ortema pforzheim - Arcus Sportklinik

September 2009 

Imprint: 

Publisher: 

ARCUS Kliniken Pforzheim 

Rastatter Str. 17-19 

75179 Pforzheim 

Phone: +49 7231 60556 0 

web www.sportklinik.de 

email info@sportklinik.de 

Editorial Management: 

Prof. univ. cath. Cuenca EC Bernhard Rieser 

rieser@sportklinik.de 

Editor and Marketing: 

Heiko Hecht 

hecht@sportklinik.de 

Graphics & Layout: 

Buero 01 

Pforzheim 

Print: 

Kraft Druck GmbH 

Ettlingen 

Disclaimer: 

Please note that statements made in this brochure are of general nature and do not necessarily apply for 

every patient. Therefore, individual advice of your treating physician is absolutely necessary.

Welcome 

Dear patients, 

With this information brochure we would like to present you the most important 

part of our operative work. We refer to 20 years of own experience in in- and outpatient 

services and the current scientific status. 

Since 1989, more than 65.000 patients have been operated and about 150.000 

patients treated in the ARCUS Clinics. With more than 7.600 surgeries and about 

38.000 treated patients in 2009, we have become one of the biggest orthopaedic 

sports-traumatologic accidental surgery centers in Germany and Europe. 

Where does this success come from? 

It is based on tireless dedication and hard work, consequent implementation of latest 

operation- and treatment methods and full use of the best technical possibilities. 

We always used a substantial part of our revenues for new investments. And finally, 

in 2006, we were able to open up a new clinic equipped with the highest technical 

standards and a very pleasant, patient- and staff-friendly atmosphere. It has more 

than 6 operating theatres, 70 beds and 22 beds in the ward station on a total of 

17.000 m² that means together with already available capacities of the former clinic 

9 operating theatres, 90 inpatient beds and 30 ward station beds. The clinic is 

divided into a private clinic and a clinic for other patients with 30 beds which are 

listed on the bed requirement planning of the state of Baden-Württemberg. Here, 

also patients with statutory health insurance can be offered in-patient treatment. 

We want to provide you an understandable overview of our range of services and 

answer open questions in the case of a planned operation. Should you have any 

further questions about our services, special surgery techniques or our clinics in 

general, please do not hesitate and contact us. 

More information please find on www.sportklinik.de 

Your ARCUS Clinics Team 

Rastatter Str. 17-19 • 75179 Pforzheim • Germany • Phone 07231- 60556- 0 • www.sportklinik.de • info@sportklinik.de 

General Ellenbogen Information 

3

Table of Contents 

General Information 

Welcome 3 

Table of Contents 4 

Clinic Portrait / Competence Center / Science 6 

Basic Values of the ARCUS Clinics Pforzheim 7 

Spectrum of Surgery / Facts & Figures 8 

Medical Management 9 

Specialist Areas 11 

Diagnostics 12 

Quality Management 15 

Interesting Facts & Organization 16 

Anesthesia 18 

Operative Spectrum - Knee 

Meniscus 22 

Anterior Cruciate Ligament (ACL) 26 

Knee-Cap (Patella) 33 

Arthrosis 36 

Orthobiology 44 

Knee Malalignment 46 

Knee Endoprosthetics 49 

Operative Spectrum - Shoulder 

Shoulder Impingement Syndrome 55 

Calcified Tendinitis of the Shoulder (tendinosis calcarea) 57 

Shoulder Luxation 59 

Rotator Cuff Damages 61 

Injuries and Arthrosis of the Acromioclavicular Joint (AC-joint) 63 

Collarbone Fracture (clavicle fracture) 65 

Humeral head fracture 67 

Shoulder Endoprosthetics 69 

Operative Spectrum - Hip 

Hip Joint Arthrosis (coxarthrosis) 73 

Hip Arthroscopy 76 

Step-by-step Plan for Treatment of Coxarthrosis 78 

Total Endoprosthesis: Material and Fixation 79 

4 Rastatter Str. 17-19 • 75179 Pforzheim • Germany • Phone 07231- 60556- 0 • www.sportklinik.de • info@sportklinik.de

Operative Spectrum - Elbow 

Tennis Elbow 82 

Golfer’s Elbow 84 

Sulcus-ulnaris Syndrome or Cubital Tunnel Syndrome 84 

Loose Joint Bodies 85 

Osteochondrosis Dissecans 85 

Stiff Elbow and Elbow Arthrosis 86 

Elbow Prostheses 87 

Luxations and Instability 88 

Operative Spectrum - Foot 

Foot / Ankle / Achilles Tendon 89 

Big Toe 89 

Small Toe 91 

Metatarsus/ Tarsus 92 

Heel 93 

Achillodynia 94 

Achilles Tendon Rupture 95 

Ankle Disorders 96 

Neurosurgery / Spinal Column 

General Information 102 

Cervical Spine (CS) 103 

Lumbar Spine (LS) 109 

How to find us 115 



5

The ARCUS Clinics – a Portrait 

The ARCUS Clinics comprise a private clinic with 60 beds which was opened in 1995, 

and a clinic also approved by the statutory health insurance system with 30 beds. 

The new clinic complex was opened up in 2006. Here, 6 operating theatres equipped 

with state-of-the-art technology, and 22 beds in the ward station and the intensive 

care unit are available. 

The privately insured patient which can chose individual surgical treatment within 

the private clinic is offered a specialized unit with first class hotel comfort – an 

excellent overall service. 

The statutorily insured patient is, although statutory health insurance companies do 

only pay for “basic primary health care”, still provided a high-level clinic standard 

i.e. a standard on far above-average level compared to most other clinics. 

Competence Center 

In the ARCUS Clinics up to 7.500 patients are operated each year – with increasing 

tendency. Main focuses are on sports traumatology, knee-, hip-, shoulder-, elbow-, 

orthopedic-, and accident surgery, endoprosthetics and in the private clinic also on 

spinal surgery. External cooperating surgeons additionally cover vascular- and neurosurgery 

and an experienced team of anesthetists offers besides intra-operative 

control also post-operative pain therapy for in-patients. In cases of cardiologic 

problems during and after surgery we can refer to our cardiology section and stateof-the-art 

technical equipment. 

In the adjoining orthopedic joint practice patients can get out-patient treatment. 

This enables us to constantly control and optimize our own operation- and aftercare 

results what already proved successful e.g. rehabilitation periods of our patients 

could demonstrably be shortened. 

Special importance since many years has treatment of top athletes in the conservative 

and surgical area. As medical partner of the “Deutsche Sporthilfe” we offer a 24-hour 

acute service for sponsored top athletes. This comprises best diagnostics, operative 

treatment if necessary and a comprehensive rehabilitation program to accelerate 

recovery and support the athlete to regain physical fitness as soon as possible. 

Our medical range of services is completed by cooperating partners in therapy, 

rehabilitation, prevention and orthopedic technology. 

Perfect interdisciplinary collaboration of surgeons of different areas, physiotherapists 

and orthopedic technicians form the basis for an optimal and focused patient care 

both in the in- and the out-patient sector. 

Science 

The leading physicians of the ARCUS Clinics are members of all important national 

and international professional associations and regularly work for them as referees. 

Moreover, the ARCUS Sports Clinic cooperates with the association for science and 

further education in orthopedics. Together they regularly organize training programs 

for physicians and physiotherapists which are acknowledged as such by the 

Ärztekammer Nordbaden. 

6 

Rastatter Str. 17-19 • 75179 Pforzheim • Germany • Phone 07231- 60556- 0 • www.sportklinik.de • info@sportklinik.de

Basic Values of the ARCUS Clinics Pforzheim 

Our Mission 

Our Medical Demand 

In the ARCUS Clinics Pforzheim, long-term experience and specialization in different 

medical areas as well as use and development of medical state-of-the-art technology 

is the key to success. Scientific exchange of experiences and know-how is part of 

our daily work life. Our international appreciation is our continuous commitment. 

Patient Focus 

Orientation towards the patient – our customer – is the basis of our activities. We 

make highest demands on the quality of patient care and offer dedicated medical 

attendance from prevention and therapy until rehabilitation. Competent care and 

service improve healing results. 

The architecture of the ARCUS Clinics creates an environment where efficiency and 

the patients’ individual needs are optimally harmonized. 

Employee Focus 

The dedication of our qualified employees ensures the success of our clinic. Therefore 

we expect above-average performances and support professional development by 

providing further education measures. Professional and socially competent communication 

between the employees is the most important condition for a good 

working team. 

Managers are role models and support the employees’ dedication through a cooperative 

management style. 

Economy 

Since many years now, the ARCUS Clinics Pforzheim have been successful private 

facilities on the health sector. 

Optimal treatment concepts and results as well as economic success are inseparably 

linked with each other and one area strengthens the other. 

Rastatter Str. 17-19 • 75179 Pforzheim • Germany • Phone 07231- 60556- 0 • www.sportklinik.de • info@sportklinik.de 7 

General Ellenbogen Information

Spectrum of Surgery / Facts & Figures 

Figures 

2009 1.Quarter 2010 

Anterior Cruciate Ligament Surgery 1222 335 

Meniscus Surgery 1632 394 

Cartilage Surgery 175 41 

Hip Arthroscopy 172 60 

Shoulder Surgery 1101 348 

(except prostheses) 

Elbow Surgery 179 68 

Total 7671 2210 

(except prostheses) 

Endoprosthetics (artificial joints) 

2009 1.Quarter 2010 

Knee 662 210 

Hip 327 109 

Shoulder 101 36 

Total 1105 361 

8 


Medical Management 

Prof. univ. cath. Cuenca EC 

Bernhard Rieser 

Medical Director 

Partner of the ARCUS Sports Clinic 

Medical Specialist for Orthopedic 

Surgery 

Dr. med. Wolfgang Miehlke 

Leading Physician 


Surgery, Trauma Surgery 

and Sports Medicine 

Prof. Dr. med. Christian Heisel 



Surgery, Special Orthopedic Surgery 

and Trauma Surgery 

Dr. med. Ludwig Bös 




Surgery and Sports Medicine 

Dr. med. Thomas Ambacher 



Surgery, Trauma Surgery and Sports 

Medicine 

Prof. Dr. med. Uwe Spetzger 


Medical Specialist for Neurosurgery 

Dr. med. Andree Ellermann 




Surgery, Trauma Surgery, Sports 

Medicine and Chirotherapy 

Prof. Dr. med. 

Rüdiger Schmidt-Wiethoff 

Rüdiger Schmidt-Wiethoff 



Surgery, Special Orthopedic Surgery, 

Trauma Surgery and Sports Medicine 



10 

ORTEMA PFORZHEIM 

H e r z ll ii c h 

W ii ll ll k o m m e n 

UNSERE LEISTUNGEN IM ÜBERBLICK: 

 

 

 

Schuh- und Einlagen-Technik: 

Korrektur des Gangbildes 

Rumpforthesen-Technik: 

Fixierend und wachstumslenkend 

Arm- und Beinprothesen: 

Nutzung modernster Technologien 

 

 

 

Bandagen-Technik: 

Von Kopf bis Fuß nach Maß 

Orthesen und Knieorthesen: 

Stabilisierung und Entlastung 

Sport-Orthopädie: 

Protektion & Prävention 

DAS K-COM KNIEORTHESENKONZEPT 

DIE KNIEORTHESE 

AUS CARBONFASER 

Kreuzbandriss Arthrose Varus Valgus Kinderversorgung 

INDIVIDUELLE ANFERTIGUNG, EXTREM LEICHT 

MIT OPTIMALER ANATOMISCHER PASSFORM 

www.ortema.de 

ORTEMA GmbH Filiale Pforzheim · Rastatter Straße 17-19 · 75179 Pforzheim · Tel. +49(0)72 31-139 66 67 · Fax +49(0)72 31-1 39 66 84 · pforzheim@ortema.de 

ORTEMA GmbH Filiale Waiblingen · Alter Postplatz 13 · 71332 Waiblingen · Tel. +49(0)7151-985994-0 · Fax +49(0)7151-985994-94 · waiblingen@ortema.de 

Hauptsitz ORTEMA GmbH · Kurt-Lindemann-Weg 10 · 71706 Markgröningen · Tel. +49(0)7145-912081 · Fax +49(0)7145-912980 · info@ortema.de

Specialist Areas 

We cover the whole spectrum of orthopedic surgery. Therefore, in order to ensure 

our high quality standard, eight leading physicians manage the area of their specialization. 

Our Focus Areas: 

• Sports Traumatology 

• Knee Surgery 

• Shoulder- and Elbow Surgery 

• Hip Surgery 

• Foot- and Ankle Joint Surgery 

• Endoprosthetics 

• Trauma Surgery 

• Neuro- and Spinal Surgery (for privately insured patients and self-payers) 

• Blood Vessel Surgery 

• Cardiology 

Specialist Practices within the ARCUS Clinics 

Besides the orthopedic clinics, there are also different specialist practices integrated 

into the ARCUS Clinics complex to extend the spectrum. 

• Orthopedic joint practice Rieser / Bös / Ellermann / Miehlke / Ambacher / 

Schmidt-Wiethoff / Heisel / Sobau 

• Private practice for neuro- and spinal surgery Prof. Dr. med. Uwe Spetzger 

• Practice for radiology and nuclear medicine Dr. med. Berthold Winter 

• Private practice for cardiology Dr. med. W.O. Schüler & Colleagues 

• Specialist practice for anesthesia and pain therapy Dr. med. Carla Weber 



11

Diagnostics 

Thanks to state-of-the-art technical equipment of the latest generation, the ARCUS 

Clinics can always refer to the best method to provide optimal diagnostics and 

therapy planning. 

Cross-Sectional Diagnostic Imaging and Digital X-Ray 

In the adjoining practices there exist two 1.5 Tesla MRI scanners (nuclear spin) with 

the latest equipment, technology for digital X-ray, a Dual Source CT, a nuclear medicine 

section as well as a cardiac catheter laboratory for comprehensive diagnostics. 

All digital images taken with CT, MRI and digital X-ray as well as the arthroscopic 

images generated during surgery are stored in a central PACS-system and can be 

retrieved at any time in the treatment rooms of the orthopedic joint practice, the 

wards and in the operating theatres. There are certified monitors available for 

reporting in all sections. 

CT (computed tomography) 

The Siemens Dual Source SOMATOM Definition CT (2 x 64 rows) is by using a second 

x-ray tube and a second detector much more efficient than devices of the “simple” 

construction. Its excellent image quality and high resolution at the lowest possible 

radiation exposure for the patient enables fast and precise diagnosis and increases 

its reliability. It also enables us to examine coronary heart vessels without cardiac 

catheter. Temporal resolution of the SOMATOM Definition is with 83 ms not dependant 

on the patients’ heart rate. This makes it possible to examine every heart at 

every heart rate e.g. diagnosis of acute chest pain, visualization of coronary arteries 

and function analysis of the heart. Combined with the currently highest possible 

resolution of less than 0.4 mm, the SOMATOM Definition can display smallest anatomic 

structures, whether complex osseous structures or finest details of the coronary 

tree. Thanks to the large gantry aperture, the scan length of 200 cm and the highest 

possible x-ray generator performance almost all acute in-patients regardless of their 

physical constitution and size can be examined and valuable time gained between 

scan and diagnosis. 

MRI (magnetic resonance imaging = nuclear spin 

tomography) 

The ARCUS Clinics have two 1.5 Tesla MRIs of the latest generation at their disposal. 

Equipped with AudioComfort, a combination of several innovative technical measures 

for noise reduction, the former usual noise level reached during MRI can be 

reduced by up to 97%. The ability to scan the patient in the feet first position as 

well as total-body examinations in the time of only 12 minutes make the Magnetom 

Avanto the most efficient and patient-friendliest system of its class and is decisive 

for pre-operative diagnostics of poly-traumatized patients. 

The Magnetom Avanto is furthermore equipped with the new and innovative Timtechnology. 

Heart is the revolutionary matrix coil concept where 76 coil elements can 

be combined with up to 32 high-frequency channels [76x32]. This visibly improves 

recording speed and picture quality. The Magnetom Avanto also stands out through 

12 


Diagnostik 

especially powerful gradient systems (comparable with “motors” for MR), what 

facilitates fast examinations of the heart or detailed analyses of brain functions. 

Cardio MRI is thanks to modern software a simple and fast examination of heart 

function, myocardial morphology, extension of infarction and 3D-coronary anatomy. 

In most cases the examination is completed in less than 30 minutes. This method is 

of particular importance for sports medicine. The decided diagnostic of heart muscle 

inflammation is not comparable with any other method. 

Digigal X-Ray 

The orthopedic joint practice has a dose-reduced direct-digital x-ray apparatus at its 

disposal. With only 40% of usual radiation exposure it enables images with higher 

resolution and therefore better basis for diagnostics. 

Mobile CT and Navigation Device 

With the CT, complex surgery procedures can also be carried out with navigation. 

This enables better results when being confronted with complicated anatomic conditions 

or complex fractures. 

Operating Theatres 

All nine operating theatres are connected to the digital clinic network. This ensures 

internal as well as external data transfer. All images taken during surgery are recorded 

and stored in the patient’s file. By means of an external surrounding camera 

system also transfer of external footage is possible (besides arthroscopic images). 

When conducting live-surgery, this enables transfer of e.g. positioning of the patient 

or preparation of transplants/implants to national and international congresses 

and other events. 

On two screen walls, surgery can be followed from the outside. The operation manager 

is responsible for occupancy and optimal allocation of the operating theatre. 

Sterilization Zone 

Our operating theatres are provided with sterile material via nonintersecting corridors. 

Sterilization is equipped with top quality devices only. Each instrument used can 

be referred to the respective patient via a bar code. With this, absolute traceability, 

the so-called sterile-chain can be documented. 

A modern system documents all working steps and provides insight into availability 

of the OP sets. Moreover it automatically controls withholding periods. 



Anzeige 

ARCADIS Orbic 3D - Mehr Präzision bei der operativen 

Versorgung von Knochen- und Gelenkbrüchen 

Die präzise Identifizierung und Repositionierung dislozierter Knochenfragmente, das 

Setzen von Pedikelschrauben in die Wirbelsäule und die Lagekontrolle von Osteosynthesematerial 

zählen zu den größten Herausforderungen in der Unfallchirurgie und 

Neurochirurgie. In vielen Fällen liefert die konventionelle 2D-Projektionsbildgebung 

nicht genügend Informationen, um solche Eingriffe präzise zu kontrollieren. Für die 

exakte Versorgung von Knochen- und Gelenkfrakturen steht mit dem mobilen C- 

Bogen ARCADIS® Orbic 3D von Siemens ein hervorragendes System zur Verfügung, 

das mittels der interaoperativen 3D-Bildgebung deutliche Informationsvorteile über 

die jeweilige Fraktur der Knochen und Gelenke im Vergleich zu herkömmlicher 

2D-Bilddarstellung bietet. Hauptanwendungen sind Versorgungen der oberen und 

unteren Extremität, der gesamte Wirbelsäule, Hüfte/Becken sowie des Gesichtsschädels. 

Die intraoperative 3D-Bildgebung ermöglicht dem Chirurgien die sofortige 

Beurteilung der Ergebnisse, wie z.B. der Lagekontrolle von Schrauben. Notwendige 

Korrekturen können direkt während der OP erfolgen, das postoperative CT wird 

in den meisten Fällen nicht mehr benötigt und eine nochmalige Operation kann 

vermieden werden. Dies bedeutet eine entscheidende Verbesserung sowohl für die 

körperliche Belastung des Patienten, als auch für den klinischen Arbeitsablauf und 

die notwendigen Kosten. 

Das digitale Röntgen. 

