, in some cases to L5. Curve correction of the primary curve averaged 70% with VDS (preoperative mean 84 degrees) and 64% with CDI (preoperative mean 65 degrees). We observed a spontaneous correction of the secondary curve of 38% after VDS. With CDI the correction of the secondary curve averaged 42%, however, in secondary curves measuring more than 50 degrees primary and secondary curve were fused. A preoperatively physiological sagittal plane in the CDI-group remained unchanged after operative treatment. With VDS an average kyphosis of the thoracolumbar junction of +22 degrees was corrected to +7 degrees. We conclude that in the operative treatment of severe thoracolumbar scoliosis VDS offers significant advantages compared to CDI and should therefore be preferred. In moderate scoliotic deformities, where the number of caudally unfused segments is equal in both systems, CDI is justified.

Unlabelled: We harvested the joint capsule, the glenohumeral ligaments, and the coracohumeral ligaments of 8 fresh formalin-preserved shoulder specimen. We made use of the van Gieson technique and a special silver impregnation for staining peripheral axons according to Nowotny. The ligaments were cut into slices with a thickness of 15 microns. In total we performed 10,000 cuts. We discovered axons in all ligaments. These axons had no relation to vessels or vessel walls. Besides these axonal structures we detected type II mechanoreceptors (Pacini receptor)., Clinical Significance: The neural structures discovered in the glenohumeral capsule are of clinical importance especially in consideration of the high account of recurrent shoulder dislocation and concomitant Bankart lesions. Receptors located in the glenohumeral ligaments might control the stabilizing shoulder musculature. On this premises, rupture or detachment of these ligaments will lead to a loss of the feedback mechanism.

79 patients with acute or chronic lesions of the knee were evaluated by MRI prior to and after application of Gd-DTPA. The MRI examination was performed by a 1.0 tesla imager with SE as well as FEDIF sequences. These MR studies were compared prior to and after intravenous Gd-DTPA application, focusing on the visibility and the definition of a possible lesion, and scored with a 3-point score. Statistic analysis and case analysis revealed that in patients with meniscus degeneration without a tear, Gd application yields no additional diagnostic information. However, in patients with meniscus tears Gd-DTPA significantly facilitates the definition of the lesion. Furthermore, Gd-DTPA makes differentiation possible between the synovial fluid and the synovial membrane. Whereas in cases with capsule or collateral ligament tears Gd-DTPA facilitates the documentation of the lesion, we found no advantage in using Gd-DPTA in patients with ACL tears. In patients with chondropathia patellae Gd-DTPA application supports the visualization of the secondary synovial reaction.

In a retrospective study we documented the need for blood transfusion in total knee (TKR) and hip replacement (THR). The problems with homologous blood transfusion in orthopedic surgery and alternative techniques of autologous-blood transfusions are discussed. In this series patients with primary THR needed 1.69 (+/- 2.25) blood units, with primary TKR 1.58 (+/- 1.54) blood units, and secondary TKR 1.19 (+/- 1.47) blood units, Secondary THR required significantly more units (3.85 +/- 3.07). These procedures also asked for significantly more plasma (3.27 +/- 3.95) than all other procedures. For secondary THR 2.63 (+/- 2.45) blood units were intraoperatively used and only 1.23 (+/- 1.09) blood units postoperatively. All other procedures needed postoperatively significant more units than intraoperatively. In secondary THR the use of blood transfusions increased with age. 45% of the patients with primary THR and 15% with secondary THR were operated without additional blood transfusion. In secondary THR 36% of all patients needed more than 4 blood units and 27% more than 4 plasma units. In TKR 39% of the primary cases and 50% of the secondary cases were operated on without additional homologous blood. Based on these results we established a transfusion concept for our department. Economic, practical, as well as legal aspects were taken into account.

6.5 years after lumbar chemonucleolysis (CNL) we examined 40 patients by MRI. All MRI studies were performed by a 1.0 tesla MRI. We documented the height of the discs, the chondrosis, the intradiscal MRI signal, as well as the intraosseous signal within the vertebral bodies (end plate reaction). Preoperative MRI studies (Tvor) and/or postoperative MRI studies within the first postoperative year (T1) of 18 patients were available. We found an overall reduction of the sagittal disc height of 26%. This reduction was 19% in the male patients and 45% in the female patients (p < 0.02). Comparing the T1-studies with the T6.5-studies, we could still reveal a proceeded reduction of 13%. In those patients who underwent three MRI studies, there was a reduction of 20% between Tvor and T1. Among one half of the patients we found a further decrease in disc height of 15% between T1 and T6.5, whereas the other half showed an increasing disc volume of 15%. At time of follow up (T6.5) all treated discs showed a reduced MRI signal (STIR) within the disc. The signal further decreased comparing the MRI signal (STIR) preoperatively with the follow up evaluation in 64.3% of the cases. However, we found an increase of the signal in 70% of the cases between T1 and T6.5. 6.5 years after CNL we documented an end plate reaction in almost 70% of all patients. There was no correlation between end plate reaction and age of the patients, level of CNL, amount of injected chymopapain or the clinical outcome.

