Biomedical subjects
Publications and source records attributed to H Contzen.
An older person has very limited resources at his disposal for physical and psychological compensation and he is thus particularly affected in the case of accident. Therapy must therefore be aimed at retaining or reestablishing the general mobility of the patient, above all his physical re-mobilization, within the shortest possible space of time. Practical consequences are discussed here.
Autogenous spongiosa or, in osteoplastic surgery, autogenous corticospongious bones are considered as substance of choice for the surgical transposition of missing bones, to strengthen bones with insufficient loading capacity, and for a biological activation of atrophic bones. Even deep-freeze allogenous spongiosa can be inserted into a sterile, stable implantation site able to absorb the spongiosa to a large extent. The success will be delayed, but in the end a good functional result will be achieved with this method. In case of such an optimum implantation site, a comparable therapeutic effect can also be obtained with osteoinductive ceramics which can be modified with respect to their osteoinduction and loading capacity, both values showing a reciprocal ratio. Xenogenous bone grafts are no longer applied. A clinical example is presented in order to describe some criteria for the choice of a suitable transplant and to give some practical indications for its therapeutic application.
Healing-up of the bone is achieved by immobilization in 96 to 98% of all recent scaphoid fractures. The average immobilization period is eleven weeks. Different methods of immobilization are used. The majority of authors apply an upper arm plaster cast including the thumb for a period of six weeks and then a forearm plaster cast. Even fractures showing a delayed healingup of the bone can be cured in more than two thirds of the cases by prolonged immobilization. In case of dislocated and not reducible fractures as well as fractures with great fragment diastases, conservative treatment with a fist plaster cast should only be performed exceptionally, for example if there is an increased anesthesia risk. In case of negative X-ray findings (four planes) and only clinical suspicion of scaphoid fracture, an initial fracture therapy is recommended with repeated X-ray examination 14 days later. Most of the fractures which have not healed up are vertical oblique fractures within the proximal third, fractures with great diastases, or fractures which have not been immobilized long enough.
Development of practically feasible methods for intramedullary stabilisation of fragments is inseparably linked to the name of Gerhard Küntscher. The principle of elastic transverse fixation of the nail in the medullary cavity permits its use only in fractures in the median diaphyseal range of tubular bones. For multiple and comminuted fractures Küntscher recommended a so-called "detention" or "locking" nail. This was developed further by Klemm and Schellmann, thus extending the range of indication for intramedullary fragment stabilisation. The origins and phases of development of this method are shown.
The biomechanical system "knee joint" which is disturbed in chronic knee ligament instabilities can be repaired by means of synthetic ligaments; however, the correspondent materials have to meet some technical requirements which are described in the present work. The introduction of foreign bodies into tissue incite some defined reactions which may increase or decrease the functional value of the alloplastic ligament prosthesis; the correlations and dependencies are presented. An appropriate alloplastic knee ligament prosthesis is offered taking into account the requirements for material and the biologic reactions described.
A number of criteria relating to operating conditions as well as to the working comfort of the operation team have to be considered with respect to the most favorable lighting system in the operating theatre, especially the operation field and its surroundings. These criteria, some of which are standardized, are indicated. Their realization is demonstrated by giving practical examples.
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The results of treatment by alloplastic ligament replacement are generally comparable to those achieved with autologous pedunculated or free tissue transplants with regard to band stability as well as total function. We consider the indication for this not yet universally recognised surgical technique with alloplastic material to lie exclusively in patients with multiple previous knee operations and for whom autologous tissue was not present in adequate quality intraoperatively. Here the usage of the polyester band was a last resort. The long term preservation of function and stability are ultimately the most important factors, but we cannot yet convincingly assess these after only one year's experience of this method. It is possible that the already known problems with only plastic possible corrections of chronic capsule-ligament instability of the knee joint can be reduced by the usage of polyester band.
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To allow a definite diagnosis in cases of rupture of the fibular ligaments of the ankle-joint, stress-x-rays of the upper ankle joint were taken in ap. and lateral view. The intraoperative findings in 150 patients with rupture of the fibular capsule/ligament were compared with the preoperative x-rays. The results justify the conclusion that stress-x-rays in ap.-view are sufficient. Additional information can be obtained about the different components of the capsule and the ligament.
Early surgical treatment of a complex instability of the knee joint is not always possible. Even the autologous ligament graft indicated in such a case is not always successful. Furthermore, there is often a lack of autologous material due to previous operations. A textile polyester ligament, developed at the BG-Unfallklinik in Frankfurt, was used since August 1980 in order to perform corrective plastic surgery in eleven patients suffering from a chronical rotation instability repeatedly operated upon. The various problems connected with this method are mentioned: structure and shape, tissue tolerance, lasting stability, durable and solid fixation of the implant. The results are classified according to different criteria and compared to those of autologous ligament grafts. The "very good" results achieved with alloplastic material are due to the better stability. Therefore the application of textile synthetic ligaments can possibly reduce the well-known problems of corrective surgical interventions only feasible by means of grafts.
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X-rays taken under mechanical positioning of the joint with standardized conditions are helpful aids in the diagnosis of injuries of the knee capsule and ligaments. In comparison to the non-affected knee the extent of instability of the joint can be exactly demonstrated. Arthrography is of little help in fresh injuries to the knee capsule and ligaments, but can be useful to assess the residuals of old damage to the joint. Arthroscopy has its place mainly in the diagnosis of old injuries and hardly any in fresh lesions. In general, however, arthroscopy is a very valuable diagnostic procedure.
Between 1974 and 1978 at the "Berufsgenossenschaftliche Unfallklinik" Frankfurt/Main 124 patients with lesions to the knee ligaments were treated; 117 patients could be followed up. All cases were classified according to the accident, the impact and the mechanism of the injury. The case-reports were supplemented by a graduation of the rotation stability and a general description of the own surgical technic and the postoperative care. For evaluation the surgically treated cases were divided according to the time they received treatment (immediately, early or late). All three groups were evaluated separately using the same objective and subjective criteria. It was found that the functional late results depended on the time of the first treatment. The findings led to the conclusion that injuries to the ligaments of the knee joint should be treated immediately by surgery.