Digitales Röntgen 

Digitaler OP 

„Mehr Zeit für Medizin.“ 

Dr. med. Michael Müller-Autz – STARC PACS-Anwender 

Digitales Röntgen & Digitaler OP 

STARC medical GmbH · Jathostraße 9 · 30916 Isernhagen · Tel. 0511 260962-00 · Fax 0511 260962-90 · info@starc-medical.de · www.starc-medical.de 

14 


Quality Management 

In 2005, already before moving into our new buildings, the ARCUS Clinics implemented 

a comprehensive quality management system in which all employees were 

gradually included. 

Thanks to the great acceptance and the dedication of our staff we were able to form 

working groups which from then on continuously have been analyzing, adapting 

and optimizing our internal working procedures and structures. 

On this basis we decided to choose CTQ (Cooperation for Transparency and Quality 

in the Healthcare Sector) as quality management system. 

The aim of this system is to motivate directors and employees of the respective facility 

to implement an internal quality management system with patient orientation 

and continuously improve it on a self-managing basis (source: http://www.ktq.de/..). 

The first certification was successfully completed in November 2006 by the company 

NIS Zert. Recertification was passed in 2009. 

Responsible for quality management are: 

Quality Manager: Quality Representative: 

Sigrun Goos Dr. med. Wolfgang Miehlke 

Head of Nursing Services Leading Physician ARCUS Clinics 

goos@arcus-klinik.de miehlke@arcus-klinik.de 

Qualitätsphilosophie & Qualitätspolitik 

The ARCUS Clinics management has committed to integrate quality management in 

any operating structure. Orientation towards the patient is the focus of our activities 

and patient satisfaction is our continuous aim. 

Our employees are the main driving force for the success of our clinic. 

Therefore employee oriented management, a broad offer of further education 

programs and professional cooperation are being paid special attention. 

In all areas and professional groups quality is a major aim and all our employees 

are bound to active contribution. Volunteer working groups help improving the 

quality. This continuous process of improvement includes all structures, processes 

and results of our clinic. 



15

Interesting Facts & Organization 

Day of Surgery 

You are planning to undergo surgery at our clinic. We would like to provide you 

with some information. 

On the day of surgery 

• do not eat for 6 hours before the operation 

• do not drink for 2 hours before the operation (exception: some mineral water or 

normal water in combination with medication, see chapter „Anaesthesia“ from 

page 18). 

• do not chew gums or suck on sweets 

• do not smoke 

• do not use make-up or cream on your face 

Furter information regarding anaesthesia please find in chapter “Anaesthesia” 

from page 18. 

Appointment and length of stay: 

Please note that the time of your appointment and the actual start of the operation 

may vary; amongst other things because of the time needed for preparation 

procedures. 

This does also apply for the time needed in the recovery room before you are moved 

to your room or can leave the hospital (if treated out-patiently). Length of your stay 

depends on many different factors and therefore cannot be definitely planned. It 

is only an estimated time slot. 

Leaving the Recovery Room: 

• the most important criteria is the physical condition of the patient. Whether 

being in the condition to leave the hospital is exclusively subject to the decision 

of the anesthesiologist and surgeon 

• also important is the completeness of the medical documents needed for further 

treatment 

16 


Interesting Facts & Organization 

Average Recovery Time after Surgery: 

• 2 hours for minor surgeries 

• at least 4 hours for larger surgeries, for major surgeries also over night if need 

be 

We hope you understand that there might be longer waiting times. Please apologize 

for any inconvenience. 

Accompanying Person: 

• your accompanying person can leave the house in the meantime. Please leave a 

contact phone number with the recovery room staff and you will be informed 

as soon as the patient is able to leave the hospital 

• out of hygienic reasons, access to the recovery room is not allowed (special exceptions: 

e.g. operations of children) 

• to facilitate transport of the patient to the car, a wheel chair is at your disposable. 

Please leave it in front of the recovery room afterwards. 

Pharmacy: 

Please note that the pharmacy is only open until 7.00 pm. You should hand in the 

prescription for the thrombosis prophylaxis in time. 

For out-patient operations: 

You will get the first anti-thrombosis injection before leaving the recovery room 

out of our stock. Thus it is important that you take one anti-thrombosis injection 

out of the package you received and leave it with the operation theatre staff at 

the reception desk. 

Please do not underestimate the importance of a consequently carried out thrombosis 

prophylaxis. Even young patients are in the potential risk of thrombosis. 



17

Anesthesia 


There are different anesthetic procedures possible to stop the feeling of pain during 

surgery. Under general anesthesia you are asleep during the procedure; under 

regional anesthesia, only a particular part of the body becomes anesthetized. 

Sometimes the best solution is a combination of both methods, e.g. for hip-, and 

knee replacement surgery, or cruciate ligament replacement and shoulder operations. 

By using “pain catheters” excellent pain therapy can even be ensured in the days 

following the operation. 

All operating theatres of the ARCUS Clinics are equipped with state-of-the-art anesthesia 

apparatuses and monitoring units. 

Our anesthesiological team will care for your safety and well-being during the 

whole surgery. We ensure a pain free procedure, seamless monitoring of your vital 

functions such as circulation and respiration, and thus are anytime able to react to 

any changes and take the appropriate measures. 

What should be considered before anesthesia? 

You will receive individual advice regarding the appropriate and necessary anesthetic 

procedure. Please consider that you can contribute largely to the success of 

anesthesia. Therefore, the following introductions should be strictly observed: 

• do not eat for 6 hours before the operation 

• do not drink for 2 hours before the operation (exception: some mineral water 

or normal water in combination with medication) 

• do not chew gums or suck on sweets 

• do not smoke 

• do not use make-up or cream on your face 

• please inform the anesthesiologist about all medication you take regularly at 

home. He will decide which medication can be taken on the day of surgery. It 

also may be necessary to stop taking particular medicines some days before surgery 

(2-10 days). This does apply in particular for medicines with anticoagulant 

activity (e.g. Marcumar), acetylsalicylic-acid-containing drugs (e.g. Aspirin, ASS), 

clopidogrel (e.g. Plavix, Iscover) as well as metformin-containing substances for 

treatment of Diabetes mellitus. 

18 


Anesthesia 

Preanesthetic Preparation 

Before going under anesthesia, an infusion cannula is placed into your arm vein to 

give you a mild sedative. Small electrodes are affixed to your chest for later cardiac 

monitoring. Then you are moved to the preparation room. Here, we start as preparation 

of the anesthesia with seamless monitoring of your cardiac activity (ECG) 

and continuous measurement of the oxygen level in your blood (via finger sensor). 

Your blood pressure is checked automatically. 

General Anesthesia 

To induce general anesthesia, well-tolerated narcotics and analgesics are injected 

into your vein through the previously placed permanent venous cannula, and during 

anesthesia permanently given into the blood with a syringe pump. As soon 

as you are asleep a breathing aid in form of a laryngeal mask is inserted into your 

mouth. Ventilation via laryngeal mask is a simple and gentle procedure without any 

negative effect on the vocal cord functions. If the operation requires the patient to 

be positioned in prone- or lateral position, easing ventilation is generally reached 

with endotracheal intubation with medicinal muscle-relaxation i.e. by means of a 

laryngoscope and under visual control, a tube is inserted past the vocal cords directly 

into the trachea. Of course we are monitoring you the whole time with the utmost 

care. While you are under anesthesia, your heart- and circulation- as well as your 

breathing parameters are recorded with a modern automatic monitoring system. 

This enables us to immediately react on anything abnormal. The ideal depth of anesthesia 

is investigated by recording your brain activities. The length of anesthesia 

is adjusted precisely to the duration of the operation. This means you will wake up 

immediately after the end of the operation. 

Aftercare will then be carried out in the ward station, where you can drink something 

shortly after the operation and see your family. 


Ellenbogen 

Anesthesia 

19

Fig. 1: 

Plexus Anesthesia 

Fig. 2: 

Spinal Anesthesia 

Fig. 3: 


Anesthesia 

Regional Anesthesia 

Plexus Anesthesia 

For operations of shoulder, elbow and hand, a possible anesthetic procedure is 

plexus anesthesia. 

Here, sensivity to pain in your arm or shoulder is stopped temporarily for several 

hours by anesthetizing the nerve plexus supplying your shoulder and arm with a 

local anesthetic. In this time it is “normal” that you are not able to move your arm. 

Additionally you are given a “mild” general anesthesia to ensure your well-being 

and comfort during surgery. 


Pain free operations of the lower stomach area below the belly button are also 

enabled by spinal anesthesia. 

For this local anesthesia of the spinal marrow a very thin cannula is used to inject 

the anesthetic between the 3rd and the 4th spinous process of the lumbar vertebrae 

(far away from the spinal cord) into the so-called “liquor area”. 

You can make it much easier for us to find the spinal channel by arching your back 

during the puncture i.e. bend forwards and press your chin to your chest. 

After only a short time you will feel a sensation of warmth and an increasing heaviness 

of your legs. Before starting the operation, sufficient spread of the anesthesia 

is checked. Depending on the type of local anesthetic used, it may last for up to 6 

hours. Sometimes, anesthetizing the bladder nerves may cause temporary urinary 

retention. In rare cases, especially younger patients may develop headaches after 

spinal anesthesia. 

Peridural Anesthesia 

Peridural anesthesia (PDA) is also regarded as one of the procedures which are 

close to the spinal cord. Compared with spinal anesthesia however, the hard outer 

membrane surrounding the spinal cord and the nerves branching from it are not 

punctured. This means that more local anesthetic has to be injected than with spinal 

anesthesia, and that the effect comes slightly delayed. Basically, a PDA could be 

used as sole anesthetic agent for surgical procedures of the lower part of the body; 

however, because of the delayed effect it is rather used as additional method for 

postoperative pain therapy with major surgeries. The thin catheter placed into the 

peridural space for this procedure can be used for continuous pain therapy during 

the first days after surgery. 

Whether one of these techniques is appropriate in your case should be discussed 

with your anesthesiologist. 

20 


Anesthesia 

Combination of General- and Regional Anesthesia 

As already mentioned before, it may be useful for many operations to combine 

both types of anesthesia. 

General anesthesia saves you having to consciously witness the operation and ensures 

safe artificial ventilation. 

Regional anesthesia stops the pain during and after surgery. By continuously giving 

local anesthetics you will need considerably less strong analgesics, so that there are 

fewer side effects such as nausea, vomiting or tiredness. 

In case that a catheter has been inserted, it is also possible to use it several days for 

in-patient pain therapy. 

Leg nerve Block (so-called 3-in-1 blockade / femoral and 

sciatic catheter) 

These forms of so-called peripheral regional anesthesia are used especially for 

cruciate ligament surgery, knee joint replacement as well as complex foot surgery. 

Here, normally after indication of the general anesthesia, the femoral nerve in the 

groin supplying the front parts of the knee joint, knee extensor and hip flexor muscles 

is identified by means of an electrical nerve stimulation device. A single injection 

of local anesthetics brings long-lasting pain reduction. Insertion of a thin catheter 

near the nerve enables further injections in the days following the operation, so 

that first physiotherapeutic treatment can be carried out largely without pain. If 

knee joint replacement shall be done by means of a (partial-) prosthesis, a second 

catheter is being placed near the sciatic nerve which mainly supplies the posterior 

thigh area and the lower leg. 

Therefore it is quite understandable that even after major surgery you will feel no 

or only slight pain when waking up from the general anesthetic. 

For arm- and shoulder operations there are analogue procedures. 

Peripheral Nerve Blocks 

For operations on hands or feet, additional very effective pain therapy can also be 

achieved by nerve blocks which are carried out peripherally, that means further away 

from the main nerve trunk. This includes the hand- and the foot block. 

The advantage is only small impairment on muscle activity of the affected limbs, a 

reduced demand for anesthetics and long postoperative pain reduction. 


Ellenbogen 

Anesthesia 

21

Meniscus 


The human knee joint has an internal and external meniscus. Each meniscus consists 

of elastic collagenous fiber tissue. Both menisci lie between the sliding surfaces of 

thigh and lower leg. When flexing or stretching the knee, they move along into the 

same direction, just as they do with inner- and outer rotating movements. The external 

meniscus is smaller and more flexible than the internal meniscus. Menisci 

serve as balance of the incongruence between the thigh and the lower leg and as 

extension of the supporting surface and power transmission. When transmitting 

power, menisci effect a stress distribution of 30-70 % of total load (after removal 

of the complete meniscus stress on the cartilage increases). Furthermore, the meniscus 

is responsible for shock absorption and joint lubrication, and also increases 

stability of the entire knee joint. Meniscus ruptures can have a traumatic or degenerative 

reason, and they occur three times as often on the inner side as on the 

outer side of the knee joint. 

Fig. 1: 

Top view inner- (medial) and outer (lateral) meniscus (source: Smith & Nephew GmbH) 

Often, the trauma of a twisted knee results in a meniscus injury. 

However, in most cases it is the degenerative meniscus damage which occurs due 

to the early aging process of the meniscus tissue without having an adequate trauma. 

This is mostly the result of overload and/or axial malposition, or the result of 

repeated microtraumas. 

22 


Meniscus 

Medical Conditions 

The most common symptoms of meniscus damages are pain in the outer- or inner 

side of the knee joint, especially under stress and specific rotational movements. A 

“block” in the joint i.e. temporary inability to flex or stretch the knee is a specific 

indication for a basket handle- or lap tear. Another indication can be swelling or 

hyperthermia of the knee joint due to the acute irritation. 

Fig. 2: 

Complex rupture after partial meniscectomy 

Therapy 

Fig. 3: 

Complex rupture without any suture 

option 

Therapy of meniscus damages can, depending on the degree of severity, be carried 

out conservatively or surgically. When having a stable meniscus rupture which is 

relatively free of symptoms and stands physical stresses of everyday life, treatment 

can be made with combined medical-physical therapy. 

Operative therapy is made with a minimally invasive and arthroscopic technique. 

Because of known long-term consequences, therapists always try to retain as much 

meniscus tissue as possible with young patients. When having a basket handle or lap 

treat of the meniscus, in some cases even stitching up the rupture is enough. When 

these ruptures lie within the central area of the meniscus which is well supplied with 

blood, there are good chances of recovery. The chance of this kind of therapy being 

successful has to be decided by the experienced surgeon during surgery. 

Fig. 4: 

Bucket handle tear 

Fig. 5: 

Meniscus suture 


Ellenbogen Knee

Meniscus 

Meniscus Suture 

In our ARCUS Clinics different suturing techniques are used, depending on the need. 

All of them are well-proven, and show few complications and good chances of recovery. 

In order to accelerate wound healing of the torn part of the meniscus and 

induce ingrowth of blood vessels, fissures are previously prepared by “needling” and 

“rasping” them with microsurgical instruments. When having a small fissure only 

or a cruciate ligament rupture at the same time, this often is completely sufficient 

and is seen as indirect suture technique. When having an isolated meniscus injury 

or a bigger fissure, however, a direct meniscus suture is necessary and carried out 

by stitching up the fissure. 

Partical Meniscectomy 

If it turns out that stitching up the meniscus is not possible, partial meniscectomy is 

being carried out. Here, as much as necessary but as little meniscal tissue as possible 

is being removed to keep the remaining meniscus stable and functional. Due to this 

partial removal of the meniscus the supporting surface becomes smaller, but (of 

course depending on the amount of tissue removed) this normally has no negative 

effect on joint functions. 

Aftercare 

After surgery, you are not allowed to drive yourself. In most cases we prescribe 

an anti-inflammatory medication which has to be taken regularly. Furthermore, 

prophylaxis of thrombosis and embolism by an abdominal injection is essential as 

long as walking on crutches. A drainage positioned into the knee joint normally 

is removed after one or two days, suture material after 10-12 days. This process is 

being carried out by the referring specialist or family doctor. 

Having had a meniscus suture, the knee should not be bent under stress for more 

than 90 degrees within the first 12 weeks (do not squat!). During the first 2 weeks, 

the only pressure the knee shall be load with is sole contact. The 3rd and 4th week, 

load can amount to 20 kg and afterwards the patient can start with moderate 

muscle training. In most cases, start of intensive sporting activities is possible after 

3-4 months. 

After partial meniscectomy it is not allowed to put full weight on the leg for about 

5-7 days. Moreover, as long as walking on crutches, adequate prophylaxis of thrombosis 

and embolism is necessary. 

24 


Meniscus 

Meniscus Replacement 

When a large portion or even the complete meniscus had to be removed with a young 

patient, meniscus transplantation or meniscus replacement should be discussed as 

a lacking meniscus may very early lead to diseases such as arthritis. The treatment 

can delay beginning arthrosis and its success is closely connected with existence of 

health cartilage tissue, intact ligaments and the physiological axis of the leg. 

Transplantation of a donor meniscus (“allograft”) is possible as well as implantation 

of artificial meniscus replacement tissue (“CMI” = collagen meniscus implant or 

“ACTIFIT” = polyurethane meniscus implant). Implants are operatively tailored to fit 

perfectly into the prepared defect. Then, the chosen implant is being sutured and 

has to heal for several weeks. The new tissue shall restore normal functions of the 

meniscus, relieve pain and even stop the degenerative process. Due to very strict 

indications, however, this surgery is being carried out rather rare. 

Fig. 6: 

Meniscus replacement (source: ReGen Biologics) 

Aftercare 

After meniscus replacement surgery, walking on crutches for 2-3 months is necessary 

to support the healing process of the donor meniscus. 


Ellenbogen Knee

Anterior Cruciate Ligament (ACL) 


Cruciate ligament injuries are often the result of acute accident- or sports injuries. 

When having injured the cruciate ligament, the knee joint swells up due to the hematoma. 

More symptoms are painful limitation of knee movability and, depending 

on the severity of injury, the feeling of instability on the affected leg. In this acute 

condition, diagnosis may be very difficult as pain, swelling and tense muscles hinder 

medical examination. A positive result of the pivot-shift test is seen as reliable sign 

for an anterior cruciate ligament rupture; a positive Lachman provides the best 

likelihood ratio. 

Besides the orthopedic examination, magnetic resonance imaging (MRI) is recommendable 

with new cruciate ligament injuries as a high percentage of patients also 

have concomitant injuries such as meniscus-, medial collateral ligament-, and cartilage 

damages. With the magnetic resonance imaging the entire extent of the injury can 

be detected. Therefore, MRI has special relevance with regard to surgery planning 

as well as for allocation of concomitant injuries to be operated (e.g. menisci, lateral 

ligaments and/or the dorsolateral capsule edge with rupture of the Popliteus tendon). 

anterior cruciate 

ligament 

inner (medial) 

meniscus 

Tibia (shinbone) 

Fig. 1: 

Knee joint with cruciate ligaments and menisci (source: Smith & Nephew GmbH) 

Difficulties with Cruciate Ligament Ruptures 

Femoral condyle 

posterior cruciate 

ligament 

outer (lateral) 

meniscus 

Fibula 

Our cruciate ligaments form the central stabilizing column of the knee joint 

(fig. 1). Their principle purpose is to prevent the knee joint against abrupt stopping- 

and accelerating movements as well as rotational movements. Injuries of cruciate 

ligaments occur in more than 90 % of all cases to the anterior cruciate ligament 

(ACL). The cruciate ligament rupture causes serious impact on natural movements of 

the joints. Although with muscular and trained athletes a cruciate ligament rupture 

26 



can be compensated in the beginning with conservative therapy, damage of further 

structures and with this a considerably higher risk of arthrosis has to be expected. 

After having had a cruciate ligament rupture, most patients focus on regaining their 

condition first. Need for surgery depends on activity, symptoms of instability and age, 

and especially the athletic patient benefits here from prompt operative treatment. 