For a biomechanical study 10 specimen of the lumbar spine (L1-S1) were scanned with MRI. After that 18 normal motion segments were prepared for the experiments. The paraspinal musculature as well as the posterior elements were removed. Under an axial load of 500 N, in each disc 500 J and 1000 J of energy were applicated with a Holmium-Yag laser (2060 nm, fiber thickness 600 microns) into the nucleus pulposus. In nine of the 18 discs also 1500 J and 2000 J were applicated. At the beginning of every standardized experiment of a motion segment, as well as after every 500 J, the height of the disc, intradiscal pressure, the contour of the disc and the size of the transversal plane of the disc were determined with an axial load on the motion segment of 1000 N. The change in radial bulging of the disc was measured using the computer-assisted recordings of each disc contour. All the data were statistically analyzed using the Friedman-/Wilcoxon-test. After every application of 500 J energy, in the 18 discs as well as in the 9 discs, the height and the intradiscal pressure reduced. The differences per 500 J were for all measurements not significant (p < 0.05). Up till the application of 1500 J the radial bulge and the size of the transversal plane of the disc increased, although the differences per 500 J were not significant. From 1500 J to 2000 J the radial bulge and size of transversal plane of the disc decreased.(ABSTRACT TRUNCATED AT 250 WORDS)

In 82 asymptomatic subjects aged 8-62 years we evaluated the menisci by MRI [1.0 tesla; SE (spin-echo) 700/20, PS (partial saturation) 500/10, STIR (Short-Time-Inversion-Recovery-Sequence) 1600/130/30]. The meniscus was graded by means of a standard classification (grades 0-4). In SE sequences we found grade 0 in 45.5% of all cases, grade 1 in 33.2%, grade 2 in 16.1%, grade 3 in 4.5%, and grade 4 in 0.7%. In PS sequences we found grade 0 in 23.9%, grade 1 in 27.5%, grade 2 in 31.5%, grade 3 in 15.9%, and grade 4 in 1.1%. In STIR sequences we found grade 0 in 56%, grade 1 in 25.4%, grade 2 in 11.1%, grade 3 in 6%, and grade 4 in 1.6%. Correlation of meniscus degeneration with subjects' age showed relation of meniscus degeneration with subjects' age showed relation of meniscus degeneration with subjects' age showed an increase of grade 3 and grade 4 lesions with advancing age. Subjects older than 50 years presented grade 3 and 4 lesions in the SE sequence in 28.5% of the cases, in PS sequences in 40.7% of the cases, and in STIR sequences in 25% of the cases. MRI shows meniscal lesions in a significant proportion of asymptomatic patients, especially among subjects older than 50 years. The orthopedic surgeon has to test whether the clinical findings in patients with knee complaints coincide with the results of MRI.

Unlabelled: In a prospective study we examined the dominant shoulder of 11 athletes from the 1992 German Olympic water polo team. Their mean age was 25.4 +/- 3.5 years. Water polo had been practised generally for 14.1 +/- 4.3 years and professionally for 11.6 +/- 3.9 years. The weekly training amounted to between 12.5 and 19.5 hours. All athletes were submitted to standardised clinical, sonographical and MRI tests. In 5 cases we found anamnestic and/or clinical indications of rotator cuff pathology. In all 5 cases the supraspinatus tendon was affected, and in three cases both the supra- and the infraspinatus tendon were involved. Sonographically, no specific pathology except a thickened rotator cuff was seen. Remarkable changes were revealed by magnetic resonance imaging. In 8 cases changes were present in the insertion of the rotator cuff at the humeral head. The subacromial bursa was not pathologic. The tendon of the long head of the biceps was pathologically changed in 9 cases. In 7 athletes a so-called biceps halo and in two an osteophyte in the area of the bicipital groove was visible. In all of the 11 dominant shoulder joints massive hypertrophy of the articular capsule and pathologic changes of the anterior glenoid labrum existed. Occult osseous lesions were detected in 5 athletes, and osseous lesions of the humeral head in 8 athletes. In all athletes we could document degenerative changes at the acromioclavicular joints such as effusion in 7 cases, arthritis in two cases, and evident synovitis in two cases., Clinical Relevance: Many of the changes detected by MRI were not symptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)

