Biomedical subjects
Publications and source records attributed to M Rittmeister.
A case of spontaneous occipitocervical fusion is discussed. The authors believe that fusion at the occipitocervical junction will occasionally occur in rheumatoid arthritis in the adult population. As a result of fusion, the dens axis is unable to exert compression on the spinal cord with increased neck flexion.
Pelvic fractures (PF) sustained from accidents are commonly believed to be a major cause of mortality in polytraumatized patients. The purpose of this paper is to determine whether PF are usually the primary cause or a contributing cause of mortality in these patients. A 10-year retrospective review was performed of all polytrauma patients with PF who were admitted to, and died, at a large, level-I trauma center. The pelvic injury was graded according to Schatzker and Tile into stable (type A), partially stable (type B), and unstable (type C). The injury severity score (ISS), which incorporates associated injuries and their potential impact on mortality, was calculated for all patients. For each patient, a separate subjective designation of the probable cause of death was determined. We identified 74 decedents with PF following deceleration trauma. The pelvic fractures were classified as 12 type A (16%), 36 type B (49%), and 26 type C (35%). The mean ISS was extremely high, 40.6 +/- 1.4 (range 18-75), more than four times the score for simply a severe PF. The ISS was also not significantly different among the three pelvic fracture groups (P = 0.613). The records subjectively identified PF as the precipitating cause of death in only 13% of the patients. In this study, patients who died with PF had an ISS that implicated at least one or two additional major visceral injuries. These data do not support the hypothesis that PF, regardless of its complexity, is the usual primary cause or the major precipitating event of death in the polytraumatized patient. In these patients, mortality appears to be a function of the associated injuries based on the ISS calculation.
A very rare case of recurrent chondroblastoma of the upper thoracic spine with a follow-up of more than 20 years is presented and discussed with a review of the literature.
This study determined whether patients with severe knee disease below a hip arthrodesis can be treated successfully with total knee replacement alone or whether such patients require total hip arthroplasty followed by knee replacement. Eighteen patients who had hip arthrodesis for a mean of 33 years underwent total hip replacement alone, total knee replacement alone, or a combination of both. The Harris hip score improved from a mean of 55.3 to a mean of 86.9 points at 45 months after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 33 to a mean of 78 points in patients who had total knee replacement after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 35 to a mean of 44 points in patients having total knee replacement alone below a hip arthrodesis. The followup after total knee replacement averaged 53 months. These data suggest that a knee replacement alone in a patient with a fused hip is unlikely to provide a satisfactory result. Patients with severe knee disease below hip arthrodesis require total hip arthroplasty followed by knee replacement. This applies even when severe osteoarthritis of the knee is the primary complaint.
Results of surgical synovectomy and radiation synovectomy (radiosynoviorthesis) of the tibiotalar joint in rheumatoid patients are reported. The staged concept for management of the rheumatoid ankle joint is presented which is based on the radiographic appearance of disease progression. Results of 16 rheumatoid patients with disease to the ankle joint suggest that pain and walking capability is positively influenced by synovectomy and radiosynoviorthesis. Follow-up of 30 months revealed no deterioration of postoperative clinical improvement. In the absence of contraindications to radiosynoviorthesis it is suggested to combine arthroscopic synovectomy with radiosynoviorthesis for the treatment of early stages of rheumatoid disease of the ankle joint. Open synovectomy is preferred to arthroscopic synovectomy, if tenosynovectomy is simultaneously required.
We discuss 69 metacarpophalangeal (MP) implant arthroplasties performed in 30 patients with rheumatoid arthritis. The follow-up averaged 5 years. We studied 19 finger joint prostheses by Condamine, digital joint operative arthroplasty (stabilized version; DJOA) and 50 flexible silicone Swanson implants. We used a new comprehensive scoring system to evaluate the MP alloarthroplasties. Such a scoring system incorporates clinical and radiological data. The outcome following MP joint replacement with DJOA was never evaluated as 'good'; in 11 joints the result was 'fair', and in 8 joints, 'poor'. As regards MP arthroplasty with Swanson implants, the results were evaluated as 'good' in 40 joints, as 'fair' in 10 joints, and in none as 'poor'. In our series, DJOA did not provide stability in arthritic MP joints. In all joints replaced with DJOA, dislocation of the articulating surfaces and signs of loosening were present. We regard three factors as being the main causes contributing to the poor outcome of DJOA when used as MP replacements. Firstly, the proximal prosthetic component is poorly matched to the anatomical shape of the metacarpal bone (conisation of the bone). Secondly, adequate coaptation cannot be achieved with this prosthetic design, even in the presence of extensive soft-tissue reconstruction. Thirdly, the use of polyethylene in MP joint replacements is questionable. In contrast, the silicone Swanson implants in our series provided superior results when used as MP implants in the rheumatoid hand.