Conservative treatment, however, is also completely justified with low instability 

symptoms and low physical activity. With cruciate ligament injuries in childhood and 

adolescence, operative reconstruction by the use of appropriate techniques should 

be considered to prevent serious consequential injuries such as damages of secondary 

joint cartilages or menisci. We have just published comprehensive experiences and 

numerous studies regarding this issue. 

Fig. 2: 

Arthroscopic image of a fresh ACL-rupture 

Current Surgical Techniques 

Thanks to the enormous development of arthroscopic surgical techniques, treatment 

options for cruciate ligament replacements have improved considerably over recent 

years. Shorter operation times and a reduced surgical trauma, less pain and better 

cosmetic results speak for today’s minimally invasive operation methods. Correct 

surgical treatment, however, needs maximum experience (fig. 2+3) and therefore 

should be carried out in specialized centers. In the ARCUS Clinics in Pforzheim more 

than 1200 arthroscopic cruciate ligament surgeries are carried out every year. Arthroscopic 

cruciate ligament replacement using autologous tendon transplants has 

reached standard level by now. Used are hamstring tendon transplants (semitendinosus- 

and gracilis tendon) in triple- and quadruple binding technique as well as 

patellar tendon strips, quadriceps tendons and after multiple ruptures also donor 

grafts. Common characteristics of all these transplants are their tear resistance and 

flexibility which are similar to the anterior cruciate ligament. But they differ regarding 

the removal technique and their anchoring possibilities. 

Fig. 3: 

Cruciate ligament reconstruction of semitendinosus tendon graft 


Ellenbogen Knee

Fig. 4: 

Quadrupled harmstring tendon 

graft reinforced by Endobuttons ® 

or Retrobuttons ® . 

(source: Arthrex GmbH) 

Fig. 5: 

Patellar tendon graft as ACL/ 

PCL reconstruction (source: 

Arthrex GmbH) 

Fig. 6: 

Double-bundle ACL reconstruction 

(schematic image) 


Hamstring Grafts (hamstring tendons: semitendinosus- and gracilis 

tendon) 

Through a small incision at the inner shinbone head, the semitendinosus- and gracilis 

tendon are being removed and then doubled to create a quadruple-transplant 

(fig.4). Alternatively, when having a sufficiently long semitendinosus tendon, there 

is also the possibility to remove the semitendinosus tendon only and tie it together 

to a triple- respectively quadruple bundle. 

Advantages of the usage of hamstring tendons are fewer problems with removal, 

less pain, and cosmetically more favorable scars. Another essential advantage of 

this method is the hamstring graft gaining almost the natural elasticity of a cruciate 

ligament during the healing process. Relevant dysfunctions due to the removal of 

the hamstring do not occur. 

Partellar Tendon (tendon below knee cap) 

As cruciate ligament replacement, the middle third of the tendon is being removed 

as “bone-tendon-bone” graft (fig. 5). Advantage of this method is stable fixation 

and fast bone ingrowth of the transplant. 

Disadvantageous however is pain which may occur at the donor site and a possible 

reduction of muscle power of the thigh extensor muscle. Statistics show that the socalled 

“anterior knee pain” occurs more often after having had an anterior cruciate 

ligament reconstruction with patellar tendon than with hamstring graft. 

„Double-Bundle“ Reconstruction 

Some teams favor currently a new procedure using hamstring tendons in doublebundle 

constructions. With this technique, replacement of the ACL is made according 

to its anatomic structure with a doubled transplant string of anteromedial and 

posterolateral fiber bundles (fig. 6). The higher biomechanical efficiency gained by 

this double-bundle reconstruction technique however has so far only been proven 

by experimental simulations. Furthermore, it needs more complex surgery- and 

anchoring techniques which long-term efficiency regarding optimized knee stabilization 

has not been shown yet. Within the scope of controlled studies, this method 

is also being used by us. 

Quadriceps Tendon (tendon of thigh extensor) 

The quadriceps tendon graft with small patellar bone block is mainly used in revision 

surgery (re-rupture of cruciate ligament). Although it shows biomechanical characteristics 

comparable to the natural cruciate ligament, removal of the transplant is 

very complex and time-consuming, and therefore did not gain general acceptance 

as first line therapy. Advantage of this method is the possibility of implant-free 

press-fit anchoring of the quadriceps tendon graft into the thigh bone, whereby 

biologically optimal healing and simplified surgery in case of revision treatment is 

ensured. Disadvantages are the demanding surgical procedure for removal of the 

tendon and weakening of the thigh extension functions. 

28 



Donor Tendons 

Donor tendons (allografts) are mainly used in America. Advantage of this method 

is the fact that removal of suitable reconstruction material is no longer required. 

Disadvantageous however are possible immune responses and the higher failure 

rate. Usage of donor tendons is being considered as alternative treatment especially 

with secondary- or third operations when there is lack of the patient’s own transplant 

possibilities. Since 1993, the ARCUS Clinics are regarded the most experienced 

specialized surgery unit in Germany using donor tendons for cruciate ligament 

reconstruction. 

Fixation of Cruciate Ligament Grafts 

Common aim of all reconstruction techniques is primary stable graft anchorage. 

For this purpose, there are many different fixation materials such as metallic or 

bioabsorbable interference screws, staples, pins or fixation buttons available (fig. 

7, 8a, 8b). For all systems used at present, an initial retention force which meets 

post-operative stabilization demands has been certified. In the end, however, 

anchorage of the implant until complete healing remains the real weak point of 

cruciate ligament plastics. 

Fig. 7: 

Fixation of ACL replacement: 

Transfix ® and bioabsorbable screw 


Time of Cruciate Ligament Reconstruction 

Fig. 8a: 

Fixation of ACL replacement: Endobutton ® or 

Retrobutton ® (source: Arthrex GmbH) 

When having a new rupture, treatment in the sense of first line therapy can be done 

within the first 24 to 48 hours. This option is possible for example when treating an 

osseous rupture of the cruciate ligament or other concomitant injuries that need 

immediate medical care (e.g. meniscus ruptures that can be stitched up or complex 

knee instabilities with rupture of medial- or lateral collateral ligament). In normal 

cases, surgery is planned after 4-6 weeks when the inflammation has subsided. 

During this inflamed phase, operative treatment is not recommended due to the 

proven increased complication rate in the sense of post-operative movement disor- 

Fig. 8b: 

Fixation material: bioabsorbable 

screw and Endobutton ® 

(source: Smith & Nephew GmbH) 


Ellenbogen Knee


ders. Reduction of this “6-week-period” is possible and supportable when the joint 

becomes irritation-free before. 

Until the date selected for surgery, the joint is being treated with functional conservative 

methods, where the focus lies on how to reduce the swelling and regain 

functional mobility. Furthermore, preoperative usage of stabilizing knee orthoses 

is indicated for strong instability symptoms and concomitant lesions of the medial 

collateral ligament. 

Fig. 9: 

Donjoy ® knee brace (source: Ormed.DJO) 

Aftercare 

Rehabilitation after cruciate ligament reconstruction surgery is an important component 

of our therapy concept. On the one hand, treatment concentrates on regaining 

the full range of physiological mobility, full muscular control and coordination, and 

returning to full activity. On the other hand, current methods of Aftercare are adapted 

to scientifically proven phases of healing. At present, the accelerated rehabilitation 

program propagated in the 90ies has given way to adapted and more restrictive 

postoperative therapy planning which considers individual tissue reactions and the 

healing process. Today, postoperative care with knee orthoses stabilizing the knee 

joint is considered standard. With optimal rehabilitation, stable reconstruction of 

knee joint function and –stability can be expected after 6-9 months. 

ARCUS rehabilitation program for cruciate ligament reconstruction: 

Stationary phase (2-3 days): 

Ice-pack and lymph drainage. Start with physiotherapy in the pain free area as well 

as “walking school” on elbow crutches. Further measures are muscle stimulation, 

lymph drainage and thrombosis prophylaxis. Removal of redon-drainage the 2nd 

day after surgery. 

30 



Post-stationary phase: 

Therapy to reduce swelling, physiotherapy. Primarily work on active stretching, 

quadriceps isometry, self training, physical exercises and dynamic splint: 1st week 

60° of knee reflextion, 2nd - 4th week 90 °. Afterwards approval of physical mobility. 

Increase weight slowly: in first week, only “heel-to-toe” movement of the foot with 

elbow crutches and with a load of no more than 5 kg is permitted, 2.-3. week about 

20 kg, then full body weight can put onto affected leg depending on muscular 

control and toning. 

Coordination- and proprioceptive training (balance board, posturomed, areostep, 

aqua jogging). Ergometer. Squat- and leg press training possible (in closed system). 

Please avoid forced stretching against resistance in order to treat the donor site 

with care. 

Sporting activities: 

• cycling, walking approx. 6 weeks after surgery 

• jogging approx. 3 months after surgery 

• contact sports such as football, handball, skiing, tennis approx 6-9 months after 

surgery 

Medial- or Lateral Collateral Ligament Injuries 

Injuries of the medial collateral ligament can thanks to their tendency to spontaneous 

healing often be treated conservatively. An exception is a complete rupture 

of the medial capsular ligament complex with involvement of posterior transverse 

ligament and dorsomedial capsule. Here, indication for surgery is suture of ruptured 

ligament structures. Injuries on the outside of the knee joint generally are not 

being seen as favorable spontaneous prognosis. In these cases immediate surgical 

reconstruction is needed. 

Posterior Ligament Rupture 

Injuries of the posterior cruciate ligament are mostly the result of a violent weight 

shift of the lower leg backwards compared to the thigh; for example through direct 

impact from the front onto the shinbone head. With immediate correct diagnosis, 

the posterior cruciate ligament injury shows a good spontaneous healing tendency. 

It requires consequent wearing of a special PTS® splint (fig. 10) which permanently 

supports and pushes the lower leg to the frontside. Should the “dorsal drawer 

test” however, remain positive even after several weeks of conservative treatment, 

surgery is unavoidable. 

Current Surgical Techniques 

Surgical therapy of the posterior cruciate ligament rupture is carried out – as the 

ACL rupture – on fully endoscopic basis (fig. 11), whereby the patient’s own tendon 

grafts are used for ligament replacement. 

Fig. 10: 

Knee positioning splint for 

PCL-rupture 

(source: medi GmbH & Co. KG) 

Fig. 11: 

PCL replacement, schematic image 



Ellenbogen Knee

32 

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Knee-Cap (Patella) 


The knee-cap (patella) is a free running “supporting bone” for the extensor tendon 

of the thigh. It does not have any firm osseous joint guidance, but is only attached to 

muscles, tendons and ligaments. It glides in a V-shaped groove of the femur (femoral 

trochlea or sliding bearing). When having a congenital malformation of the trochlea 

or in reaction to changes in muscle balance (e.g after surgery), it is susceptible to 

problems and injuries. The patient mostly suffers from „anterior knee pain“. The 

most common diseases are the plica symptom (pain), habitual- or traumatic patella 

luxation, and cartilage-bone damages at patella and its sliding bearing. 

Femur sliding bearing 

Fig. 1: 

Patella / Femur sliding bearing 

Plica Syndrome 

Patella 

Here, enlarged synovial folds and thickened synovial membranes might, due to 

repeated impactions, cause pain or even changes to the free movement of the 

patella. This could result in uneven- or excessive loading and with this in damages 

of the cartilage of the knee-cap. If conservative therapy is not sufficient, the plica 

may be removed arthoscopically. 


Ellenbogen Knee 

33

Femur 

Patella 

Fig. 2: 

Outer capsule: patella lateralization 


Habitual- or Traumatic Patella Luxation 

A distinction is made between congenital disorder and acute injuries when having 

had an accident. The habitual patella (sub) luxation occurs congenitally and instability 

of knee-cap is due to shallow tracks or weak ligaments and muscles to hold 

the kee-cap and knee joint capsule. With the traumatic patella luxation instability 

is usually the result of an accident (luxation towards the outside). 

Conservative Therapy 

Depending on severity of the knee deviation, a conservative treatment approach 

can be carried out first. Exercises shall train the vastus medialis muscle regarding leg 

extension. Important is cooperation of the patient as treatment can only be successful 

when exercises are consequently being carried out for at least 3-6 months. Longer 

periods of immobilization and leg rest, however, should be avoided in any case. 

Surgical Treatment of Habitual Patella Luxation 

In case that conservative treatment alone is not enough, operative measures have to 

be considered. Depending on cause and detected damages correcting surgery may 

be necessary. Lateral release (fig. 2+3) and/or medial tightening (fig. 4) are treatment 

options. Another option for treatment of cartilage damages of the knee-cap or 

osseous knee-cap luxation may be to transfer piece of the lower leg bone inwards. 

Here, the attachment of the patellar ligament at the tibia is detached from the 

bone, and reattached with screws about 1-2 cm further inside. Should the damage 

be caused by thigh problems, surgical correction of the hip joint may be necessary. 

Depending on the case, it makes sense to carry out supplemental cartilage therapies 

and/or a combination of the treatment methods described above. 

Patella 

capsule cut 

Fig. 3: 

Outer capsule after lateral release 

knee arthroscopy 

(right) 

Fig. 4: 

Inner capsule: medial tightening 

34 



Surgical Treatment of Traumatic Patella Luxation 

In some cases, when only the joint capsule has been torn by the traumatic patella 

luxation and caused a haematoma within the knee, an arthroscopic knee washout 

can be sufficient to prepare the knee for conservative treatment. Operative methods 

are needed for cracked cartilages or torn medial patellofemoral ligaments (MPFL). 

Most often, the cracked-off cartilage-bone fragment can be reattached through 

a small insicion, using bioabsorbable anchors. A suture of the cartilage capsule 

can also be treated with this arthroscopic method. Replacement of a torn MPFL is 

biomechanically necessary for restoring the patella function and carried out with 

the patient’s own tendon material from the inner side of the thigh. Similar to ACL 

reconstruction, the method of choice is minimally-invasive surgery. 

Aftercare 

During aftercare the patient can put full weight onto the straight leg after 2-3 weeks, 

squatting or climbing stairs is possible after 5-6 weeks. At this time, an intensive 

muscle training shall be started to strengthen the especially quick weakening vastus 

medialis muscle. 

Spontaneous Cartilage-Bone Lesions (osteochondrosis 

dissecans) 

There are cases where the area around the patella and its sliding bearing is not sufficiently 

supplied with blood and begins to die. At an advanced stage, the cartilage 

lying above is also destroyed. 

Therapy 

Initial treatment depends on the stage and is conservative in most cases. Rest, no 

sporting activities and anti-inflammatory medication may be necessary for pain relief. 

If X-ray or MRI examinations show progress of the disease, small holes should be 

drilled surgically into the center of inflammation to stimulate vascularization and 

healing. This is called antegrade- or retrograde drilling. In some cases, dead tissue 

has to be removed before it comes loose and becomes a “joint mouse”. This would 

cause further cartilage damage to still healthy sections of the joint. Afterwards, the 

bone lying below is also surgically drilled in order to stimulate vascularization and 

regeneration of cartilage tissue. In recent years, we have increasingly become able 

to successfully treat such disorders with bone-cartilage transplants (mosaic plastics, 

see chapter arthrosis). 



35

Fig. 1: 

Knee joint damaged by arthrosis 


grade I 

grade II 

grade III 

grade IV 

Fig. 2: 

Schemed image of arthrosis 

grades of severity 


Arthrosis 

How does a normal joint actually work? 

Generally spoken, a joint movably connects the ends of two bones. To avoid these 

rough bones rubbing against each other directly, these contact surfaces are covered 

with an approx. 3-4 cm thick layer of cartilage (fig. 1). This layer is extremely 

smooth, reduces friction within the joint (lower than two smoth ice surfaces against 

each other) and elastically absorbs shocks when walking. These special mechanical 

characteristics are maintained by complicated biochemical, molecular and electrophysiological 

connections and require an intact closed surface and a stable collagen 

fiber network. This complex “composite material” is produced and controlled by 

cartilage cells (chondrocytes). Disorders can be of mechanical kind (sudden physical 

force such as the impact experienced in a car accident, high grade sprains, chronic 

overweight, varus/valgus malalignment, cruciate ligament instabilities, lacking menisci) 

or of biomechanical kind (metabolic diseases, rheumatism, gout, calcification, 

circulatory disorder). Several facts are here ensured: so does reasonable endurance 

sport, marathon runners included, not increase danger of arthrosis, whereas the 

varus/valgus alignment especially in combination with meniscus damage, radical 

meniscus surgery and/or overweight poses a significant risk of arthritis. 

Cartilage damage is divided into four different levels of severity: 

1. stage: slight superficial fibrillation 

2. stage: deeper tear and large surface fibrillations 

3. stage: deeper defect (to the bone) with strong fibrillation, mechanically not 

acceptable 

4. stage: exposed bone 

Traumatogenic Cartilage Damages 

When twisting one’s knee or incurring a contusion as a result of an accident (skiing, 

playing football etc.) a piece of cartilage (diameter approx. 1-2 cm) may crack off 

the complete cartilage layer. Surrounding edges are intact and of normal height, the 

bone below is unaffected and shows good regenerative ability. This kind of damages 

responds well to all treatment methods mentioned in the following. 

Degenerative Wear 

Less positive are prospects for cartilage damages developed during one’s lifetime 

by monotonous stress alone or in conjunction with varus- or valgus deformity, gout, 

rheumatism, or damages to menisci or cruciate ligaments. These damages soften the 

cartilage (1. stage) and later result in fibrillation of the complete layer (2. stage). 

In stage 2-3, the cartilage layer is only half as thick as normal and extremely frayed 

and there may occur detached or loose fragments of cartilage. 

This stage can no longer be repaired by the body itself without outside help. Specialists 

already talk of severe cartilage damage even though pain may still be bearable 

for the patient and thus is not perceived as warning signal. Especially this early stage 

of progressive cartilage degeneration though offers good prospects of successful 

cartilage surgery. Unfortunately, many patients wait too long. 

36 


Arthrosis 

In the final stage (4. stage) the cartilage tissue is completely destroyed, the „tyre 

tread“ completely gone. Bone grinds on bone, grooves develop and osseous overhangs 

make stretching the leg increasingly difficult. Varus- and valgus deformities 

increase. Even modern surgical measures for cartilage reconstruction are only limitedly 

successful in this stage. Real hyaline cartilage cannot regenerate. The only thing an 

orthopaedic surgeon can do is facilitating growth of replacement- and fiber cartilage 

and help improving its quality and strenght, or carry out time-consuming cell 

culture and transplantations which, however, are still quite limited in their range 

of application. 

Basically it can be said that once cartilage damage has begun, the wearing process 

will continue with increasing speed, and without early therapeutic intervention, 

freedom from pain can only be achieved by implanting artificial joint prostheses. 

Treatment of Arthrosis 

Method of treatment depends on cause and severity of the disease. With instruments 

for arthroscopic surgery we are not only able to see the cartilage damage and record 

it for later documentation; we can also very gently treat the damage by means of 

these micro-instruments at the same time. 

Debridement 

Frayed edges are removed with a mini cutter and the surface is smoothed. Instable 

cartilage parts are removed to prevent further fraying. 

At the same time meniscus damages are being repaired whereby, in an early stage, 

suturing the meniscus should be the preferred treatment method. In some cases, it 

makes sense to remove part of the synovial membrane to reduce risk of contusions 

within the joint. 

Methods of Cartilage Regeneration (stem cell 

techniques) 

They base on “migration” of bone marrow stem cells into damaged cartilage areas 

where they develop into replacement cartilages. 

