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In der modernen Unfallchirurgie und Orthopadie wird die Anwendung allogener Knochentransplantate durch das mogliche Ubertragungsrisiko von Infektionserkrankungen erheblich eingeschrankt. Eine Losungsmoglichkeit bietet die Anwendung eines thermischen Desinfektionssystems (Lobator SD-1), welches mit einer Inaktivierungstemperatur von 80 °C arbeitet und in der Lage ist, zahlreiche bakterielle und virale Infektionserreger abzutoten. In dieser Studie wurde die Inaktivierungskinetik von HIV durch Warmebehandlung im Lobator SD-1 untersucht. Dabei wurden humane Femurkopfe mit 100 µl einer hochangereicherten Suspension von freiem und zellgebundenem HIV (1010) beladen und dem Desinfektionsprozes fur 5, 10, 20, 30, 40, 50 bzw. 62 min ausgesetzt. Die anschliesende Rekultivierung erfolgte mit Hilfe von HUT-78 Zellen durch Titration der Virussuspension in 10facher Verdunnung uber 10 Verdunnungsstufen und Inkubation bis maximal 21 Tage. Der Virusnachweis wurde durch Beobachtung von Riesenzellformationen und quantitativem p24-Antigennachweis im ELISA-Test durchgefuhrt. Dabei konnte eine lineare Virusinaktivierung in Abhangigkeit von der Erwarmungszeit gefunden werden. Ab einer 40minutigen Behandlung im Desinfektionssystem (Normalprozeszeit 92 min, Zieltemperatur 80 °C) war eine vollstandige Virusinaktivierung zu verzeichnen. Die Ergebnisse zeigen, das durch eine Behandlung humaner Femurkopfe im thermischen Desinfektionssystem eine sichere Inaktivierung von HIV erreicht wird.

Mit einem Zweikammerdiffusionssystem wurde untersucht, ob eine 70% ige wasrige Athanollosung nach einer Diffusion von 24 Stunden durch Spongiosascheiben mit einer Schichtdicke von 3 mm bzw. 6 mm eine HIV-Suspension inaktivieren konnte. In beiden Fallen blieb HIV infektios und konnte in Zellkulturen angezuchtet werden. Weitere Versuche mit gaschromatographischen Analysen belegten die schlechte Diffusionsfahigkeit des Athanols durch humane Spongiosa. Zur Bestimmung der Strahlenresistenz wurden HIV-Suspensionen verschiedenen Dosierungen ionisierender Strahlung ausgesetzt. Nach einer Applikation von 15 kGy erfolgte keine Infektion der Zellkulturen mit HIV. die mit 2, 7 und 10 kGy behandelten HIV-Suspensionen fuhrten dagegen zu einer Virusproduktion in den Zellkulturen.

In einer experimentellen Studie an Spongiosazylindern von Schlachtschweinen wurde der Einflus verschiedener Sterilisationsmethoden auf die biomechanischen Eigenschaften des behandelten Knochens untersucht. Die Temperaturbehandlung ergab bei 100°C eine Reduktion der Stabilitat auf zirka 60%, bei Autoklavierung mit 134°C wurde sie auf Werte zwischen 13% und 25% der Ausgangswerte herabgesetzt. Eine Behandlung bei 60°C fuhrte zu keinem Stabilitatsverlust; bei 80°C sind die Ergebnisse nicht bei allen Mesparametern statistisch eindeutig. Die Bestrahlung mit 25 kGy reduzierte die Festigkeit auf zirka 65% des Kontrollwertes, geringere Dosen fuhrten zu keiner signifikanten Reduktion der Stabilitat. Die klinische Anwendung der verschiedenen Sterilisationsverfahren sollte aus biomechanischer Sicht die unterschiedlichen Anforderungen an die Festigkeit der sterilisierten Transplantate berucksichtigen.

Allogenic bone grafting is an established method in revision surgery of artificial joint replacement and spinal surgery in case of bone defects. In Germany, femoral heads from living donors undergoing total hip replacement are frequently used. These grafts are processed according to the "Guidelines for the management of bone banking" issued by the Federal Medical Board. Bone grafts are drugs according to German law. Local bone banks are excluded from the regulations of the federal law on drugs [Arzneimittelgesetz (AMG) section sign 4a (4)] if certain requirements are fulfilled. The Directive 2004/23/EC of the European Parliament and of The Council on Setting Standards of Quality and Safety for the Donation, Procurement, Testing, Processing, Preservation, Storage and Distribution of Human Tissues and Cells has to be implemented into national law within 2 years. The exception of section sign 4a (4) will no longer be possible. Thus a legal construction has to be found which allows running local bone banks in compliance with the new legal settings. Three conditions will be possible: (1) a single physician procures a graft for another patient of his, (2) grafts are procured in one hospital and are used exclusively in this hospital: a license from the local authorities and a strict quality assessment according to GMP-rules is required, (3) if the grafts are distributed to other hospitals, a license from the local authorities and registration as a drug by the federal authorities are necessary.