Whilst neurologic injury following correction of scoliosis with CD-instrumentation is generally known to be an early complication, any late occurrence of cauda compression secondary to employment of a laminar hook-rod construct is exceptional. We report on such a rare case of late occurrence of cauda equina syndrome, when a laminar hook at level L2 became symptomatic causing compression of the cauda equina almost a decade after spine surgery. This case demonstrates that one should not only be aware of a potential neural injury at intraoperative placement of laminar hooks, but also one is reminded that a laminar hook poses the threat of late neurologic injury years after successful osseous spinal fusion. The surgeon treating patients with scoliosis must be aware of the possible complication described in our patient in addition to those that have already been well documented.
PURPOSE: We present data of 27 radiolunate and 23 Mannerfelt arthrodeses in patients with rheumatoid arthritis. METHOD AND CLINICAL MATERIAL: Benefits of surgery, i.e. the reduction of pain, swelling, tenderness, and signs of instability as well as radiographic findings of carpal height, carpal collapse, progression of rheumatoid disease beyond the site of wrist fusion were assessed after a mean time of 44 months. RESULTS: Wrist pain and swelling were better managed by Mannerfelt than by radiolunate arthrodesis. Average grip strength of wrists with radiolunate fusion exceeded the strength developed in wrists with Mannerfelt-fusion. However, grip strength of wrists with Mannerfelt-fusion was greater than in the opposite unfused hand, while this was not found in wrists with radiolunate arthrodesis. Postoperative improvements in hand intensive activities were more frequent in the radiolunate fusion population. CONCLUSION: Advancement of carpal degeneration in radiolunate wrist fusions beyond the fusion site may indicate a rising number of symptomatic wrists with increase of follow-up time. Our results have led us to suggest radiolunate fusion for the non-dominant hand in patients with slow carpal progression of rheumatoid disease and especially if complete wrist fusion of the opposite--often dominant hand--has already been performed.
In the absence of coexisting active pulmonary disease, tuberculosis is frequently not considered in the differential diagnosis of chronic inflammation of the joints. The cases of two immigrant patients with tuberculous arthritis involving the forearm are reported. In both cases non-specific arthritis or trauma was suspected, resulting in a delay between the onset of symptoms and institution of specific therapy of 21 and 24 months, respectively. Diagnosis was achieved by histological and microbiological examination of synovial biopsy material. Polymerase chain reaction for Mycobacterium tuberculosis complex was positive in only one patient. Treatment consisted of antituberculosis chemotherapy, surgical synovectomy, and debridement of the affected joints. These cases serve as a reminder that, although rare, tuberculosis can cause chronic arthritis.
To our knowledge, quantitative studies on the significance of disorders of the upper cervical spine as a cause of vertigo or impaired hearing do not exist. We examined the cervical spines of 67 patients who presented with symptoms of dizziness. Prior to the orthopaedic examination, causes of vertigo relating to the field of ENT and neurology had been ruled out. Fifty patients of the above-mentioned group were studied. They followed the outlined treatment protocol with physical therapy and were available for 3 months of follow-up. Thirty-one patients, hereinafter referred to as group A, were diagnosed with dysfunctions of the upper cervical spine. Nineteen patients, hereinafter referred to as group B, did not show signs of dysfunction. Cervical spine dysfunctions were documented as published by Bischoff. In group A dysfunctions were found at level C1 in 14 cases, at level C2 in 6 cases and at level C3 in 4 cases. In seven cases more than one upper cervical spine motion segment was affected. Dysfunctions were treated and resolved with mobilising and manipulative techniques of manual medicine. Regardless of cervical spine findings seen at the initial visit, group A and B patients received intensive outpatient physical therapy. At the final 3-month follow-up, 24 patients of group A (77.4%) reported an improvement of their chief symptom and 5 patients were completely free of vertigo. Improvement of vertigo was recorded in 5 group B patients (26.3%); however, nobody in group B was free of symptoms. We concluded that a functional examination of motion segments of the upper cervical spine is important in diagnosing and treating vertigo, because a non-resolved dysfunction of the upper cervical spine was a common cause of long-lasting dizziness in our population.