Thus, having a case of half-thickness cartilage defect with furthermore severe fraying, 

there is still a possibility to stimulate the body’s own cartilage repair. For the first 

3-4 years, this replacement cartilage is relatively rich in cells and does not consist of 

as many cartilage cells (chondrocytes) which produce synovial fluid. Furthermore, it 

can not stand as much mechanical load as original hyaline-cartilage and therefore 

often causes knee irritations and knee pain. However, this replacement cartilage 

(fibrocartilage) is still better than a completely exposed bone. Just compare this 

damage for example with a burn injury: the skin is wrinkled, less elastic, sensitive 

to injury, does not get a tan and is hairless - but it is far better than having a permanently 

open wound. 

There are clear indications that in most cases (unfortunately not always) replacement 

cartilage develops into better load-resistant hyaline-cartilage after several years. 



37

Arthrosis 

“Microfracture Technique” (according to Steadman) 

Operative beginnings of surgical refreshing of cartilage date back to the 50’s (Pridie 

drillings). Here, several holes of about 2 mm are sieve-like drilled into the exposed 

surface of the bone. With this, small “islands of regeneration” are created, but only 

in few cases a continuing cartilaginous scar tissue. Nowadays, we prefer the less 

traumatizing “microfracture technique” according to Steadman which has been 

developed in the early 90s (fig. 3+4). 

The bone surface is pierced with a fine awl to create hairline cracks and tiny holes, 

resulting in a stronger cartilaginous scar tissue to cover the entire affected area. 

Just imagine grass seeds on trodden down and dry soil: without previously breaking 

up the ground, the seed would have no chance to take root. After sowing the seeds, 

it is not allowed to walk on the lawn for some time to protect it. The same applies 

to a joint: piercing the bone loosens the bony surface and enables bone marrow 

stem cells to seep out and potential blood stem cells to settle. And to protect this 

sensitive area, it is necessary to walk on crutches at the beginning. 

Fig. 3: 

Grade IV cartilage damage at the knee, 

treatment with micro fracture 

Fig. 4: 

Cartilage repair 1 year after micro fracture 

Abrasion Arthroplasty (according to L. L. Johnson) 

If parts of the bone are already exposed (4. stage), one treatment possibility is to 

debride and smooth the remaining bone and wait for improvement. But there is also 

a chance of helping the body filling bald areas with new cartilage-like scar tissue 

again – and results can be as good as after treatment with microfracture technique. 

We just refresh the exposed, extremely hardened surface of the bone with small 

cutters, as developed by L. Jonson in the early 80’s. 

38 


Arthrosis 

Different Methods of Cartilage Transplantation 

Cartilage-Bone Transplantation (OATS and mosaic plastics) 

Small cartilage-bone cylinder-shaped pieces are removed from knee areas with lower 

physical load and fit into prepared holes in the defective area. Advantage: this 

method creates immediately functioning hyaline cartilage for the defective area 

and healing is very fast thanks to the “press-fitted” bony cylinders. Furthermore, 

expenses are rather limited. However, this method is technically demanding and 

requires a high degree of surgical expertise and experience, especially when being 

carried out arthroscopically. 

Fig. 5: 

Mosaic plastics at femoral condyle of knee joint 

Fig. 6: 

Mosaic plastics at knee joint 

Thus, although seen as routine surgery on knee joint and ankle, it is still not recommendable 

for shoulder and hip. 

Specific demands of ankle surgery: the typical cartilage-bone defect is situated 

behind the inner ankle, inaccessible from the front. Thus, the inner ankle has to be 

detached first to be able to press the donor-cylinder extracted from the knee (the 

ankle joint does not have enough cartilage tissue to create a transplant) into the 

defect of the talus, and then screwed back in afterwards. 

Problems finding donor sites arise in about 10% of all cases when 1-2 donor cylinders 

shall be extracted. Therefore, the amount of donor cylinders is limited. There 

exist artificial, absorbable plugs with cartilage-like characteristics (Trufit®, fig. 7), 

which have proven to be very successful in filling up these donor-holes. In some 

cases, smaller defects (also at ankle joint) can be treated with such absorbable plugs 

immediately. After 1-2 years these plugs are replaced by the body’s own bone-, 

cartilage- and connective tissue cells. 

Cartilage Cell Cultivation = Autologous Chondrocyte Transplantation 

ACT 

This method caused quite a stir in the media in the mid 1990’s. In a first operation, 

several cartilage particles are removed from the knee joint, propagated in a complex 

cell culture and finally implanted in the defective area in a second surgical procedure. 

The new cells have to grow and propagate further cells for a new cartilaginous structure 

– a very complex process that requires strict adherence to Aftercare guidelines 

given; that may include walking on crutches for 8-10 weeks. During this time, enough 

exercise with a continuous passive motion device (4-6 weeks, 4-6 hours each day) 


Fig. 7: 

Scheme of resorbable Trufit ® dowel 


39

Arthrosis 

as after microfracture treatment is necessary, respectively strongly recommended 

by us. With this exercise, formation of a good and stable new cartilage surface is 

essentially supported (see below). 

In some cases, after verification of the diagnosis and indication, approval of cost 

transfer has to be obtained from the health insurance company first before cell 

removal and transplantation afterwards can be carried out. Thus, bureaucracy sometimes 

makes 3 surgical steps necessary. 

And costs are high; the cultivation of new cells in a laboratory alone costs 4.500.00 

– 8.000.00 Euros – and is covered from public health insurance companies only for 

part of the patients. Furthermore, operation technique is very demanding and may 

require a second surgical procedure, let alone the arthroscopically controlled check 

after 1-2 years. 

All these methods can help rebuilding the attacked or worn cartilage layer of the 

joint. However, this can only be successful if any possible causal disturbance factor 

has been eliminated: 

• Meniscal lesions have to be smoothed or even better sutured. Meniscus transplantations 

are so far not available for wider clinical usage. 

• Ligament instabilities have to be eliminated, especially the anterior cruciate 

ligament (ACL) has to be sufficiently stable. 

• Leg axes need to be straight (see chapter varus/valgus malalignment). 

• Overweight shall consequently be reduced until a bodymass index of less than 25 

is reached. This is done by reducing food intake and starting sporting activities 

(at the beginning in the water). 

Aftercare for joint-preserving Arthrosis Treatment 

See chapter varus/valgus malalignment page 46. 

40 


Arthrosis 

Results 

Until today, there unfortunately has not been found any general patent remedy 

for the advanced stage of the degenerative joint disease – except for artificial joint 

reconstruction which should be delayed as long as possible. With treatment by continuous 

passive exercise the Canadian R. Salter achieved excellent results already in 

1984 (in an animal experiment with a 6 weeks continuous training even in cases of 

severe joint damage). Of course, on the one hand, a human patient cannot be tied 

to a motion device for 6 weeks, and on the other hand many diseases heal much 

faster and better with animals than with humans. However, we think that this aftercare 

concept is a revolutionary method for the future. 

Our experiences with abrasion arthroplasty for arthrosis treatment – whether with 

or without continuous passive motion - date back to its beginnings in Germany 

in 1984. In own tests carried out during aftercare we can, similar to the American 

studies, achieve good and satisfying results in about 60-70%. Please consider that 

without any treatment constant worsening of joint functions has to be expected. 

Supportive Medication Therapy 

Injections with hyaluronic acid have shown to be successful in improving joint lubrication, 

and we at the ARCUS Clinisc are very proud to have actively contributet to 

the launch of hyaluronic acid in Germany in the early 90’s. A step that has proven 

to be successful in the long term. In extensive studies, hyaluronic acid has mainly 

been proven positive. Generally, a series of 3 to 5 injections is recommended (at the 

price of approx. 230 euros each/status 2009). Unfortunately, neither public health 

insurance companies nor the employers’ liability insurance association are willing 

to pay for this treatment so far; the patient is yet again self-payer. 

In order to support cartilage repair, we recommend an additional long-term therapy 

with cartilage builders glucosamine and chondroitin (e.g. 3x1 capsule ARTROSTAR ®). 

This combination of approx. 1500 mg glucosamine and approx. 1200 mg chondroitin 

sulfate per day is commonly regarded as supportive cartilage therapy. International 

studies and in the meantime working groups in Germany as well are proving the 

anti-inflammatory- and cartilage supporting characteristics of these substances 

which furthermore are free of unpleasant gastrointestinal side effects such as the 

for cartilage unfavorable NSAR. A capsule of ARTROSTAR ® contains 500 mg glucosamine 

HCL and 400 mg chondroitin sulfate. Unfortunately, public health insurance 

companies do not pay for this treatment. Positive effects of homeopathic medicines 

such as Zeel® or Ney Arthros® are much less proven and only a few treatments are 

normally not suitable as therapy approach. 



41

Arthrosis 

Exercise Therapy 

The best thing you can do for your joint is to have plenty of exercise while avoiding 

overexertion, e.g. by loosing weight, wearing well-padded shoes in the initial phase, 

avoiding long walks/runs on hard surfaces such as asphalt etc. Train your muscles 

with slowly increasing endurance sports. Suitable are “soft straightforward sports” 

such as cycling, walking, Nordic walking and swimming. 

New Physiotherapy Options: 

• Aqua jogging which enables intensive circulatory- and muscular training without 

overloading the affected knee. 

• Reflective muscle training with the whole body vibrator type Galileo. The patient 

stands on a plate vibrating with about 40 Hz what is automatically balanced by 

the muscles. This has already been proven to be an effective training method for 

muscles and bones. We are currently investigating positive effects on cartilage 

regeneration after the surgical procedures mentioned above. 

Tips for Further Improvement of Treatment Success: 

• Stick to the period of no or restricted weight-bearing given by us. 

• Move your joint as intensively as possible without overloading it. 

• Make use of the advantages of hyaluronic acid injections for the affected joint: 

start first series 3 weeks after surgery; repeat after 6-12 months. 

• Work consequently on weight reduction. Even a few kilograms less add up with 

2-3 million steps per year as a knee-, ankle- or hip joint is loaded with the 2 to 

5 fold of body weight; depending on height of step. 

• Drink enough water (instead of coffee or soft drinks) so that body and cartilage 

do not become dehydrated and with this brittle and prone to injuries. 

• Train your joints according to a varied program: 

- In the initial build-up phase, about 2-6 months after surgery soft, we recommend 

guided movements without transmitting the load of body weight such 

as cycling or water training. Then slowly start with walking / Nordic walking 

e.g. also combined with special training shoes (MBT-shoes). 

- Later you can add a mixture of cross-training, running (at the beginning on 

hard ground, then cross-country), as well as total body exercise in the gym. 

• Accept that not every joint affected by arthrosis can regain its former sporting 

ability. 

• Keep to the follow-up appointments stipulated. 

• Make use of our offer for an arthroscopic check about 1 year after surgery. 

• Please consider that without any treatment constant worsening of joint functions 

has to be expected. 

42 


Arthrosis 


Ellenbogen Knee

Fig. 2: 

Minimally invasive Achilles tendon 

suture 

Fig. 3: 

Injection of body-own growth factors 

(PRP) 

Ortho-Biologie 

Modern Therapy Methods in Orthopaedics / Trauma 

Surgery 

Tissue Regeneration Principles 

Different types of human tissue need different time periods for regeneration. An 

injury of the oral mucosa for example heals completely within a few days, muscle 

injuries need 3-4 weeks, bones usually 6-12 weeks. 

It has been known for some time now, that any information needed for the formation 

of new tissue cells lies in these cells and in-between areas as well as to a large 

extent within the platelets. 

Fig. 1: 

Development of stem cell into bone cell. Besides correct surrounding conditions (type of surrounding 

tissue, pressure, exercise, rest, chemical composition of surrounding etc.) availability of several different 

growth factors at the perfect time and in the optimal concentration are necessary. 

Bone Growth Factors: 

Research to this topic dates back until far into the 80’s, and since the mid-90’s, concentrates 

of such collagenous bone growth factors, gained of animal bone extract, 

are allowed as preparation and for clinical use. In 1997, the ARCUS Clinics have been 

one of the first orthopaedic specialist units to officially use these bone growth factors, 

and since then has been treating hundreds of bone defects that do not normally 

heal very successfully. Particularly suitable is this material for very problematic bone 

healing processes with infections (infected pseudo-arthrosis). 

Besides such concentrates which provide a huge number of bone growth factors 

in the perfect mixture ratio quasi as seed capital for bone healing, there are also 

treatment possibilities with isolated special factors (e.g. BMP7). However, they have 

to be given in a local overdose what may increase possible unwanted side effects. 

Growth Factors of Platelets PRP (Platelet Rich Plasma) 

In recent years, treatment with the body’s own growth factors - 10 to 60 ml of the 

patient’s own blood which is specially prepared and centrifuged – has become more 

and more popular. Here, growth factors within the platelets are enriched and the 

liquid gained (several milliliters) is given into the areas with low healing tendency 

(e.g. Achilles tendon- or meniscus suture). And there are also many cases in which 

artificial bone material is saturated with those factors to fill bone defects. The 

advantage is improvement of healing free of side effects, especially in cases with 

unfavorable conditions. Another new treatment method is injecting the patient’s 

own factors directly into the affected area. When using this method at the Achilles 

tendon, the patient is with suitable orthotic shoe inlays capable of walking already 

after 4-5 weeks thanks to good healing acceleration. 

44 


Ortho-Biologie 

Support of Cartilage Repair 

Real regrowth of original cartilage substance is still a dream. But nevertheless we 

have learned a lot about cartilage reconstruction (fibrous cartilage) and how it can 

be improved to become a more stable long-term scar. Besides operative requirements, 

injection therapy with hyaluronic acid has become an important factor. It does not 

only reduce friction (with “synovial fluid”) but affected cartilage cells are also provided 

an immediately functioning basic frame for formation of cartilage as “composite 

material”. Furthermore, hyaluronic acid icreases, and that is very important, 

the water-binding capacity of the attacked and frayed cartilage. It becomes more 

elastic and nutrition of cartilage cells is improved by the water flowing in and out 

with every step. More water molecules in turn increase the piezoelectric effect to 

which the biological meaning of stimulation of cartilage metabolism is attributed. 

There is enough literature available about the positive effects of hyaluronic acid 

therapy. It is no coincidence that more and more orthopaedists and surgeons recommend 

this therapy. They daily experience patients which achieve an improvement 

of their symptoms - in some cases already after the third injection - and that 

this condition lasts for 6-12 months (after a therapy of only 3-5 injections). That is 

incredibly much longer than the pure biochemical half-life of molecules within a 

joint which in most cases is 1-3 days. 

Unfortunately, decision-making committees of public insurance companies refer 

to the few neutral or negative studies (which can be found on every scientifically 

discussed problem) and the current situation is: self-payer status. 

Costs 

Our surgeons at the ARCUS Clinics are highly qualified specialists which always 

offer the latest state-of-the-art surgical techniques, as far as they have proven to 

be successful. To what extent health insurance companies are willing to pay for the 

respective treatments however, has to be checked in each individual case. Unfortunately 

we cannot give any generally binding statement as to how one or another 

medical progress will be reflected in cost transfer of public- or private health insurance 

companies in the future. 

We care about your health. Therefore we will always offer you the most promising 

treatment options; regardless of the cost situation. In a personal interview we will 

see which treatment option suits you and your needs. We will always be at your 

disposal to inform you about minimally necessary measures, the recommended 

therapy and an optimal, comprehensive and holistic treatment. 



45

Knee Malalignment (varus-/valgus 

malalignment) 

Transposition Osteotomy for Treatment of Knee 

Malalignments 

Normally the leg axis should be straight. Small deviations into bandy-leg (mostly 

men) or knock-knees (mostly women) are not regarded as disease. Problematic however 

are bigger deviations as well as partial meniscectomy, chronical instability (old 

cruciate ligament rupture) and continuing knee overload e.g. through ball games, 

tennis, intensive skiing etc.. 

Conservative Treatment Options 

• Reduction of knee load by changing to more gentle sports (e.g. swimming, cycling, 

walking, training in gym etc.). This also includes reasonable muscle- and 

coordination training. In many cases, elastic joint bandages can help improving 

perception of joint movements (proprioception). 

• Reduction of body weight (what you always wanted to do). 

• Marginal elevations on shoe soles. 

• Focused walking instructions after walking analysis and provision of inlays if 

necessary. 

• Hyaluronic acid injections into arthritis joint (in the meantime proven successful 

and by specialists approved). Or injection of the body’s own growth factors (first 

results are positive). These modern biological treatment methods however, are 

so far not covered by public health insurance companies. 

• Regular intake of a combination of glucosamin- and chondroitin capsules. They 

contain elements of the bone matrix, are favored particularly in the USA, and 

are said to have the same pain reducing effect than usual rheumatism medicines 

(e.g. Diclofenac), but without side effects. Recommended is a daily dosage of 

1500 mg glucosamine and 1200 mg chondroitin. 

Surgical Treatment Options 

In the case of severe symptoms, serious leg axis deformities or high sporting activity, 

anatomic correction of the knee malalignment should be discussed in order to delay 

the time of knee joint prosthesis. Such correcting measures will furthermore support 

the conservative therapy options mentioned above to be successful. The typical age 

is between 30 and 60 years. Beyond this age, the recovery rate of 80% will decrease 

considerably and an artificial knee joint (knee resurfacing) will certainly be of more 

help to the patient. 

Treating a varus deformity the most common method is opening up the inner side, 

or removing a v-shaped piece of bone on the outer side of the shinbone head. Correction 

of a valgus deformity is carried out just above the knee joint. In both cases, 

the bone is carefully severed and then precisely positioned to be fixed again with 

metal clamps or screws until healing of this artificially created “fracture”. By using 

46 



malalignment) 

so-called stably-angled plates and screws the healing process has considerably been 

improved in recent years: 

• reduced pain 

• improved mobility 

• possibility of a reliable healing rate. 

Such treatments can normally be combined with cartilage regeneration- or cartilage 

transplantation procedures. All metal parts used are removed after 1 year when 

carrying out an arthroscopically controlled check. Insufficiently healed cartilage can 

immediately be treated again. 

Even if it seems to be a serious surgical treatment: these correction measures heal 

faster than cartilage within the knee joint as it needs time for creation of a new 

cartilage layer, the so-called “bioprosthesis”. By combining all these surgical therapy 

methods (operative refreshment of arthrosis and cartilage transplantation if necessary, 

correcting measures for knee deformities, cartilage supportive hyaluronic injections) 

it is today in fact possible to stimulate regrowth of new stable cartilage tissue. 

Fig. 1: 

Bow-leg deformity with singlesided 

wear of inner joint space 

Fig. 3: 

Stably-angled spread-up correction 

of bow-legged lower leg 

Fig. 4: 

Stably-angled spread-up correction 

at thigh 

Aftercare for joint-preserving Arthrosis Treatment: 

Depending on severity and extent of the arthrosis, walking on forearm crutches to 

keep pressure off the affected area might be necessary for up to 10 weeks. During 

the first 4-6 weeks, only a “heel-to-toe” movement of the foot with a load of not 

more than 5 kg is permitted; during the following 2-6 weeks about 20 kg (walking 

on crutches is still necessary). In this period in some cases even driving is possible. 

Cars with automatic transmission can be driven much earlier with operated left knee 

joint. For the whole time though, you should move your joint as much as possible. 

Therefore we prescribe use of a continuous passive motion device. The more often 

you use this device (at least 4 hours per day and additionally 2-3 hours at night) the 

better the result (proven by numerous studies). 


Fig. 2: 

X-ray image of whole leg with 

planning scheme for determination 

of correction angle 


47


malalignment) 

Should your joint react with swelling and pain after these 8-10 weeks of careful 

rehabilitation training, it is still not ready to carry your whole body weight. Another 

phase without too much pressure, further medication and external treatment measures 

such as radiotherapy and ointment bandages is inevitable. Please don’t give 

up in this hard time, as after 3-6 months (in rare cases up to 9 months) noticeable 

and lasting improvement, even in cases with severe arthrosis, will show up. 