In a prospective clinical trial, plasma histamine levels were measured in 28 polytrauma patients on day 1, 5 and 14 after trauma. Only those subjects who died were drop-outs. All patients had severe polytrauma with at least 3 body regions involved. The median plasma histamine levels at all three time points were significantly higher than in patients with single trauma of the extremities or before selective orthopaedic surgery but still in the normal range (less than 1 ng/ml). However, all patients with plasma levels above 1 ng/ml on days 1 and 5 died, as did all patients with levels above 0.5 ng/ml on day 1. Thus the elevation of plasma histamine levels, for whatever reason, appears to be a prognostic factor for bad outcome in polytrauma patients.

The use of allogenic bone transplants in surgery has been greatly diminished owing to the risk of transmitting infectious diseases. This risk can be reduced by the use of a thermal disinfection system (Lobator SD-1). This is achieved by increasing the temperature to 80 degrees C, inactivating a number of bacterial and viral agents. In this study the decay of HIV at high temperature in the Lobator SD-1 was researched. In the center of human femoral heads 100 microliters of a highly concentrated suspension of free and cell-bound HIV (10(10)) was exposed to the thermal process at intervals of 5, 10, 20, 30, 40, 50 and 62 min. For the recultivation HUT-78 cells were used through titration of the virus suspension in ten-fold dilutions over ten dilution steps and incubation up to a maximum of 21 days. Evidence of the virus was checked through observing giant cell formations and quantitative determination of p24 antigen using an Elisa test. Linear virus inactivation was found based upon the time the virus was exposed to heat. After a treatment of 40 min in the disinfection system, total virus inactivation was achieved. The normal disinfection process time using Lobator SD-1 is 92 min. A temperature of 80 degrees C is reached after approximately 45 min. The results prove that this system totally inactivates HIV in human femoral heads.

Ruptures of the anterior cruciate ligament are among the most frequent injuries of the joints. There is no longer any doubt regarding the necessity for surgical intervention. Several clinical and experimental studies suggest that the instability of the knee joint results in an accelerated degeneration of the menisci and cartilage. There are differences of opinion regarding the type of surgical procedures to stabilize the knee-joint. Although there are many different surgical procedures described in various publications, only one technique emerges as the preferred one. This paper will demonstrate different therapeutic concepts, based on the biomechanical background for the treatment of the anterior knee instability. It will consider the morphology of injuries, the demands of the patient and the full range of rehabilitative possibilities. Described herein are the indications and techniques of augmentation, protection and prosthetic replacement.

The surgical treatment of acute and chronic injuries of the anterior cruciate ligament (ACL) is still incontinous. Different techniques and materials are used to reconstruct and repair this important structure. This causes that the kind of postoperative treatment is even inhomogeneous. Concepts of "early mobilization" correspond to the results of basic research on pathobiomechanical effects of joint immobilization. There is a large variety on the information concerning method, success and length of rehabilitation. The final aim of our research was the development of a new rehabilitation strategy for patients in addition to out-patient physiotherapy. The reconstruction and repair of ACL is in our hospital done by an autograft of patellar tendon, "bone-tendon-bone", in augmentation with a "3-mm-Trevira cruciate ligament prosthesis". In our prospective, controlled and randomized clinical study "group A" (n = 20) practiced in addition to their out-patient physiotherapy twice a week under the direction of a medical doctor and the control of a physiotherapist with the equipment of a fitness-center. "Group B" (n = 20) passed only the out-patient physiotherapy. Both groups were examined regularly with special regard to the active motion of the knee joint, the power and the circumference of the leg. Also the "Marschall-Tegner" and the "Lysholm-Gilquist-Score" were determined. In our study we found that the "New-Marburg-rehabilitation-concept" is an useful supplement to the out-patient physiotherapy. All examined data showed a clear increase in "group A" in comparison to "group B".

Die Gefahr der Ubertragung von Krankheitserregern mit dem allogenen Knochentransplantat ist seit langem bekannt (Doppelt et al. 1981; Malinin et al. 1985). Auch unter Berucksichtigung der Richtlinien zur Fuhrung einer Knochenbank (American Assoc. Tissue Banks 1990; Wissenschaftlicher Beirat Bundesarztekammer 1990) ist trotz genauer Spenderanamnese und Untersuchung sowie der Durchfuhrung der serologischen Tests und der bakteriologischen Abstriche vom Transplantat die Moglichkeit der Infektion des Empfangers mit bakteriellen oder viralen Erregern des Spenders nicht sicher auszuschliesen. Dies trifft insbesondere auf eine mogliche HIV-Ubertragung zu (CDC 1988). Bereits sehr fruh wurden daher Versuche unternommen, das allogene Knochentransplantat zu desinfizieren oder zu sterilisieren. Dabei wurde die Autoklavierung als eine in der klinischen Sterilisation routinemasig eingesetzte Methode haufiger angewandt (Ewers u. Wangerin 1986; Harrington et al. 1986; Wagner u. Pesch 1989).