A dysfunction of a joint is defined as a reversible functional restriction of motion presenting with hypomobility according to manual medicine terminology. The aim of our study was to evaluate the frequency and significance of sacroiliac joint (SIJ) dysfunction in patients with low back pain and sciatica and imaging-proven disc herniation. We examined the SIJs of 150 patients with low back pain and sciatica; all of these patients had herniated lumbar disks, but none of them had sensory or motor losses. Forty-six patients, hereinafter referred to as group A, were diagnosed with dysfunction of the SIJ. The remaining 104 patients, hereinafter referred to as group B, had no SIJ dysfunction. Dysfunctions were resolved with mobilizing and manipulative techniques of manual medicine. Regardless of SIJ findings, all patients received intensive physiotherapy throughout a 3-week hospitalisation. At the 3 weeks follow-up, 34 patients of group A (73.9%) reported an improvement of lumbar and ischiadic pain, 5 patients were pain free. Improvement was recorded in 57 of the group B patients (54.8%); however, nobody in group B was free of symptoms. We conclude that in the presence of lumbar and ischiadic symptoms our presented data suggest consideration of SIJ dysfunction, requiring manual medicine examination and, in the presence of SIJ dysfunction, appropriate therapy, regardless of intervertebral disc pathomorphology. This could avoid wrong indications for nucleotomy.
The frozen shoulder syndrome and the Sudeck syndrome are clinically in many aspects similar. Radioisotope bone scan shows an increased uptake in the affected areas in both diseases, while standard radiographs show a progressive demineralization. With measurement of bone-mineral density by quantitative digital radiography these local decalcification processes were diagnosed in an early stage of the frozen shoulder syndrome: of 12 patients with primary frozen shoulder 10 had a bone-mineral density decrease of more than 21% in the humeral head of the affected shoulder compared to the unaffected side. In the control groups (n = 32) the difference between affected and unaffected side (left and right humerus of the healthy probands) was in only one case each above 21%. There are several indications in the literature assuming the frozen shoulder to be an algoneurodystrophic process. Our observation supports this hypothesis, and may possibly lead to earlier diagnosis and improved therapeutic management.
We present a single case study of a 47-year-old female patient with a rare form of primary dysostotic dwarfism. This syndrome was first described by Fuhrmann in 1972. Seven years ago, this patient underwent bilateral cementless total hip arthroplasties for severe osteoarthritis about her hips. Custom-made components were used. While achondroplastic patients present with wide femoral medullary canals, it is clinically relevant that Fuhrmann Syndrome features narrow femoral medullary canals. This complicating anatomical factor in Fuhrmann syndrome as well as the increased anteversion angles were overcome by the use of CAD stems. We conclude that the custom-made stems, although in our case measuring half the size of the smallest commercially available design, have proved to be durable and able to withstand physiological loads at follow-up period of 72 months.
AIM: Oligo- or monarthritis is reported as an uncommon complication of both acute and chronic leukemia. Childhood leukemias are complicated more frequently by leukemic arthritis (LA) than adult cases. LA occurs rather in acute than in chronic leukemia and can present at any stage of the disease. Proposed pathogenic mechanisms of arthritis in leukemia are leukemic infiltration of synovial tissue and resulting periosteal and capsular inflammation. As the primary manifestation of chronic lymphocytic leukemia (CLL) and immunocytoma (IC), LA is extremely rare. In such cases osteoarthritis may then be misdiagnosed as the source of joint disease. METHOD: We report a case of glenohumeral arthritis with complete rotator cuff tear and humeral head migration in an 88-year-old patient. Surgery exposed joint effusion, synovitis and chondromalacia with glenohumeral joint destruction. RESULTS: Histopathological examination revealed an articular chondrocalcinosis and bone marrow infiltration by an immunocytoma (B-cell non-Hodgkin lymphoma of low malignancy). CONCLUSION: Although LA is an uncommon complication in CLL and IC, it may be considered in elderly patients with lymphocytosis and arthritis.