Until today, there unfortunately has not been found any general patent remedy 

for the advanced stage of the degenerative joint disease – except for artificial joint 

reconstruction which should be delayed as long as possible. Please consider that 

without any treatment constant worsening of joint functions has to be expected. 

Hochleistungsdisziplin Kniegelenk 

Wir haben unsere Implantate für die arthroskopische Sportmedizin 

entwickelt. Die hohen Ansprüche von Patienten aus dem Leistungssport 

mit Kreuzband- und Meniskusverletzungen sind unser Maßstab 

für anatomische Präzision, komplikationsfreie Einheilungsprozesse 

und Haltbarkeit auch bei extremer Beanspruchung des Gelenks. 

Unser Beitrag zu uneingeschränkter Bewegungsfreiheit – 

auch für Nichtleistungssportler. 

Smith &Nephew GmbH 

Mendelssohnstraße 15d 

22761 Hamburg · Deutschland 

Tel. +49 (0)40 70 700 - 0 

Fax +49 (0)40 70 700 - 201 

endo.hamburg@smith-nephew.com 

www.smith-nephew.de 

48 


Knee Endoprosthetics 


Arthrosis stands for the degenerative wear of joint partners rubbing against each 

other (cartilage wear). Healthy joints are covered with a cartilage layer in order to 

improve sliding properties. However, there are cases when these joint surfaces are 

such worn, that the underlying bone surfaces are in direct contact and there is no 

more chance for improvement by arthroscopic cartilage shaving (joint arthroscopy) 

or osseous joint transposition. Here, artificial replacement of the joint is in most 

cases a reasonable alternative to joint reconstruction. Major aim is long-lastingly 

reduce pain and rebuild the patient’s physical activity. 

Already more than hundred years ago there have been made attempts to artificially 

replace painful joints. First successes were achieved in the 60’s and many prostheses 

of this time had a long life-time. Since then, the number of artificial joints implanted 

has continuously increased. Today, more than 300 000 hip- and knee joints are 

successfully used every year in Germany. Thanks to the good results of the last decades, 

artificial shoulder joint replacement is experiencing a growing number too. 

This artificial joint is a so-called endoprosthesis (Greek: endo-inside) and is often 

also called total endoprosthesis as both joint segments are replaced by an artificial 

surface respectively an artificial joint partner. In case that only one joint segment is 

replaced, it is called hemi-endoprosthesis. This form is sometimes used for treatment 

of shoulder fractures. At hip- and knee joint however, always both parts of the joint 

are replaced as they carry the whole body weight and a hemi-prosthesis does not 

ensure sufficient pain reduction. 

Of course there are also risks with endoprosthetics as it is a complex and challenging 

surgical procedure. Nowadays, implanting an artificial joint replacement is a routine 

operation but possible complications such as inflammation, thrombosis (blood clots) 

or damage of surrounding structures (nerves and vessels) cannot be excluded. Therefore, 

such surgical treatment should only be carried out in specialized units which 

have sufficient experiences with of artificial joint replacement. As parts of the joint 

are replaced by metal implants, loosening of the prosthesis can happen in the long 

term. However, a lifespan of more than 25 years is possible with hip prostheses. This 

depends on the one hand on the implants and the anchoring technique used, but 

on the other hand also on the surgeon and its experience. 

Used materials correspond to highest demands. They shall ensure highest sliding 

properties with minimal friction and at the same time have the lowest wearing effect 

as possible. Therefore, they are adjusted to each other perfectly and selected 

accordingly. Today, the most common materials used are: metal alloys (titanium- 

and cobalt-chromium-alloys), plastics (polyethylene) and ceramics (aluminium- or 

zirconium oxide). 


Ellenbogen Knee

Fig. 1: 

Unicompartmental patellofemoral replacement 



Anatomy and Functions 

The biggest human joint is the movable connection between femur and tibia and 

consists of three parts: an inside and an outside section of the joint between the 

femur and the tibia (femorotibial joint), in between in the joint gap the menisci, 

and the third part which lies between patella (kneecap) and thigh bone (patellofemoral 

joint). 

All parts of the joint are covered with a cartilaginous layer and are enclosed in a 

common joint capsule. The synovial membrane produces a liquid that nurtures the 

cartilage wich has together with the menisci a shock absorbing effect. Ligament 

structures between the bones stabilize the joint (e.g. cruciate- and collateral ligaments); 

muscles and tendons ensure movability of the joint (primarily straightening 

and bending). With bent knees, small rotational movements are also possible. 

Fig. 2: 

Bicompartmental partial replacement 


Knee Joint Arthrosis (gonarthrosis) 

Fig. 3: 

Total knee endoprosthesis 


Most common reason for a knee joint disease is cartilage wear (arthrosis), which is 

mainly caused by leg axis deformities (varus- or valgus malalignment). Moreover, 

gonarthrosis may occur as the consequence of injuries, rheumatic- and metabolic 

disorders as well as deformities. 

Loss of cartilage results in increasing stiffening and deformation of the joint, whereby 

stretching is in most cases the first movement to be lost. Osseous overhangs 

(osteophytes) form which in some cases even can be felt through the skin. At the 

same time, the pain occurs; at the beginning only in association with initial movements 

or periods of stress, later also at night and at rest. This results in increasing 

reduction of walking distances and finally in limitation of the quality of life. 

Arthrosis can be seen in a normal X-ray image, whereby the narrowing of the joint 

cavity between femur and tibia is regarded as indirect sign of cartilage loss. Joint 

50 



surfaces are often destroyed and do not optimally fit together, and the leg axis becomes 

more and more deformed (bow-leg or knock-knee malposition). Moreover, 

the joint may swell due to the permanent irritation. 

Knee Joint Prosthesis: Material – Fixation - Durability 

If a joint maintaining therapy is not possible due to severity of the damage or 

because of the age of the patient, and all other conservative and surgical options 

(physiotherapy, painkillers, joint irrigation etc.) have been tried, a total knee replacement 

is necessary (TKR). 

Major aim of this surcigal procedure is a pain-free, stable and movable knee joint 

whereby the natural leg axis is restored. 

Operation techniques and implants which have been more and more improved over 

the last decades make this therapy method to one of the most common and most 

successful routine operations in orthopaedic surgery (with about 150 surgeries per 

year in Germany). 

The knee endoprostheses used these days are known as resurfacing implants as 

they only replace worn cartilage surfaces, while preserving the patient’s own knee 

ligament structures. Depending on the severity of the arthrosis, there are different 

types of prostheses which do only replace frayed parts of the joint and support 

healthy areas. 

Generally a distinction is made between the following types of 

prostheses: 

• Unicompartmental prostheses (fig. 1, 4, 5) (unicondylar sledge or patellofemoral 

replacement): the isolated replacement of only one joint segment requires the 

other segments to be affected only very slightly and the ligament structures to 

be intact. 

• Bicompartmental prostheses (fig. 2, 6) (mono- or bicondylar). 

1) Monocondylar prostheses only replace inner (medial) joint segments and the 

joint between patella and thigh. 

2) Bicondylar prostheses (TKR) replace joint surfaces of inner (medial) and outer 

(lateral) joint segments, while maintaining the patient’s own ligament structures 

as far as possible. The segments of thigh and lower leg are not mechanically 

linked with each other. In case that the ligament structures are damaged, a 

zylinder-shaped connection of both segments enables stabilization of the joint 

even without ligaments. Knee endoprostheses lying parallel to the bone which 

were formerly used very often, dispense preserving the patient’s own ligament 

structures under resection of large bone areas. Today, these prostheses are 

used only in exceptional cases. 

All prosthesis types are available in different sizes; by means of the pre-operative 

planning sketch, model size and fixation of the prosthesis are specified. Here, individual 

requirements such as age, gender, shape of bone, body weight etc., are 

taken into consideration. According to this planning, leg axes are measured and the 

prosthesis planned in its alignment. 



51

Fig. 4: 

Slide prosthesis, front view 


There exist different fixation techniques for implantations: The cemented TKR is 

regarded as the “gold standard” worldwide. Here, the implants are fixed to the 

bone with antibiotic cement. In rare cases, also the cement-free “press-fit” anchoring 

technique can be used. Depending on the fixation technique used, the components 

are either made of titanium or a chrome-cobalt alloy. As gliding support a polyethylene 

inlay is inserted between the replaced surfaces, which is either fixed to the basis 

plate or rotates and glides between the surfaces (mobile inlay). 

Regardless of the fixation type, a life-span of normally 12-15 years is expected. 

When being in a good physical condition, second surgery to change the prosthesis 

can be carried out at any time. Here, special prostheses are available for any stage 

of bone defects. 

Fig. 5: 

Slide prosthesis, side view 

Fig. 6: 

Total knee endoprosthesis 

Treatment prior to Surgery and Surgical Procedure 

Surgery is preceded by an in-depth patient interview, clinical and radiological examinations 

and detailed planning. Additionally, an internistic/anaesthesiological check 

including ECG, pulmonary function- and blood test is carried out. In most cases the 

operation is carried out using a tourniquet, and need for allogenic- or autologous 

blood can normally be excluded. The blood collected in the drainage during surgery 

can at the end be led back to the patient via a feedback system. Stationary 

(in-patient) admission usually takes place the day of surgery. 

Depending on the individual arrangement made, the operation is carried out under 

general anaesthesia or spinal anaesthesia. Access to the affected joint is conducted 

through an approx. 10 cm long incision at the front side of the knee. When having 

removed the destroyed joint surfaces with precision instruments, the prosthesis 

components are fixed to the femur and the tibia. Due to the general public opinion 

and own experiences, replacement of the posterior patella surface is only carried 

out in cases of severe damage. When having checked the artificial joint for mobility, 

the wound is closed layer by layer with insertion of drainage tubes. Finally, a control 

X-ray is taken after surgery. 

52 



Aftercare 

Joint replacement operations are exclusively carried out unter in-patient conditions. 

In order to ensure optimal success, early postoperative mobilization by means of 

physiotherapy is strongly recommended. Depending on the already mentioned 

techniques for implantation, in most cases immediate load on the operated leg is 

permitted. However, crutches have to be used for 4-6 weeks to protect the soft part 

tissue. For most patients, the stay in the clinic of about 7-10 days is followed by a 

3-week rehabilitation program. Within the scope of regular, outpatient check-ups 

at close intervals, the progress of the patient is documented and if necessary the 

mobilization therapy prolonged. 

Joint Replacement and Sports 

Having a severe knee joint arthrosis, noticeable limitation of physical activities has 

to be expected. When the symptoms are gone after joint replacement surgery, the 

desire for more sportive exercise certainly comes up again. Internationally there is a 

broad consensus that at least so-called “low-impact” sports such as cycling, swimming, 

sailing, diving, playing golf and bowling can be supported. Sports such as tennis, 

basket ball and skiing however, are only possible to a limited extent. Completely 

avoided shall be contact sports such as foot ball or hand ball. Recommendations 

for those different sports are also dependent on the patient’s performance level. 

As a rule of thumb it can be said that sports practiced prior to surgery are allowed 

afterwards as well. 



53

54 

Leben in Bewegung 

Die Zimmer Holdings Inc. ist das weltweit führende reine Orthopädie-Unternehmen in der 

Forschung, Entwicklung, Produktion und im Vertrieb von Implantaten der Wiederherstellungs- 

und Unfallchirurgie. Das Unternehmen entwickelt, produziert und vertreibt u.a. künstlichen 

Gelenk ersatz, Trauma- und Wirbelsäulenprodukte, Produkte zur biologischen Regeneration 

defekter Gelenke und Dentalimplantate. Zimmer besitzt Niederlassungen in 25 Ländern, beschäftigt 

über 7.700 Mitarbeiter und vertreibt Produkte und Technologien in mehr als 100 Ländern. 

Menschen erwarten von einem künstlichen 

Gelenk, dass sie sich damit 

wieder gut bewegen und aktiv am Leben 

teilnehmen können – und dass es 

möglichst lange hält. 

Zimmer entwickelt seit 75 Jahren Implantate, 

Werkstoffe und Operationsmethoden 

und kann Langzeitergebnisse 

von bis zu 25 Jahren vorweisen. Und wir 

forschen weiter: An weichteil schonenden 

minimalinvasiven Operationstechniken, 

immer individuelleren Lösungen und 

knochensparenden Implantaten für 

die Ansprüche jüngerer und aktiver 

Patienten. 

Zimmer Germany GmbH 

Merzhauser Straße 112 

DE-79100 Freiburg 

www.zimmergermany.de 

ZIM_Anz_Patient_d_185x135_neuer Text.indd 1 12.01.2009 14:58:23 Uhr 

Am Anfang steht immer die Idee. 

Warenzeichen von Smith & Nephew. 

Gemeinsam mit renommierten Ärzten und Wissenschaftlern 

schaffen wir in unseren Forschungseinrichtungen in der Schweiz, 

Großbritannien und Belgien neue Produktlösungen für die Orthopädie 

und Traumatologie. Die Schenkelhalsprothese NANOS oder das 

GENESIS II Kniesystem in Kombination mit dem innovativen Werkstoff 

OXINIUM sind beste Beispiele dafür. Wir von der neuen 

Smith & Nephew lassen kreative Visionen Realität 

werden – für die optimale Versorgung des Patienten. 

Smith & Nephew GmbH 

Orthopädie & Traumatologie 

Mainstraße 2 

D 45768 Marl 

T +49 (0)2365 91 81 0 

F +49 (0)2365 91 81 10 

info.marl@smith-nephew.com 


www.arthrose-info.com

Shoulder Impingement Syndrome 

Causes 

The shoulder joint is stabilized and moved mainly by the four tendons of the socalled 

rotator cuff. These tendons are situated in a narrow bony canal between the 

ball and the socket (acromion) which directly surrounds the shoulder joint. During 

the course of life, possible signs of wear can cause increasing narrowing of this 

canal what in turn may lead to painful inflammations of tendons and bursae. In 

advanced stages permanent damages of the rotator cuff may occur which lead to 

lasting painful movement restrictions of the shoulder joint. 

Signs and Symptoms 

Patients mostly complain of pain at night when lying on the shoulder or pain which 

occurs with spreading movements from a certain angle. This pain is due to compression 

of the rotator cuff and the bursae lying above between ball and socket. Mobility 

of the arm is in most cases painfully limited; sometimes occurs also loss of power. 

Diagnostics 

Examination and questioning of the patient give in most cases decisive indications 

to impingement. Besides this, bony changes which result in narrowing of the sliding 

canal of the supraspinatus tendon can be visualized by special x-ray images. In order 

to confirm this diagnose of tendon damage, sonography of the shoulder or a MRI 

are needed. 

Treatment 

In early stages freedom or at least reduction of pain can be achieved by simple 

measures such as: temporary rest (avoiding working overhead within the painful 

area, no carrying of weights with outstretched arms), medication with analgesic and 

decongestant effect, local ice- or heat treatment as well as special physiotherapy. 

However, if the painful condition continues even after several months of consequent 

treatment, or the diagnosed tendon damage is confirmed, surgical repair of 

the tendon and removal of the bony narrowing is recommended. In case that the 

tendon has only minor damages, enlargement of the bony narrowing is sufficient. 


Ellenbogen Shoulder

Shoulder Impingement Syndrome 

Surgical Treatment 

The first operation step is thorough assessment of the damage by arthroscopy. 

Further steps depend on the injuries detected during arthroscopy. Injured tendons 

can be treated through a small incision. In case that there is no obvious damage at 

the tendons, the only thing to do is grinding the bone edges at the acromion (socket) 

to reduce narrowing of the tendon gliding canal. Grinding the acromion is called 

acromioplasty and can be performed arthroscopically through two small incisions. 

After surgery, an in-patient stay of 1-2 days is necessary. If no operation of the tendon 

has been necessary, special rest of the operated shoulder is not needed. However, 

the shoulder joint should be treated with care for about 4-6 weeks. Informations 

about a special aftercare program you will receive from your ward physician. Pain 

limits always have to be respected, but supportive therapies such as decongestant 

medication and local ice-treatment are possible. 

Results and Risks 

With about 90% of the patients, complaints resolve within 3-6 months. In rare cases 

painful movement restriction of the arm remains. Operation-related risks such as 

infects, injuries to nerves and vessels occur rather infrequent. 

56 


Calcified Tendinitis of the Shoulder 

(tendinosis calcarea) 

Causes 



ball and the socket which directly surrounds the shoulder joint. During the course 

of life and often unnoticed at first may occur signs of wear, particularly with the 

supraspinatus tendon. This in turn can result in calcifications which also occur mostly 

with the supraspinatus tendon. These calcifications may lead to the so-called shoulder 

impingement syndrome (p. 55). 



occurs with spreading movements from a certain angle. In most cases mobility of the 

arm is painfully limited. Acute pain may also be an indirect indication for break-up 

of a calcium deposit. 

Diagnosis 

Examination and questioning of the patient offers in most cases the essential hint 

that leads to a disorder in the area of the rotator cuff. Diagnosed calcium deposits 

can then be confirmed by x-ray images and sonography. These measures also help 

to differentiate between a chronic stage or an acute stage with break-up of the 

calcium deposit. 

Treatment 

Generally speaking, calcium deposits can resolve spontaneously. Unfortunately, this 

involves in most cases considerable discomfort. Being in this stage the motto is “first 

wait and see”. By temporary rest, analgesic- and decongestant medication, and local 

treatment with ice or heat, pain can be eased and calcium resorption supported. 

However, if the pain continues unchanged over a longer period of time, and the 

calcium deposit remains on the x-ray images without any changes operative removal 

of the deposit is recommended. Alternatively, the calcium deposit can also be 

destroyed by shockwave therapy, but effectiveness of this method is not definitely 

proven so far. 


Ellenbogen Shoulder

Calcified Tendinitis of the Shoulder 

(tendinosis calcarea) 

Operation of Calcium Deposits within the Rotator Cuff 

First step of this operation is localizing the calcium deposit by means of arthoscopy. 

After longitudinal incision of the affected tendon, the calcium is removed with a 

spoon as completely as possible. Possible occurring bone edges which lead to compression 

of the affected tendon are grinded arthroscopically. In rare cases, when 

the deposit cannot be found during arthroscopy, a small incision is needed for calcium 

removal. Very often, complete removal is not possible, but a large part of the 

remaining calcium residues resolves little by little by itself. 

Aftercare 

After surgery, an in-patient stay of 1-2 days is necessary. Discomfort will not disappear 

immediately after surgery but slowly during the following weeks. Therefore, rest for 

4-6 weeks is recommended. Mobilization of the shoulder should be started carefully 

with the painfree area, and pain limits should strictly be respected. Aftercare can 

be supported by decongestant medication and local ice treatment. Convalescence 

of about 3-6 months should be expected until recovery of painfree functioning of 

the shoulder joint. In order to achieve good operation results, aftercare should be 

performed according to a previously defined schedule which is given to you by your 

ward physician. 


With about 90% of the patients, the surgery brings back a painfree situation. With 

incomplete removal of the calcium deposit, some discomfort may remain. Operationrelated 

risks such as infects or injuries to nerves and vessels occur rather infrequent. 

58 


Shoulder Luxation 

Causes 

The shoulder joint consists of a ball and a socket. Stabilization of the joint is ensured 

by the joint capsule, tendons and muscles as well as a cartilaginous ring (the socalled 

Labrum) which encloses the socket. Causes for shoulder dislocations can be of 

generic kind (e.g. too large capsule, loose ligament apparatus) or may be the result 

of injuries. Injuries of the shoulder may lead to tear of the labrum or the capsule or 

even to break-off of parts of the socket. This in turn can impair the stability of the 

shoulder joint in a way that repeated luxations occur, or that a painful movement 

restriction remains. 