Das Risiko der Ubertragung bakterieller Infektionserkrankungen mit dem kryokon- servierten allogenen Knochentransplantat ist wesentlich hoher als die virale Infek-tionsgefahr (HIV, Hepatitis B und C, CMV). Literaturangaben uber die bakterielle Kontaminationsrate von unter “sterilen” Bedingungen entnommenen Knochentrans-plantaten schwanken zwischen 5%-65% [2, 3]. Diese Unterschiede lassen sich durch die unterschiedlichen mikrobiologischen Screening-Techniken erklaren. Wahrend die deutschen “Richtlinien zum Fuhren einer Knochenbank” aus dem Jahre 1990 nur eine einfache Abstrichuntersuchung der Transplantatoberflache vorschreiben, werden an den Gewebebanken in den USA umfangreiche bakterielle Untersuchungen mit bis zu 200-300 mikrobiologischen Kulturen pro Organspender [3] vorgenommen. Als Keimnachweismethoden kommen das herkommliche Abstrichverfahren mit einem Wattetupfer, die direkte Bebrutung einer Knochenprobe oder die Inkubation und Untersuchung der Spulflussigkeit von allogenen Knochentransplantaten in Frage. Ziel dieser Untersuchung war es, die Sensitivitat des Wattetupfer-Abstrichverfahrens zu testen und diese Methode mit anderen Verfahren zu vergleichen.

Um das Risiko der Ubertragung bakterieller oder vitaler Infektionen durch eine allogene Knochentransplantation auszuschliesen, wurden in der Vergangenheit eine Vielzahl unterschiedlicher chemischer Sterilisations- bzw. Desinfektionsverfahren erprobt (Cloward 1980; Lo Grippo et al. 1957; v. Versen 1974).

Thermal energy (80 degrees) for the disinfection of cancellous allogenic bone grafts was employed, and it proved to be an advantageous, safe and easily accessible method. The effects of this treatment on biological values were examined in terms of biomechanical and biodynamic (graft incorporation) loss of the treated grafts versus the autoclaved and untreated samples. Given the thermolability of the pathogens in question, the thermal approach presented here has the advantage of being readily controllable. The lack of toxic or mutagenic risks through this method and its accessibility represent further advantages. In thermal treatment of bone allografts, it is essential that one knows the thermoconductivity of the bone sample and that one can demonstrate pathogen inactivation through the entire graft volume. All of the parameters in the 80 degrees C group that were measured in this study indicate clear biological superiority over the autoclaved group. A newly developed thermoincubator is introduced for gentler disinfection of allogenic bone grafts and it inactivates common vegetative pathogens as well as HIV. It is still necessary to conduct serological screening for hepatitis antigens in the donor pool, however. Based on these results, we conclude that the clinical use of autoclaved allogenic bone grafts needs to be reviewed and possibly limited.

Fractures of the sternum often are not discernable on X-rays. The standard lateral X-ray of the sternum may allow the diagnosis. The aim of this study was to find out whether sternal fractures can be visualized by ultrasound. The flat, plane and broad bone provides an ideal rest for a linear scanner; the one used in our study had 5 MHz. We show that sternal fractures can easily be diagnosed by means of ultrasound, and because of an interruption of the cortical reflex, possibly better than on radiographs. We also wanted to show whether sonography, which is in widespread use for the diagnosis of blunt abdominal trauma, can also be used in an emergency situation of blunt thoracic injury (e.g. seat belt injury). In 16 cases of fractures of the sternum already diagnosed by X-ray, an examiner unacquainted with the X-ray results was able to locate and diagnose all fractures by ultrasound within 1 min.

After amputation of the thumb good functional results can be achieved by lengthening the first metacarpal bone, if a suitable technique is used. Since 1987 we have treated six patients in this way. In all of our patients the thumb was mechanically stable and sensitive after lengthening, thus improving the patients' ability to use their hands for grasping. Other advantages include the relative simplicity of the method, the fact that no experience of microsurgery is necessary and that the surgery does not result in soft tissue damage. In most cases treatment is on an outpatient basis. Between the various operations the patient can be reintegrated into his professional and social life. The period of absence from work (about 12 weeks) is relatively short when the severity of the injury is taken into consideration. Distraction of the first metacarpal bone cannot be considered an alternative to replantation but represents a complementary procedure in accordance with the modern management of severe hand injuries.