AIM: As a result of stress shielding bone resorption occurs around straight femoral stems following total hip replacement (THR). The question arises whether this pattern of periprosthetic bone loss is altered with use of custom made anatomic femoral stems. METHOD: DEXA method was used to examine proximal femora of two groups of patients after cementless THR. Data of 16 patients with a standard straight femoral stem and 15 patients with a custom made anatomic stem were acquired at 1 week and 2, 4, 6, 9, 12 and 24 months postoperatively. Periprosthetic bone density was recorded in regions of interest (ROI). RESULTS: Similar pattern of periprosthetic bone changes were seen in femora with straight and anatomic hip stems at 24 months postoperatively. Femoral bone loss, up to 36 % in the calcar ROI, was seen with straight and anatomic stems. CONCLUSION: Custom designed anatomic femoral hip stems were unable to prevent periprosthetic bone resorption. However it is concluded, that implantation of custom made stems in grossly distorted femoral anatomy induces transmission of forces similar to standard femoral stems implanted in normal medullary anatomy.
AIM: Aim of the investigation was to identify prognostic factors predicting the level of postoperative function following Girdlestone ("G")-arthroplasty. METHODS: Data were derived from 87 patients, 90 hips, treated with "G"-arthroplasty at one institution between 1983 and 2000. RESULTS: Hip scores amounted to 38.7 (HHS) and 3.5 (Merle) points. The number of previously implanted total hip arthroplasties (THR) did not correlate with the functional result of "G"-arthroplasty (r = - 0.1400; p = 0.4524). On average, the duration of THR prior to "G"-arthroplasty was 44.6 months. Survival time of the latest THR and function of "G"-arthroplasty did not correlate (r = 0.0705; p = 0.7065). Patient age at primary THR, at follow-up, or at "G"-procedure did not correlate with HHS (r = - 0.0367, p = 0.8418, r = 0.1527, p = 0.4121; r = - 0.0151; p = 0.9356, respectively). Time following "G"-arthroplasty, averaging 90.6 months, did not correlate with patients function (r = 0.0920, p = 0.6289). Revision following "G"-procedure and the presence of diabetes positively correlated (p = 0.0104). The appearance of cement in the femoral canal and radiographic signs of persistent bone infection correlated significantly (p = 0.0572). CONCLUSION: Patient age, duration of "G"-hips, and number of prior THR were not reliable to predict the function of "G"-arthroplasty.
AIM: The aim of this work was to compare the functional results of secondary Girdlestone hips with the results of total hip replacement (THR) after a Girdlestone situation. METHODS: 72 patients with THR following a Girdlestone situation and 87 patients with a Girdlestone situation (90 hips) were compared with regard to defined endpoints. RESULTS: THR following a Girdlestone situation provided for significantly higher patient satisfaction (89 % versus 13 %) and hip function (HHS 63 versus 39 points). The groups only marginally differed with regard to the incidence of complications (0.32 versus 0.26 per patient) and the necessity for surgical revision (0.38 versus 0.31 per patient). CONCLUSION: Conversion of Girdlestone hips with THR provided patient satisfaction and functional results superior to secondary Girdlestone hips while the incidence of postoperative complications and revisions were similar for both groups. These differences justify attempts at the conversion of Girdlestone situations with THR, if technically possible, in accordance with the patient's wish and as allowed by his/her general health.
AIM: The aim of this study was to assess the ratio of correct and malpositioned stems in a THR population with custom-made stems. Furthermore, any relation of the extent of deviation from the exact stem position and defined patient variables was evaluated. METHODS: Preoperatively, in three-dimensional virtual reality, CTX-individual hip stems were positioned in femora reconstructed from the individual patient's CT data until a stable cortical fit was achieved. Postoperative femoral stem position was measured with EBRA-FCA (EinzelBildRontgenAnalyse-Femoral Component Analysis). Differences of planned and actual depth of stem position were calculated for 107 CTX-custom-made hip stems implanted at one institution. RESULTS: Compared to preoperative planning 59 hip stems were placed too high, while 16 were placed exactly to within one millimeter and 32 were positioned too low. Deviations of postoperative stem position from preoperative planning did not correlate with previous femoral osteotomy found in one-third of femora or femoral anteversion exceeding 25 degrees as present in two-thirds of patients. CONCLUSION: In 71 % the intraoperative stem position did match the preoperative CTX-implant fitting into virtual patient femora. 29 % of implanted stems were malpositioned, i. e., deviations were greater plus or minus 5 mm to preoperative computer planning. None of the examined variables such as body mass index, previous femoral osteotomy, surgical approach, abnormal anteversion angle served as a predictive value for CTX-stem position in this cohort.