Fig. 1: 

Fixation of torn labrum 


Diagnosis 

Examination and questioning of the patient in most cases give the decisive hint 

whether the shoulder joint is instable and therefore endangered by possible further 

luxations. Bony injuries have to be excluded by x-ray examination. With younger 

patients under 40, the most common diagnose is a torn labrum. This can be confirmed 

by sonographic or MRI examination. With patients over 40, most common 

injuries are injuries of the tendons surrounding the shoulder joint. These diagnoses 

can also be confirmed by sonography or MRI. 

Treatment 

Fig. 2: 

Complete fixation of labrum 


Luxations which are due to generic disorders are at first treated conservatively with 

muscle training to stabilize the joint. Operative treatment is only recommendable if 

this muscle training does not show any reduction of the luxation risk after at least 

one year of consequent therapy. With young, physically and professionally active 

patients where the luxation occurred after injury of the shoulder joint, operative 

treatment of the torn labrum or bony injury is preferred; of course after respective 

diagnostic and confirmation. With elderly patients it is often possible to wait and 

see what can be achieved by temporary rest and stabilizing muscle training, at least 


Ellenbogen Shoulder

Shoulder Luxation 

if an injury of the tendons could be excluded. Generally it can be said that therapy 

has to be planned individually for every patient. 

Surgical Stabilization of the Shoulder 

The first operation step is thorough assessment of the damage by arthroscopy. 

Further steps depend on the injuries detected during arthroscopy. In case that no 

severe capsule injuries are diagnosed, stabilization can be performed arthroscopically. 

However, should severe damages to the labrum and the capsule ligament apparatus 

be confirmed, open stabilization through an approx. 6 cm long incision at the front 

side of the shoulder joint is inevitable. Primary aim of the operation is to re-attach 

the torn labrum to the rim of the socket. Here, small metal dowels are used. If there 

are furthermore bony injuries at the rim of the socket, an additional piece of bone 

retracted from the iliac crest has to be screwed to the socket. 

Aftercare 

After surgery, an in-patient stay of about 2 days is necessary. In order to avoid repeated 

luxations of the shoulder joint, special aftercare is recommended. It includes 

conservative measures such as limitation of movement and consequent wearing of 

a shoulder sling for 6 weeks. Detailed information material is given to you by your 

ward physician. Furthermore, special muscle training as well as avoidance of overhead- 

and contact sports is necessary for about 4-6 months. 


With 90-95% of the patients stabilization can be regained. In rare cases, limitations 

to outward movements of the arm due to shortening of the joint capsule remain. 

Operation-related complications such as infects and injuries of nerves and vessels 

occur rather infrequent. 

60 


Rotator Cuff Damages 

Causes 



ball and the socket which directly surrounds the shoulder joint. During the course 

of life and often unnoticed at first may occur signs of wear, particularly with the 

supraspinatus tendon. In extreme cases a complete hole can develop in a tendon; 

and here, the supraspinatus tendon is the very often affected too. In many cases 

there already has been a damage to the tendon which first is detected after a fall 

or physical overload. Acute tendon ruptures occur rather infrequent. 

Fig. 3: 

Supraspinatus tendon defect 

(source: Zimmer Germany GmbH) 



occurs with spreading movements from a certain angle. This pain can radiate up 

to the hand and in most cases mobility of the arm is painfully limited. Sometimes 

there also is loss of power. 

Diagnosis 

Fig. 4: 

Supraspinatus tendon suture 


Examination and questioning of the patient in most cases give the decisive hint to 

a damage of the rotator cuff. Bony changes which lead to narrowing of the sliding 

canal of the rotator cuff can be detected by special x-ray images. Normally, a sonographic 

examination is enough to securely confirm the tendon damage; only in 

rare cases MRI is needed. 


Ellenbogen Shoulder

Rotator Cuff Damages 

Treatment 

With younger patients and with the rare acute injuries, surgery is recommended in 

order to re-attach the tendon to the bone and with this regain power and functionality. 

With elderly patients of more than 70 years, simple measures such as temporary 

rest, decongestant- and analgesic medication, local ice- or heat treatment as 

well as special physiotherapy can bring a painfree situation again. However, if an 

inacceptable and painful movement restriction remains even after several months 

of consequent therapy, repair of the tendon and removal of the bony entrapment 

should be done by surgical treatment. 

Surgical Treatment of Rotator Cuff Damages 

The first operation step is thorough assessment of the damage by arthroscopy. Further 

steps depend on the injuries detected during arthroscopy. The bony entrapment 

can be removed in arthroscopic or open surgery by grinding the narrowing bony 

edges. In most cases the tendon can be reattached to the bone through an about 

4 cm long incision. 

Aftercare 

After surgery, an in-patient stay of about 2-3 days is necessary. For optimal healing 

of the tendon in the bone, an abduction pillow has to be worn for 6 weeks. In order 

to achieve the best possible operation result, some long term aftercare instructions 

given to you by your ward physician should be objected. Physiotherapeutic treatment 

for example is necessary for about 6 months. For a good overall result the exercises 

learned during physiotherapy should be performed at home for further 3-6 months 

whereby the pain limit always has to be respected. Aftercare can be supported by 

decongestant medication and local ice treatment. 


With 80-90% of the patients, an almost painfree situation can be regained. Experiences 

show however, that functions and power are not essentially improved and 

that early stress or non-wearing of the abduction pillow can result in the sutured 

tendon tearing a second time. After surgery, movement restrictions or loss of power 

in the arm may remain. Operation-related risks such as infects or injuries to nerves 

and vessels occur rather infrequent. 

62 


Injuries and Arthrosis of the 

Acromioclavicular Joint (AC-joint) 

Causes 

The joint lying between the socket and the collarbone is called AC-joint. Falling 

onto the shoulder is often accompanied by ruptures of the joint ligaments. This 

can result in an upward dislocation of the collarbone. But the AC-joint can also be 

damaged in association with degenerative signs (arthrosis) which may occur when 

physically working hard. 


After ligament ruptures arises painful movement restriction of the shoulder joint, 

which fortunately recedes with 80% of the patients. Very often, patients also complain 

of pain at night when lying on the shoulder or pain which occurs with spreading 

movements from a certain angle. When palpating the joint, pain arises on pressure. 

In some cases after ligament ruptures, one can even see that the outer end of the 

collarbone points upwards. 

Fig. 5: 

Stabilization of AC-joint (source: Arthrex GmbH) 

Diagnosis 

Examination and questioning of the patient in most cases give the decisive indication 

of an AC-joint damage. With ligament ruptures, the outer end of the collarbone 

may visible and palpable point upwards and cause heavy pain. Bony changes can 

be visualized by focused x-ray images. With arthrosis, cause of discomfort respectively 

localization of the AC-joint as definite cause can be achieved by injecting an 

analgesic into the joint space. 

Treatment 

Fig. 6: 

Stabilization of AC-joint (source: Arthrex GmbH) 

Treatment of ligament ruptures of the AC-joint can be performed either conservatively 

or surgically. If surgical treatment is necessary depends on severity of the 

ligament rupture. Up to a grade III rupture we in most cases recommend conservative 

therapy first. That means resting the shoulder and avoiding weight stress and 


Ellenbogen Shoulder

Injuries and Arthrosis of the 

Acromioclavicular Joint (AC-joint) 

spreading movements over the horizontal level for about 6-8 weeks. Only in few 

cases there is absolute need for immediate operation. When having treated the 

ligament rupture conservatively and a painful movement restriction develops there 

are several operation methods to regain painfree mobility and correct position of 

the collarbone even after years. 

Pain which results from degenerative wear of the AC-joint can be eliminated by 

chiseling off the outer end of the collarbone. 

Operative Treatment 

In case of an isolated arthrosis of the AC-joint, the outer end of the collarbone is 

removed (approx. 7-10 mm). This can be done by arthroscopic surgery or open surgery 

through two small incisions. If the arthrosis results from a former injury with 

rupture of the joint ligaments, the outer end of the collarbone is removed (like with 

AC-arthroscopy) and the collarbone reattached in correct position with a body-own 

ligament which passes to the socket (there additionally may also be need for wires, 

screws or an artificial ligament). When operating ligament ruptures directly after 

the accident we mostly make use of temporary fixation of the collarbone by wires. 

They are removed in a second small operation 6-8 weeks later after healing of the 

ligament suture. 

Aftercare 

After surgery, an in-patient stay of about 2-3 days is necessary. Aftercare of AC-joint 

operations depends on the surgical method used. Removal of the outer end of the 

collarbone alone does not require special rest. When having stabilized the joint 

with ligaments, wire slings or screws, limitation to movement has to be objected 

for about 6-8 weeks to avoid avulsion of the ligaments or breakage of the metal 

implant. You will receive a special aftercare program from your ward physician. The 

pain limit always has to be respected. Aftercare can be supported by decongestant 

medication and local ice treatment. 


About 80% of the patients regain painfree mobility of the shoulder joint within 3-6 

months. After joint stabilization with metal implants, there is the danger of 20% 

of breakage or loosening of the metal as well as repeated upward dislocation of 

the outer end of the collarbone. Further operation-related risks which occur more 

often are wound healing disorders and infects. Injuries to nerves and vessels occur 

rather infrequent. 

64 


Collarbone Fracture (clavicle fracture) 

Collarbone fractures are often the result of a fall onto the shoulder. Especially affected 

are sportsmen who practice sports with higher risk of falling (cycling, skiing, 

playing football). 


Directly after falling heavy pain occurs in the area around the fracture. The shoulder 

joint can hardly be moved due to the severe pain. The mere weight of the arm 

hanging down triggers strong discomfort. Therefore patients use the healthy arm 

to hold the affected arm to the body. 

Diagnosis 

Most collarbone fractures are visible at first sight as the mostly extremely dislocated 

fragments of the collarbone lye directly under the skin. Palpation of the fracture is 

very painful; the bone ends grinding against each other can often be felt. For assessment 

of the fracture and further treatment planning, a special x-ray is necessary. 

Fig. 1: 

Collarbone fracture without 

dislocation that can heal without 

surgical treatment 

Treatment 

Fig. 2: 

Heavily dislocated collarbone fracture 

Fractures without or with slight dislocations can be treated by strictly resting the 

arm for 3-4 weeks. With strong professional or sportive shoulder strain as well as 

fractures with heavy dislocation or bone fragments which are lying on top of each 

other we definitely recommend operative treatment. This shortens duration of 

aftercare and normally offers better results. We prefer stabilization by means of a 

plate which is performed through an about 10 cm long incision directly over the 

affected area. During surgery, the bone fragments are moved back into the correct 

position and both fracture ends are stabilized with a metal- or titanium plate and 

at least 6 screws. 

Fig. 3: 

that has been stabilized by means of a metal plate 


Ellenbogen Shoulder

Collarbone Fracture (clavicle fracture) 

Fig. 4: 

Fracture at the external end of the 

collarbone 

Aftercare 

Fig. 5: 

A special clavicle hook plate is needed for stabilization 

After surgery the arm should be relieved by wearing a shoulder sling until removal 

of the stitches after 2 weeks. This eases the pain and supports healing of the wound. 

From the first day on you can move your arm in the shoulder sling. You will learn 

respective exercises from your physiotherapist. After about 2 days you can leave the 

hospital. From the third week after surgery you can take off the sling and move the 

arm without additional weights. Most fractures are stably healed after 12 weeks 

but the plate should not be removed before one year after surgery what is done in 

a short out-patient surgery. Complications such as infects, healing disorders of the 

fracture or a repeated fracture after plate removal occur rather rare. 

66 


Humeral head fracture 

A humeral head fracture is often a result of a fall onto the shoulder. Especially 

affected are elderly women with osteoporosis as well as sportsmen who practice 

sports with higher risk of falling (cycling, skiing, motorcycling). 


Directly after falling heavy pain occurs in the area around the fracture. The shoulder 

joint can hardly be moved due to the severe pain. In many cases the patient can 

feel the bone ends grinding against each other. The healthy arm should hold the 

affected arm to the body. 

Fig. 1: 

Slightly dislocated fracture, 

healing by immobilization and 

physiotherapy 

Diagnosis 

Fig. 2: 

Completely dislocated fracture 

Fig. 3: 

Stabilization with plate 

In order to assess whether it is “only” a heavy contusion or a real humeral head 

fracture, x-ray images are needed. With them also type and severity of the fracture 

can be defined. A distinction is made between fractures with 2, 3 and 4 bigger bone 

fragments as well as difficult comminuted fractures. By means of the x-ray images 

taken further treatment can be planned. 


Ellenbogen Shoulder

Humeral head fracture 

Treatment 

By means of the x-ray images is decided whether an operation is necessary. Heavily 

dislocated fractures are operated. Fractures without or with slight dislocation can 

normally be treated conservatively by temporarily resting the affected arm and 

practicing physiotherapeutic exercises afterwards. However, with heavy professional 

or sportive strain we nevertheless recommend surgery also for slightly dislocated 

fractures as it shortens the period of aftercare and supports better results. The surgery 

method used depends on the type of fracture. Fractures with only one fragment can 

often be stabilized with screws. Complicated fractures with 3 or 4 bone fragments 

require stabilization by nails or plates. And with comminuted fractures is sometimes 

even makes sense to use a prosthesis. We prefer stabilization with a plate – even 

with complicated fractures. During surgery all bone fragments are moved back into 

the correct position by opening the skin directly over the fracture for approx. 15 cm. 

Then all those fragments are affixed to one plate (of metal or titanium). 

Aftercare 

After surgery the arm should be relieved by wearing a shoulder sling until removal 

of the stitches after 2 weeks. This eases the pain and supports healing of the 

wound. From the first day after surgery on you can move your arm in the shoulder 

sling. You will learn respective exercises from your physiotherapist. After about 4-5 

days you can leave the hospital. From the third week after surgery you can take off 

the sling and move the arm without additional weights. Most fractures are stably 

healed after 12 weeks but the plate should not be removed before one year after 

surgery. Complications such as infects, healing disorders of the fracture or a repeated 

fracture after plate removal occur rather rare. Typical for humeral head fractures 

is that with about a third of all patients, discomfort when lying on the shoulder, as 

well as discomfort or movement restrictions when spreading the arm or moving it 

outwards can remain despite correct stabilization. 

68 


Shoulder Endoprosthetics 

Shoulder prosthesis with arthrosis and after bone fractures 

Causes 

Within the frame of age-related wearing processes, or after circulatory disorders 

or fractures of the ball, there might occur loss of joint cartilage and damage of the 

shoulder joint with painful limitation to its functions. In later stages then the musculature 

recedes what results in increasing stiffening of the joint. 

Fig. 1: 

Shoulder ball replacement without socket 



At the beginning, increasing pain occurs with rotational movements and spreading 

of the arm to the side. Later, every movement is accompanied by pain and the 

shoulder joint shows progressing movement restrictions; the patient suffers from 

pain at night and rest pain. 

Diagnosis 

Fig. 2: 

Total shoulder joint endoprosthesis 


Examination and questioning of the patient in most cases offers the decisive indication 

of shoulder joint arthrosis. This assumption can then be confirmed by x-ray. 

For operation planning and assessment of the tendons surrounding the shoulder 

joint, further examination by sonography is necessary. In some cases even CT or MRI 

are needed. 


Ellenbogen Shoulder


Treatment 

In early stages it is often possible to regain a painfree situation with simple measures 

such as: temporary rest, decongestant- and analgesic medication, local ice- or heat 

treatment and special physiotherapy. It is important to keep the shoulder mobile – 

even if only within the painfree area – and train the muscles. In some cases injections 

with anti-inflammatory substances into the joint may be necessary. However, if this 

heavily painful movement restriction remains, a progressing movement restriction 

and muscular athrophy develop and respective damage can clearly be seen on the 

x-ray image, usage of prosthesis should be considered. With younger patients under 

50-60 implanting a prosthesis should be delayed as long as possible to avoid future 

problems such as for example loosening of the prosthesis. 

Fig. 3: 

Inverse shoulder prosthesis 


Fig. 4: 

Shoulder ball replacement without shaft 

Implantation of shoulder prosthesis or humeral head 

prosthesis 

Access is made through an approx. 15 cm long incision at the front side of the 

shoulder joint. The damaged fragment of the humeral head is removed, and as long 

as the cartilage of the socket is intact, it may be enough to only replace the ball. 

The prosthesis consists of a steel ball with attached shaft which is cemented to the 

upper arm. Otherwise also the socket has to be provided with a new surface which 

is mostly made of special synthetics. 

70 



Aftercare 

After surgery, an in-patient stay of about one week is necessary. In order to achieve 

the optimal operation result, aftercare should be carried out according to a previously 

defined scheme which is given to you by your ward physician. It depends on the 

type of prosthesis used and on the tendons sutured during operation. During the 

first weeks, limitation to outward rotations has to be objected in order to prevent 

sutured tendons from tearing again. Physiotherapy is necessary for about 3-6 months 

but to achieve the best possible result, exercises should be practiced independently 

at home for further 3-6 months. 


With 80-90% of the patients, shoulder prosthesis helps regaining painfree functioning 

of the shoulder joint. The achievable level of movability depends on condition of 

the joint prior to operation and your contribution. Operation-related risks such as: A 

humerus fracture during attachment of the prosthesis, sprains of the artificial joint, 

infects or injuries to nerves and vessels occur rather rare. As with any artificial joint, 

the shoulder prosthesis may loosen some day and need to be replaced. According to 

the experiences made so far, an average lifespan of 10 years is expected, whereby 

loosening mostly occurs with the artificial socket. 


Ellenbogen Shoulder

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BORT OmoFX 

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wie der anatomische Anspruch dieser komplexen Indikationen. 

Das intelligente Design und die Zuverlässigkeit unserer Instrumente 

und Implantate ermöglichen optimale Operationsergebnisse für die 

nachhaltige Wiederherstellung der Bewegungsfreiheit der Patienten. 

BORT OmoFX 

Smith &Nephew GmbH 

Mendelssohnstraße 15d 

22761 Hamburg · Deutschland 

Tel. +49 (0)40 70 700 - 0 

Fax +49 (0)40 70 700 - 201 

endo.hamburg@smith-nephew.com 


Variable Arm-Abduktionsorthese zur therapeutisch 

korrekten Lagerung in 30° oder 50° 

Impingementsyndrom, Schultergelenksverletzungen, Zustand nach 

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72 


Hip Joint Arthrosis (coxarthrosis) 

Anatomy and Functions 

The hip joint (fig. 1) connects torso and legs and consists of the acetabulum in the 

pelvic bone and the femoral head. All joint portions are covered with a cartilaginous 

sliding layer and are enclosed by the joint capsule. The synovial membrane produces 

a liquid that nurtures the cartilage which in the end serves as kind of a shock absorber. 

As more than half of the femoral head lies within the bony-connective-tissue 

socket you can also talk of nut lying in its shell. 

Cartilage 

All joint portions are covered with a cartilage cover. 

Labrum 

This ring-shaped cartilaginous sealing (labrum, fig. 2) forms the edge of this bony 

socket. 

Capsule 

The joint is enclosed by a connective-tissue capsule whose inner layer – the synovia 

– permanently produces the so-called synovial fluid. 

Ligaments 

The joint capsule is stabilized by strong ligament structures. Joint capsule, ligaments 

and surrounding musculature keep the joint in its position. 

Fig. 1: 

X-ray image of healthy hip joint 


Fig. 2: 

Labrum of the hip 

Most common cause of a hip joint disorder is cartilage degeneration: i.e. arthrosis 

of the hip or coxarthrosis. In most cases the reason for this degeneration is known 

and a distinction is made between three main causes: 

1. Mechanical hip dysfunctions (e.g. offset disturbance) 

2. Circulatory disorders (e.g. osteonecrosis of the femoral head) 

3. Inflammatory disorders (e.g. chronic polyarthritis) 

But the mechanical hip disorder is by far the most common cause. 