In our study we examined bone disinfection by ethanol and by irradiation. A 70% aqueous ethanol solution diffused through a 3 mm and a 6 mm slice of human cancellous bone against 2 ml of a HIV-sample (RTA: 300,000 cpm/ml) for 24 hours. In both cases HIV could not be inactivated. Infected T-lymphocyte cultures showed specific morphological cell changes. The Abbott HIV-antigen-EIA proved the treated HIV-samples to be infectious after cultivation in macrophage-cultures. Additional gas chromatography measurements of ethanol diffusion through 3 mm and 6 mm of human cancellous bone supported these observations: a 70% aqueous ethanol solution achieved a concentration of 25.6% (18.0%) in median after 24 hours and a thickness of 3 mm (6 mm). The effect of different doses of irradiation on HIV-samples (RTA:300,000 cpm/ml) was examined. The samples were irradiated with 2, 7, 10, 15 and 25 kGy to determine the appropriate dose for inactivation. Irradiation with 15 kGy caused HIV inactivation since no virus production could be detected in the macrophage culture (Abbott HIV-antigen-EIA). The samples irradiated with 2, 7 and 10 kGy were still infectious.

Die Sternumfraktur ist seit Einfuhrung der Gurtpflicht und infolge des zunehmenden Verkehrsaufkommens beim angeschnallten, verunfallten Pkw-Fahrer als sog. „Gurttrauma“ keine Seltenheit mehr.

Die allogene Knochentransplantation ist eine weltweit verbreitete Operationsmethode zur Fullung ossarer Defekte. Nach eigenen Erhebungen werden in der Bundesrepublik Deutschland ohne Berucksichtigung der neuen Bundeslander pro Jahr ca. 10 000 bis 20 000 derartige Transplantationen durchgefuhrt [2].

Cylindrical specimens of trabecular pig bone were tested to uniaxial compressive strain levels of 30% to study the influence of various sterilization techniques and methods of HIV-inactivation on the mechanical properties characterized by compressive modulus, yield point, energy absorption and maximum stress. Heat inactivation at 60 degrees C (Lactated Ringer, 1 h) showed no effect; 80 degrees C (Lactated Ringer, 1 h) resulted in a diminution of the yield point and the maximum stress (p less than 0.005), while energy absorption and compressive modulus were not affected. No reduction in the stability was seen when ethanol was used instead of Lactated Ringer. At a temperature of 100 degrees C, all measured parameters were reduced to approximately 60% compared with the control group. A decrease to 13% to 25% was seen after autoclavation (120 degrees C, 2 bar, 20 min and 134 degrees C, 3 bar, 12 min). Irradiation (60Co) with 3 respectively 10kGy did not impair the stability, whereas a dose of 25 kGy led to a reduction to 61% to 69%. No additional effect was seen when irradiation was followed by storage at -80 degrees C for one week. These effects on bone stability should be considered when choosing a method of bone preparation to obtain HIV-inactivated bone grafts. Autoclavation should be used with caution when stability of the bone graft is essential. In this case, irradiation seems to be a safe method of sterilizing bone grafts ensuring both a high degree of safety and stability.

An inquiry at German surgical departments about their bone bank techniques showed that 45% of clinical hospitals use allogeneic bone implants among other implants. In 1989, the year of the official survey, allogeneic bone was transplanted about 6000 times in these clinical hospitals. Despite of this high transplantation frequency important differences turn out regarding selection and testing of recipients, transplantation storage and treatment. A lot of clinical hospitals do not perform important donor examinations inspite of proven transmission risks of bacterial and viral diseases by deep frozen bone. A trend analysis shows that despite of the risk of an HIV-transmission and the resulting difficulties in the logistic of the bone bank, the transplantation frequency allogeneic bone stays constant. The official surveys prove the large range of bone bank techniques and should give rise to make efforts to take note of the recommendations for bone banking techniques.

33 bone allotransplants (cryopreserved) of AB0- and Rh-incompatible (donor-recipient) patients were performed to evaluate the question which AB0 Rh-incompatibility leads to immunization of the bone transplant recipient. Several different antibodies were tested pre- and postoperatively in the recipient. Regarding the Rh-system no immunization was demonstrable; however, a significant increase of antibody leads was found regarding the AB0-system. Thus, in bone bank techniques AB0 compatibility is important for allogeneic bone transplantation in young women. Otherwise, there is a risk for the development of MHN in case of pregnancy. Blood group-typing is not necessary in other patient groups. Although no Rh-antibodies were demonstrable, a similar mechanism can be postulated for the Rh-system. We, thus, conclude that in allogeneic bone tx in young women the Rh-system has to be taken into consideration.