Unlabelled: In a vitro study we evaluated the influence of surgical technique on the postoperative tension of the supraspinatus tendon in rotator cuff ruptures. In ten shoulder specimens Hall-Effect Strain Gauge (HEST) were implanted in the supraspinatus tendon close to the insertion at the humerus. We documented the tension in specimens with intact rotator cuff as well as after reconstruction of small and large tears in different joint positions. In the specimens with an intact rotator cuff there was almost no tension registered. Only in adduction with external rotation and flexion we found slightly increased values. After reconstruction we found the highest tension in adduction, flexion, and external rotation of the humerus. Release of the coracohumeral ligament resulted in a decrease of tension in flexion and external rotation. Whereas in extension coracohumeral ligament release had no influence on the tension of the tendon. However, after complete capsule release the tension in extension also decreased., Clinical Relevance: If mobilisation in cases of rotator cuff reconstruction is necessary we recommend first release of the coracohumeral ligament in small and moderate tears. In major tears a complete capsule release is necessary. During physical therapy in the early postoperative course, flexion in the adducted and externally rotated arm should be avoided.

Unlabelled: 93 patients with a mean follow up of 73 months (30-133 months) after lumbar percutaneous radiofrequency denervation (PRFD) were evaluated. Mean age of the patients at time of surgery was 47 years (18-76 years). 54 patients had no lumbar spine surgery prior to facet denervation, 32 patients had one or multiple disc surgery prior to denervation, and 7 patients had spinal fusions. 51 patients were in the process of early retirement or already retired at time of surgery. Out of all 93 patients only 50% had significant pain relief immediately after PRFD. 3 months after PRFD the success rate dropped down to 38%. 6 years after surgery only 25% of all patients had long lasting good results. Patients who were pain free after facet infiltration had significant better initial results, but were similar to the others after 6 years. 6 out of 7 patients after lumbar spinal fusions demonstrated bad results. The worst results had those patients who had applied for early retirement (workmens compensation cases). In this group the recurrence rate was 74% 6 years after surgery. We found no correlation between the surgeon and the outcome., Clinical Relevance: Without pain reduction after facet infiltration the success rate after PRFD is low. Spinal surgery prior to PRFD significantly reduces the success rate. The worst prognosis have workmans compensation cases. The recurrence rate is high within the first 6 months after PRDF.

Unlabelled: In a prospective study we evaluated the benefits of iv-application of gadolinium-DPTA examining 25 patients with degenerative disease of the knee joint by MRI (1.0 Tesla). All patients were scanned with standard spin echo sequences (SE 500/20), short time inversion recovery sequences (STIR 1600/100), and FEDIF sequences (FEDIF 500/10). After gadolinium-DPTA application (0.1-0.35 mmol/kg BW) the patients were scanned with spin echo sequences (SE SE 500/20), and FEDIF sequences (FEDIF 500/10). After iv-Gadolinium the synovial membrane of joints with inflammation show significant increase of the signal. Due to this effect a differentiation between joint effusion and hypertrophic synovia is possible. Small areas of local synovitis not visible before the use of gadolinium can be documented. A differentiation between degenerative subchondral cysts and cysts due to an inflammatory process is possible., Clinical Relevance: The use of iv-application of gadolinium-DPTA in patients with degenerative joint disease seems to offer additional information. With iv-application all shortcomings of intraarticular use can be avoided. The differentiation between degenerative and inflammatory processes is possible.

In an experimental study with standardized conditions nuclear material of 40 human lumbar discs was excised. In 20 the non-automated discectomy method was used (NAPLD-method). In the other 20 the automated discectomy method (APLD-method). The excised material was weighted. After the removal, the material of the NAPLD-method was wet with isotonic saline over 45 minutes and again weighted. Afterwards the wet material of both methods was freeze dried and again weighted. The weight of the wet material of the NAPLD-method in relation to that of the freeze dried material was a factor 11 (average value: 7.7 g in relation to 0.7 g) and in the APLD-method a factor 15 (average value: 4.5 g in relation to 0.3 g). This means, that the uptake and distribution of the saline is different in both methods and for this reason it is not allowed to compare the wet weight of the two methods. This has to be considered in clinical comparative studies. Because the biomechanical changes after a discectomy are dependent of the amount of the excised nuclear material, the NAPLD- and APLD-method can only be compared when the amount of the excised material is changed in a freeze dried weight.