Ellenbogen Hüfte Hip

Fig. 3: 

Offset 


The Femoral Neck Offset 

Figure 3 shows the normal form of femoral neck and femoral head in cross-section. 

The femoral head protrudes the femoral neck both at the front and the back side. 

This midsection of the femoral neck is called offset. There are often disease patterns 

where this passage is much flatter (offset disturbance, fig. 4); this is mostly the result 

of a growth disorder of sportily active patients in the adolescence. 

This offset disturbance leads to the femoral neck hitting the socket edge when bending 

forwards (fig. 5). The first thing which becomes injured is the “sealing ring” of 

the hip, the so-called labrum. An early symptom of this offset disturbance is groin 

pain. During the following course of disease the cartilage of the socket becomes 

destroyed. Without treatment this loss of protecting cartilage leads to an increasing 

arthrosis with stiffening of the joint. At the advanced stage, ball and socket 

become partly damaged and do not optimally fit into each other any longer. At the 

same time run-in- and stress pain starts, later pain occurs also at night and while at 

rest. All this finally results in reduction of the walking distance and in an enormous 

reduction of the quality of life. 

Fig. 4: 

Offset disturbance 

Diagnosis 

Fig. 5: 

Impingement 

Diagnosis can be set by typical anamnesis, examination and by means of a normal 

x-ray image, whereby narrowing of the joint space between hip- and femoral bone 

is an indirect sign of cartilage loss. The MRI enables more precise examination of 

labrum and cartilage. 

74 



Therapy of Offset Disturbance and Prevention for Hip 

Arthrosis 

Therapy of this offset disturbance is always carried out surgically as there is no reliable 

conservative therapy known. This means restoration of the femoral neck offset 

and removal or suture of the torn labrum. With this the cartilage is protected and 

hip arthrosis prevented. 

If a patient suffers from groin pain, differentiated assessment shows the dimensions 

of this growth disorder and already existing damages. Besides clinical examination 

and conventional x-ray images, the most important method here is MRI; and it is 

decisive that NMR is made with intra-articular contrast medium and on special sequences. 

This is the only possibility to achieve a differentiated result about labrum 

and condition of the cartilage. 

In order to avoid early degeneration of the hip joint correcting surgery should be 

carried out. We offer you a new operation technique at the ARCUS Clinics to repair 

this defect by means of hip arthroscopy (p 76). The torn part of the labrum is removed 

under arthroscopic control and the lacking femoral neck midsection formed 

artificially. This takes away the femoral neck entrapment and degeneration of the 

hip can be stopped or avoided. 

Hüftbandage zur konservativen 

oder postoperativen Behandlung 

von Hüftgelenkerkrankungen. 

www.sporlastic.de · info@sporlastic.de 

Ellenbogen Hüfte Hip 

75 

75

Hip Arthroscopy 

In recent years, hip arthroscopy has become a standard surgery method when treating 

hip disorders. With this technique formerly common large incisions and resulting 

soft tissue damages as well as a long rehabilitation period can be prevented. 

Indications for hip arthroscopy are: 

• Loose joint bodies 

• Labrum ruptures 

• Degenerative changes 

• Beginning hip arthrosis (p. 73) 

• Movement restrictions of the hip 

• Cartilage injuries 

• Inflammations of the synovial membrane 

• Tear of the central hip ligament (Lig. teres) 

• Joint infections 

• Impingement of the hip (see step-by-step plan for treatment of hip arthrosis p. 78) 

• Problems after hip replacement surgery 

The surgery technique is very challenging and requires long term experience. Therefore 

we are very proud that more than 100 hip arthroscopies are carried out at the 

ARCUS Clinics every year. 

Fig. 1: 

Hip arthroscopy 

76 


Hip Arthroscopy 

We would like to outline two common indications as example: 

Loose Joint Bodies 

The most common cause for loose joint bodies (fig. 2) are accidents, followed by 

degeneration of the joint and synovial joint diseases. The loose joint bodies may 

then get caught and with this damage the joint; therefore it is recommended to 

remove them. This is possible by arthroscopic surgery through two or three 1cm 

long incisions what is an excellent alternative to formerly usual open operations. 

Femoroacetabular Impingement of the Hip 

This so-called femoacetabular impingement of the hip joint occurs due to changed 

anatomical conditions at femoral neck and/or the socket edge. It stands for direct 

contact of the two bones the when bending forwards, whereby the cartilaginous 

rim of the socket (the so-called labrum), as well as the cartilage within the socket 

become entrapped. These problems often occur with young patients and symptoms 

are pain in the area of the hip and movement restrictions. 

The labrum- and cartilage damage and the repeated bone contact results in continuous 

joint degeneration and finally in destruction of the joint by arthrosis. 

Through small incisions (about 1cm length), disturbing bony protrusions at the 

femoral neck and the socket edge can be removed and labrum and cartilage be 

treated (fig. 3+4). In many cases this prevents progression of the arthrosis and restores 

pain free mobility. 

Arthroscopic Surgery Aftercare 

Restrictions after hip arthroscopy depend mainly on extent of the surgery. During 

the first 2-3 weeks, putting full weight on the hip is possible when limiting physical 

activity, i.e. no sports activities and additional stress. In this initial period, also 

walking on crutches can be of help. In case that bone has been removed from the 

femoral neck or bone stimulating techniques carried out, strict stress reduction might 

be necessary for 2-4 weeks. Physiotherapeutic treatment prevents these limitations 

to activity and therefore should be started the first postoperative day. Thrombosis 

prophylaxis during the period of load reduction reduces the risk of blood clots in 

the leg veins. 

Fig. 2: 

Loose joint bodies 

Fig. 3: 

Preoperative x-ray image 

Fig. 4: 

Postoperative x-ray image 


Ellenbogen Hip

Fig. 1: 

46 year old man with arthritis 

Fig. 2: 

Hip with surface replacement 


Fig. 3: 

Total endoprosthesis 

Step-by-step Plan for Treatment of 

Coxarthrosis 

In case that joint arthrosis had been diagnosed, there was so far only the option 

of artificial hip joint replacement (THR) if conservative treatment methods such as 

physiotherapy, thalassotherapy, massages, pain medication etc. had already proven 

unsuccessful. 

Furthermore, treatment did consider neither severity of the disease nor age of the 

patient. Therefore we developed a step-by-step plan which ensures stage-related 

therapy. 

1. Moderate coxarthrosis with protrusions: 

Considerable improvement of discomfort can be achieved by recovering the stage of 

compensated arthrosis with arthroscopic hip surgery (p. 76). Disturbing osteophytes 

at femoral neck and socket are removed and the contract capsule partly recessed 

what brings back movability. Additionally, removal of torn parts of the labrum and 

inflamed portions of the synovial membrane allow considerable pain reduction. And 

with this method even loose joint bodies can be removed what enables the patient 

to be physically active again and delay an artificial hip implant. 

2. Advanced arthrosis with young patients 

(Female patients under 60, male patients under 65): 

When the joint is completely destroyed, joint-preserving surgery no longer makes 

sense. However, in order to preserve as many bones as possible, younger patients are 

implanted a femoral head cap (fig. 2) - a resection of the femoral neck is not necessary. 

Advantage is here preservation of normal anatomy (offset, force transmission 

and size of femoral head) what is needed for the normal range of movement. The 

resulting stability enables sportive activity without limitations. Another important 

advantage is the protection of bone substance which might become decisive with 

regard to a future revision. 

Not every hip arthrosis can optimally be treated with a femoral head cap. In such 

cases we alternatively use short-stem hip prostheses. 

3. Advanced arthrosis with elderly patients 

(Female patients over 60, male patients over 65): 

As the femoral neck is here not strong enough to carry surface replacement due to 

the reduced level of calcium carbonate in the bones, complete hip arthroplasty is 

the only option. This is another treatment where we achieve enormous progress, 

and besides better materials there have also been essential improvements with the 

operation technique. By developing the concept of minimally-invasive surgery (MIS) 

we only need very small incisions (6-8 cm). But the decisive advantage is the fact that 

almost no muscles have to be detached. This brings minimization of tissue trauma, 

an overall gentle operation method and less pain. Immediate full strain is possible 

and blood loss is reduced what in turn accelerates rehabilitation. 

78 


Total Endoprosthesis: Material and Fixation 

Hip joint prosthesis: material and fixation 

Continuous improvements in both surgical techniques and the quality of implants 

since the 1960s make this procedure one of the most common and most successful 

routine operations in orthopedic surgery (about 400.000 per year in Europe). The 

prosthesis is modeled on the actual human joint, i.e. it consists of a socket and a shaft 

to which a ball head is fitted. By means of pre-operative planning the model size 

and fixation method of the prosthesis is specified whereby individual requirements 

such as age, gender, shape of bone, body weight, etc. are taken into consideration. 

There are three different fixation techniques used with implantations: 

• Cement-free endoprosthesis fixation: shaft and socket are press-fitted exactly 

into the bone (fig. 1 + 2). 

• Cemented endoprosthesis fixation: hip socket and shaft are fixed with quickhardening 

antibiotic bone cement (fig. 3). 

• Hybrid endoprosthesis fixation: the socket is fixed cement-free; the shaft anchored 

using bone cement (fig. 4). 

The cemented socked is made of polyethylene, the cemented shaft of a cobaltchromium 

alloy. Titanium implants, often equipped with special macro- or microstructured 

surfaces are particularly suitable for cement-free fixation thanks to their 

excellent integration into the bone. 

As so-called slide bearings (joint portions with direct contact) between the socket 

and the artificial femoral head polyethylene/ceramic-, ceramic/ceramic- or metal/ 

metal combinations are used. Thanks to latest developments in this area (e.g. Durasul, 

Sulzer Orthopedics or especially hardened ceramics) the abrasion behavior 

of the components has been optimized to the extent that many years of usage are 

tolerated with almost no material wear. 

Fig. 2: 

Cement-free endoprosthesis 

Fig. 3: 

Cemented endoprosthesis 

Fig. 4: 

Hybrid endoprosthesis 

Fig. 1: 

Cement-free joint replacement 


Fig. 5: 

Hip with short-shaft prosthesis 



Ellenbogen Hip


Resurfacing 

Treatment of young patients with advanced hip joint arthrosis can – alternatively 

to the usual THR surgery - also be carried out by implanting a hip cap. Here the 

femoral head is covered with a metal cap with the advantage that practically no 

bone has to be sacrificed. Furthermore the physiological size of the femoral head is 

re-built what results in considerably improved mobility and stability. Most important 

requirement is a good bone quality as there is the risk of a femoral neck fracture 

when suffering from osteoporosis. 

Another option for younger patients which cannot undergo implantation of a hip 

cap (e.g. with femoral head necrosis) is a short-shaft prosthesis. Here only a small 

part of the femoral neck has to be removed (p. 79, fig. 5). 

Fig. 6: 



Aftercare 

Fig. 7: 



Endoprosthetic operations are carried out exclusively on in-patient conditions. In 

order to ensure an optimal operation success, early postoperative mobilization by 

means of physiotherapy is recommended. Independent of the surgery method, full 

load is permitted almost immediately whereby walking on crutches is necessary for 

3-4 weeks to protect the soft tissues. 

Most patients stay in hospital for 7-10 days followed by 3-4 weeks of rehabilitation 

time. The progress of the patient is documented by regular out-patient control 

check-ups at close intervals. If necessary, mobilization therapy has to be continued 

on an out-patient basis. 

80 



Joint Replacement and Sports 

Having a severe hip joint arthrosis, noticeable limitation of physical activities has 

to be expected. When the symptoms are gone after joint replacement surgery, the 

desire for more sportive exercise certainly comes up again. Internationally there is a 

broad consensus that at least so-called “low-impact” sports such as cycling, swimming, 

sailing, diving, playing golf and bowling can be supported. Sports such as tennis, 

basket ball and skiing however, are only possible to a limited extent. Completely 

avoided shall be contact sports such as foot ball or hand ball. Recommendations 

for those different sports are also dependent on the patient’s performance level. 

As a rule of thumb it can be said that sports practiced prior to surgery are allowed 

afterwards as well. 


Ellenbogen Hip

Fig. 1: 

Radial epicondyle 

Elbow 


The elbow is a very stable and highly congruent joint which comprises three different 

portions. It serves as hinge between upper arm and ulna and enables turning 

movements of ulna, radius and upper arm. 

Stabilization is given through the bony guide, the tight capsular ligament apparatus 

and the muscles surrounding the joint. Nevertheless, the elbow is the second most 

frequently-dislocating joint. 

Injuries and disorders of the elbow are mostly of complex nature, and understanding 

different possible diseases is an essential condition for successful therapy. Especially 

the anatomic vicinity to nerves and vessels requires an experienced surgeon specialized 

in this area. 

Besides clinical examination, there are also conventional x-ray, sonography, MRI and 

CT available for diagnostics. 

Tennis Elbow (Epicondylitis humeri radialis) 

This diagnosis rather stands for a symptom. It refers to pain occurring on the lateral 

epicondylus of the upper arm with pain radiating to the forearm extensor muscle 

(fig.1). 

In many cases this disease is caused by unusual heavy physical activity or monotonous 

work (e.g. desk jobs). This triggers an inflammation of the forearm extensor 

muscle base at the lateral humeral condyle. Normally, when being treated early with 

symptomatic therapy including physiotherapy, anti-inflammatory procedures and 

wearing of a bandage, acute symptoms can be eased or healed. 

Thus it is recommended to even treat chronic progressions (symptoms for more 

than 6 months) conservatively first for a sufficiently long time before considering 

surgical therapy. 

However, if these conservative treatment methods remain unsuccessful, operation 

indication is set after a differentiated diagnosis of the elbow with conventional xray 

and MRI (fig. 2). In case that surgical treatment is needed, the elbow should be 

operated not only open (via incision) but also arthroscopically (with camera technology). 

This is indispensable for identification and treatment of the reason for this 

chronic progression which is lying inside the joint. One of the most common causes 

for chronic pain development is instability of the outer capsule-ligament apparatus. 

82 


Elbow 

Depending on the severity of the instability, treatment is done by two different 

methods: 

• When treating a minor instability it is often sufficient to detach the forearm extensor 

from the epicondylus and remove chronically inflamed tissue. Afterwards, 

the tendons are with slight shirring stably affixed to the bone again. Aftercare is 

relatively uncomplicated. Under reduced load for approx. 6-8 weeks movability 

is increasingly regained. 

• In case that the elbow needs further stabilization, the outer capsule-ligament 

apparatus is strengthened with a tendon implant which has been taken from 

the triceps tendon (fig. 3+4). Here, aftercare of 10-12 weeks is necessary. 

Operative treatment of chronic epicondylitis humeri radialis requires a differentiated 

view on the complete joint and comprehensive knowledge of the surgeon to 

understand and treat all causes of this symptomatic pain. 

Fig. 3: 

Titanium screw fixation of 

tendon transplant 

Fig. 4: 

Inserted tendon transplant 


Fig. 2: 

Inflammatory edema at radial 

epicondyle 

Ellenbogen Elbow 

83

Fig. 5: 

Epicondylitis humeri ulnaris 

Fig. 6: 

Claw hand 

Elbow 

Golfer’s Elbow (Epicondylitis humeri ulnaris) 

This painful inflammation of the tendinous sheath which forms the forearm’s flexion 

muscle base at the medial epicondylus (fig. 2) can be treated much more effective 

with conservative methods. Generally, this painful symptomatic is a result of overload 

of the attachment zone of the forearm flexor. 

Only in rare cases it is a consequence of complex joint diseases. Thus, if conservative 

therapy does not ease the pain, this chronic inflammation can be treated relatively 

uncomplicated in an open operation (incision). The forearm flexors are detached 

from the medial epicondylus, the inflamed tissue removed and the tendons sutured. 

Aftercare needs about 6-8 weeks and includes resting the arm while having physiotherapy 

with lymph drainage. 

Sulcus-ulnaris Syndrome or Cubital Tunnel Syndrome 

This syndrome is a chronic nerve entrapment or nerve irritation within the bone 

channel at the medial epicondylus. 

Symptoms are numbness and tingling of the 4th and 5th finger with radiating electrifying 

pain from the inner side of the elbow up into the hand. Sometimes, patients 

also have a clasping feeling over the medial epicondylus. In the advances stage it may 

also lead to paralysis and weakening of intrinsic hand muscles (claw hand, fig. 6). 

Reasons are often chronic pressure load, elbow arthrosis, rheumatoid arthritis or 

scarring after accidents and operations. 

Besides clinical examination, neurological examination with determination of velocity 

of nerve conduction is used for diagnostics. 

In case that conservative therapy with anti-inflammatory treatment, wearing of a 

resting splint and general care does not bring the expected relieve, operative neurolysis 

(release of the nerve) should be carried out. 

In simple cases it is enough to treat the nerve in its “bed” by removing possible 

bondings and other interfering factors (e.g. bony irritations). This is done through 

an incision at the inner side of the elbow. However, should become obvious that 

the nerve might not recover due to heavily modified anatomical conditions in the 

nerve channel, nerve relocation should be considered. 

The ulnar nerve is then placed into another area within the subcutaneous fatty tissue 

or the forearm’s flexion muscles before the ulnar epicondylus. 

Immediately after surgery of the ulnar nerve the elbow can be moved again. Immobilization 

is generally not necessary, but special care should be observed for about 

2 – 6 weeks. About 6 months after surgery the surgeon should carry out a second 

measurement of the nerve conduction velocity to control the success achieved. 

84 


Elbow 

Loose Joint Bodies 

Symptoms are clear. It generally is a sensation of entrapment with limitation of 

movability, a painful joint, grinding and cracking. 

Loose joint bodies (fig. 7) are usually the result of an already existing disease such 

as arthrosis (loss of cartilage with damage of the joint), Osteochondrosis dissecans 

(circulatory disorder of a bone area with loss of cartilage), instabilities, synovial 

chondromatosis (formation of cartilaginous bodies within the synovial membrane) 

or the consequence of an accident. 

In most cases conservative therapy would not bring the result expected as loose joint 

bodies form a higher risk of irreparable consequential damages to the joint cartilage. 

In order to not only ease pain but also retain the joint it is recommendable to remove 

those loose joint bodies with arthroscopic surgery (minimally-invasive camera technique). 

If necessary, the real cause for the disorder can be treated at the same time. 

Osteochondrosis Dissecans or Aseptic Bone Necrosis 

(Morbus Panner) 

This disease mostly occurs with active and sportive children/teens and rather with 

boys than with girls. It is a circulatory disorder of the humerus near the joint surface 

of the radial head. Most obvious symptom is load-dependent pain, and depending 

on the stage of the disease also the sensation of entrapment and limitation of movability. 

This circulatory disorder of the bone leads to displacement of its cartilage 

layer what in turn results in further consequences (as with loose joint bodies). The 

best prognosis is given when the disease is recognized at an early stage. By reducing 

pressure load and resting the elbow, a pain-free condition can be achieved 

and rejection of the cartilage prevented. However, should the disease already be in 

an advanced stage with (partial-) displacement of cartilaginous tissue, good results 

can better be achieved with arthroscopic surgery by drilling the affected area and 

carrying out an appropriate cartilage therapy (fig. 8+9). 

Fig. 8: 

Drilling of damaged cartilage bone area 

Fig. 9: 

Cartilage therapy by microfracture surgery after 

removal of loose joint body 

loose joint body 

Fig. 7: 

Removal of loose joint body 


Ellenbogen Elbow

Stiff Elbow and Elbow Arthrosis 

Mobility limitations of the elbow are either the result of changed soft tissue conditions 

or bony, mechanical barriers. In most cases it is a combination of both. Reasons 

for these movement restrictions may be accidents and their consequences (e.g. 

step joints with resulting joint degeneration, loose joint bodies, adhesions within 

the joint, scarring after operations) or a “normal” arthrosis (wear and tear of joint 

cartilage and bony sections of the joint). But limitation can also occur without visible 

radiological changes. In these cases limitation is mostly caused by adhesions 

within the joint (arthrofibrosis) with an additional shortening/shrinkage of the 

joint capsule. Depending on the form of elbow stiffness, conservative therapy may 

be enough to increase mobility again. Useful may be manual therapy with physical 

exercise, anesthesiologic methods such as local pain catheters, or usage of special 

mobilizing splints. In most cases however (depending on discomfort and level of 

limitation) the joint needs operative treatment (open or arthroscopic) in order to 

regain a satisfactory level of mobility. 

The aims of arthrolysis (operative loosening of adhesions - possible in arthroscopic 

or open surgery) are restoration of mobility and furthermore improvement of 

joint mechanics. Thus depending on the diagnosis, disturbing bone spurs and loose 

joint bodies are removed, the cartilage surface smoothed, adhesions mobilized and 

shortened joint capsules cut. With this, pain is considerably reduced, often even 

eliminated. And the long-term prognosis is noticeably improved. 

With completely destroyed joints or after exhausted joint-preserving therapy, the 

elbow can also be replaced by an artificial joint/prosthesis. 

86 Rastatter Str. 17-19 • 75179 Pforzheim • Germany • Phone 07231- 60556- 0 • www.sportklinik.de • info@sportklinik.de 

86 

Elbow 

Fig. 10-12: 

Before and after joint cleansing of an arthritic joint

Elbow 

Elbow Prostheses 

Elbow prostheses offer perfect mobility, pain reduction and durability. However, they 

should not be load with more than 4-5 kg in order to avoid loosening or break-off. 

This low loading capacity is the main reason why prostheses should rather be used 

with elderly patients. They are mainly used for rheumatoid arthritis and posttraumatic 

conditions. 

Fig. 13: 

Osteosynthesis as attempt to preserve 

the joint 

Fig. 14: 

Endoprosthetic joint replacement 

with so-called coupled prosthesis 

Fig. 15: 

Radial head prosthesis after posttraumatic 

arthritis 


Ellenbogen Elbow

Fig. 16: 

Soft tissue injury caused 

by luxation 

Elbow 

Luxations and Instability 

An acute luxation needs prompt action. The dislocated elbow (fig. 16) should be 

put back in place within six hours in order to avoid threatening damages to vessels 

and nerves. Putting back the joint is generally performed under a short general 

anesthesia. Still under anesthesia the surgeon can determine necessary aftercare 

by checking stability. The severity of instability and bony concomitant injuries is 

decisive for further procedures. 

For better assessment of possible consequential injuries, focused diagnosis with xray, 

radioscopy, MRI and/or CT is necessary. 

Treatment of young, but also of chronic consequential injuries/instabilities requires 

comprehensive knowledge and operative spectrum of the treating surgeon. Offering 

the best possible treatment for such complex injuries in most cases requires 

individual assessment. 

Fig. 17: 

Luxated elbow joint 

Fig. 18: 

Stabilization with external 

fixation and reconstruction of 

capsular ligament apparatus 

Fig. 19: 

After removal of external fixation 

(6 weeks after surgery) 

88 


From Heel to Toe – 

Foot Problems and their Treatment 

Anatomy 

The foot has a very complex structure where 26 bones together with more than 100 

ligaments and 20 muscles form a stable system. Numerous nerves react to pressure 

and movement patterns and together with a well trained musculature ensure safe 

standing and moving. An office clerk walks about 1400 steps, a housewife with 

children about 13000 and postmen about 18000 steps per day (source: German 

Federal Ministry of Health). Thus our feet are loaded with about 1-2 million steps 

per year. Narrow shoes certainly make existing problems worse, but are probably 

not the actual cause. 

Disorders may be caused by: 

• Thickening and deformation of the ball of big toe (Hallux valgus) 

• Inflammation of the bursa at the ball of big toe 

• Stiffening of big toe joint (Hallux rigidus) 

• Hammer- or claw toes 

• Splayfoot disorders with calluses 

Problems with the big toes – Hallux Valgus 

Thickenings at the base joint of the big toe, favored by pressure spots of narrow 

shoes move the big toe outwards. Inflammatory reactions in an intermittent course 

at the ball of foot make the situation worse. 

At the initial stage a capsule indent with tightening at the outer and loosening at 

the inner side is enough (pure soft-tissue operation e.g. according to the McBride 

method). 

Fig. 1: 

Image of severe Hallux valgus due to bone 

deformity 

(source: www.stiftung-fusschirurgie.de) 

Fig. 2: 

Big toe correction surgery according to Scarf 



Ellenbogen Foot



To treat severe malpositioning of the big toe, the bone needs correcting surgery too; 

and there are numerous methods to do so. The formerly common method which 

even today is still practiced in some cases, to simply resect the base joint of the big 

toe (method according to Keller-Brandes) should only be used in exceptional cases. 

There are more modern proven possibilities to preserve the toe’s base joint such as 

surgery according to Chevron or Kramer when treating moderate cases or Scarf and 

Hackenbroich when treating severe cases. 

Aftercare is normally carried out without wearing a plaster. With a so-called forefoot 

relief shoe or a vacuum shoe (e.g. Vacopedes) even careful walking is possible. 

Fig. 3-4: 

X-ray images before and after correction surgery of severe deformity of big- and little toe 

(source: DePuy) 

90 




Big Toe Arthritis 

Hallux rigidus 

After accidents or chronic overload (e.g. by several sprains from playing football) 

joint wear within the base joint of the big toe can result in painful limitation to 

mobility. First remedy brings a stiff inlay with dispensing aid at the soles. Recommendation 

as regards the operation method is still stiffening the big toe’s base joint, as 

pain-free and normal loading capacity can be achieved without bigger long-term 

consequences. In case that bony prominences are disturbing and arthritis is not in a 

so far advanced stage, operative joint cleansing and if necessary slight shortening 

may help for some time. Small artificial toe joints are another option, but they do 

not bring back satisfactory full loading capacity in every case. 

Problems with the small toes 

Hammer Toes 

Unequal muscle drawing results in distortion of one or several of the small toes. 

Pressure points develop at the raised middle joint as well as at the tiptoe and under 

the metatarsal head. In the initial stage when the distortion can still be corrected, 

wearing inlays is often sufficient. 

Fig. 6: 

Pressure problems with hammer toe 


Fig. 7: 

Repositioning of metatarsal head 

Operation method according to Weil 

(source: DePuy) 

When treating a contracted malposition, the head of the base joint is removed 

(surgery method according to Hohmann) to form a replacement joint. Aftercare is 

normally carried out without wearing a plaster. Walking with a so-called forefoot 

relief shoe is possible. Modern operation techniques preserve the metatarsophalangeal 

joint (surgery method according to Weil) and ensure better pain reduction 

when rolling the forefoot (metatarsalgia). 

Fig. 5: 

Hallux rigidus after stiffening 

of big toe 


Ellenbogen Foot

Fig. 8: 

Bone formation after fatigue 

fracture of metatarsal bone 

Fig. 9: 

Cast replacement by removable 

vacuum support shoe 

(source: Oped GmbH, Vacopedes) 



Metatarsus 

Fatigue Fracture 

Too much load over a longer period such as jogging or long hiking trips may lead 

to hairline cracks in the bone which initially are not visible on normal x-ray images. 

The MRI helps making a diagnosis. Generally, treatment is done conservatively i.e. 

by pressure relief or a plaster-replacing shoe (e.g. Vacopedes). 

Tarsus 

Arthrosis 

The small tarsal bones can develop the same signs of wear than bigger joints of our 

body. Artificial joint replacement however is not necessary, as with simple stiffening 

of the affected small bones satisfactory and pain-free loading capacity can be restored 

without triggering functional limitations. After such a stiffening operation, 

walking on crutches is necessary for some weeks. But in many cases, full loading 

and thus walking with removable plaster-replacing shoe (e.g. Vacopedes) is possible 

after about 4 weeks. 

Bone Circulation Disorders (aseptic bone necrosis) 

The bone oedema syndrome has only been known for some years now. First discovered 

by MRI analyses, the main causes have still not been investigated in detail. 

Theories about what causes this disorder are overload, micro fractures, circulation 

disorders etc. (source: http://en.wikipedia.org/wiki/Aseptic_necrosis). 

The patient feels load-dependent pain in the foot without finding a certain possible 

reason; in most cases there are no external signs. Causal therapy is - except for detected 

fatigue fractures - not known so far. Besides relieving measures such as rest, 

inlays, relief or immobilization, the therapeutic approach focuses on stimulation of 

blood circulation. There have been good healing results when treating cases in the 

initial stage with hyperbaric oxygen therapy, but public health insurance companies 

unfortunately are not offering any reimbursement options. Alternatively, there is 

a therapy method based on circulation-stimulating infusions (Iloprost) which also 

shows noticeable shortening of this painful and disabling course of disease. Operative 

treatment is useful at a later stage (drilling of the affected bone area, near 

to joints also cartilage bone transplantations e.g. knee or Achilles joint up to joint 

replacement in severe cases). 

92 




Heel 

Plantar Calcaneal Spur 

Inflammations of tendons within the plantar plate may lead to persistent pain 

comparable to the tennis elbow syndrome. Treatment is in almost all cases conservative 

with physiotherapy, rest, anti-inflammatory medication (also cortisone 

infiltrations), shockwave treatment (free of side effects) or radiotherapy. In recent 

times good results have also been achieved when treating severe cases with injection 

of body-own growth factors in combination with rest e.g. through removable 

plaster-replacing shoe. 

Hindfoot- and Achilles Tendon Problems 

An increasingly growing heel bone (Haglund exostosis) irritates the Achilles tendon 

and triggers pressure damages, so that chronic inflammation and fraying and even 

severe partial tendon ruptures may be the result. The body’s own repair processes 

try to cover this area with excessive scarring, but the developing thickened tendons 

increase discomfort even more. In cases where conservative therapy (anti-inflammatory 

medication, physiotherapy, Achilles tendon bandages, rest etc.) did not have 

the necessary healing effect, arthroscopic removal of the bony dorsal heel bone 

and treatment of the Achilles tendon has proven successful; partly with additional 

infiltration of body-own growth factors to supports healing of the normally poorly 

circulated Achilles tendon. We gladly offer our patients a vacuum shoe for the first 

weeks after surgery. All in all, this bone removal is an effective operation method 

and should not be delayed by conservative approaches. 

Fig. 10: 

Haglund exostosis before operation 

Fig. 11: 

Heel after operative bone removal 


Ellenbogen Foot

Achilles Tendon Problems 

Achillodynia 

Achillodynia is the degeneration process of soft tissue in the centre of the poorly 

circulated Achilles tendon. The body’s own incomplete attempts to repair the damage 

lead to painful thickening of the tendons. 

Main causes are: monotonous overload (painful running training especially with 

shortened Achilles tendon), overpronation (pes valgus) or other foot deformities, 

wearing too stiff soles or too much cushioned heels what results in the Achilles tendon 

experiencing strong prestraining with every step, arthrosis-dependent uneven 

loading (knee, hip etc.). 

Fig. 1: 

Achillodynia (left side with thickened tendon) 

Fig. 2: 

Achillodynia with partial rupture of Achilles 

tendon 

Harmless in the initial stage, but very painful. Therapy is at first conservative with 

reduction of exercise load, check of running shoes and their cushioning, physiotherapy 

with instructions for stretching exercises, in some cases also kinetic tape. Individual 

inlays, especially after professional video-recorded walking-running analysis. Shockwave 

therapy (public health insurance companies do not cover the costs so far) and 

also inflammation- and pain reducing therapy via x-ray or proton radiation. We also 

made good experiences with the injection therapy of body own growth factors (see 

chapter ortho-biology, page 44), while other infiltrations e.g. with cortisone should 

be used very carefully because of the danger of rupture of the tendon. In cases of 

therapy resistance, the degenerative thickening of the tendon is removed surgically. 

New American approaches consider the mentioned hindfoot-, heel- and Achilles 

tendon problems and also their extensions to the metatarsus including forefoot 

deformities to be one single syndrome: the CT-band syndrome (calf-to-toe band, J. 

Oster 2009). Therefore, lower legs with calf musculature, Achilles tendon, plantar 

fascia, foot- and toe joints are regarded and treated together as one single unit. 

94 


Achilles Tendon Problems 

Achilles Tendon Rupture 

The complete rupture of the Achilles tendon is one of the most common sports injuries, 

mostly occurring with males between 30 and 50. Treatment is here medically 

necessary as this injury otherwise results in a scarred extension of the tendon with 

sometimes considerable loss of power and gait disorders. Conservative treatment 

is possible as long as the tendon ends have not spread. Within the first 24 hours, a 

lower leg cast is applied (or a lower leg orthosis which has to be worn very consequently). 

Afterwards an individually adjusted lower leg walker has to be worn for 4 

weeks; removable only at night and for body care. Complementary physiotherapeutic 

treatment is needed even longer. Among experts, advantages and disadvantages of 

such a conservative therapy are still controversial. We see better and above all faster 

positive results in immediate operative treatment with minimally invasive technique 

(small incisions, suture for initial hold of tendon fibers and accelerated healing 

process through injection of growth factors). Here, the patient is with appropriate 

orthoses capable of walking within 4-5 weeks in most cases. 

Fig. 3: 

Minimally invasive Achilles tendon suture 

Fig. 4: 

Injection of body-own growth factors 

(PRP) 

Fig. 5: 

Closed wound 


Ellenbogen Foot 

95

Ankle Disorders and their Treatment 

Anatomy 

The ankle joint comprises the the true ankle joint (upper ankle joint) and the subtalar 

joint (lower ankle joint). The latter is rarely affected by injuries and therefore 

discusses in association with ankle osteoarthritis. The upper ankle joint (UAJ) is the 

connection between the ground-contacting foot with the talus as lower portion 

of the joint and the tibia carrying the body weight which forms the upper joint 

surface together with the inner malleolus. Laterally lying we can see the fibula. 

This construction enables a sliding movement = flexion and extension and thus 

the power when walking or jumping. Stable ligaments prevent lateral tilting. At 

the inner malleoulus the broad and stable delta ligament, at the outer malleolus 

three considerably thinner ligaments from which the anterior- and medial collateral 

ligament are often partly or even completely ruptured when twisting one‘s ankle 

(supination trauma, distorsion). 

Ligament Injuries 

• Strain of ligaments and joint capsule, sprain (grade I) 

Treatment: ice, compressions, elevated resting, full loading possible after few 

days. 

• Partial rupture (grade II) 

Treatment: as grade I, additionally walking on crutches necessary for some days 

and wearing of a stabilizing ankle brace (e.g. Aircast or Malleo-Tri-Step) for 2-4 

weeks. Physiotherapy is recommended for improvement of coordination and 

muscular stabilization as prevention against new injuries. 

• Ligament rupture (grade III). 

Treatment: as grade II, but with the joint being splinted for up to 6 weeks. With 

severe instability even operative ligament suture. 

• Chronic instability of lateral collateral ligament after repeated distortion. If physiotherapy, 

broadened heels and elastic bandages do not bring improvement, 

operative ligament surgery should be considered. When having a sufficiently 

stable and worn-out scar, it can be doubled and sutured again to tighten it 

(surgery according to Broström). Advantage: anatomic reconstruction. In case of 

a rupture of two ligaments or severe instability, strengthening of the ligaments 

has to be carried out by using additional material e.g. periosteum (periosteal 

flap surgery), tendons from the foot or recently also tendons from the knee. 

Advantage: very good stabilizing effect. Disadvantage: complex surgery, difficult 

anatomic positioning. 

Complications of such operations: 

- Infections (less than 1%) 

- Slight movement restrictions (1-2%) 

- Sensory disturbances at the outer side of the foot 

- Insufficient stabilization 

• Syndesmosis rupture: Rupture of the tight ligament connection between lateral 

malleolus and shinbone. 

With proven rupture (by MRI), fixation with screw and walking on crutches for 

6 weeks is necessary. 

96 



Tendon Injuries 

Subluxation of the peroneal tendon: normally lying behind the lateral malleolus, 

the tendon forcefully snaps out of its position. Therapy: operative protection by 

partially tightening soft tissue or relocation of a lateral malleolus lamella. 

Tibialis posterior tendon tears: weakness or rupture of the flexor tendon behind 

the medial malleolus with increasingly painful pes valgus. If conservative therapy 

approaches are not successful, reconstruction of the tendon often combined with 

correction of the heel bone against the pes valgus deformity are necessary. 

Ankle Fracture 

• Medial malleolar fracture (second most common bone fracture). 

Treatment: smaller stable fractures can be treated conservatively with orthesis or 

plaster. Bigger fractures at the inner- or outer malleolus are regarded as serious 

joint injuries and have to be treated surgically; otherwise, there is danger of 

early degeneration of the joint (arthrosis). 

Arthroscopic Ankle Surgery 


There are numerous sports injuries and deteriorative illnesses at the ankle joint. 

Indication for surgery is mostly made on the basis of pain, swelling, movement 

restriction, instability, jams or blood in the joint. 

meniscoid lesion 

working 

access 

access for 

arthroscope 

Fig. 1: 

Scheme of ankle arthroscopy: automated milling machine on left side, optics with 

attached camera on right side (Dyonics, McGinty 91) 


Ellenbogen Foot


Arthroscopic Ankle Surgeries 

• Consequential damages after dislocations with stress pain, instability or blockages 

through loose joint bodies are the most common causes. Furthermore inflammations 

of the synovial membrane, adhesions and scarrings with movement 

restrictions (arthrofibrosis) and limitations to mobility as a result of entrapped 

scar tissue (meniscoid syndrome) can be treated successfully. 

• Protruding osteophytes at the front side of tibia and talus are especially with 

ball players and dancers a common cause for pain, swelling and movement 

restriction. Arthroscopic removal of these osteophytes is a promising and wellproven 

treatment option. 

• When suffering from joint cartilage damage, a cartilage treatment similar to 

the one at the knee joint can be carried out. In most cases, the damaged cartilage 

is carefully removed, smoothed and the underlying bone brushed up in 

order to stimulate fibrocartilage regeneration. In rare cases treatment includes 

transplantation of donor cartilage. 

Major Ankle Surgeries 

Deep cartilage defects with underlying bone defects are called Osteochondritis dissecans 

(OD). They occur mostly at the inner side of the talus which is very difficult to 

reach, and causes are severe distortions, chronic instabilities or circulatory disorders 

of the bone. They are divided into four grades: 

• Grade I: Bone oedema, circulatory disorder without changes in the bone structure, 

intact cartilage layer. 

Treatment: rest, use of crutches, circulation stimulating measures (hyperbaric 

oxygen therapy HBOT or iloprost injections, see chapter foot, p. 89). In case of 

persisting progression, the affected area can be drilled from the rear side under 

arthroscopic control. 

• Grade II: beginning demarcation, displacement of a mostly oval-shaped cartilage 

bone fragment, in most cases still intact cartilage layer, but sometimes partly 

frayed. This lesion is potentially instable and reaches grade III soon without 

treatment. Thus, either early and consequent conservative treatment with rest 

for a longer period or surgical treatment is necessary. 

• Grade III: the cartilage bone fragment has detached completely from the talus 

bone but still lies in its „mouse bed“. This condition does not heal by itself. For 

therapy please refer to stage IV. 

• Grade IV: The cartilage bone fragment has broken off the bone and as loose 

joint body causes additional damages by interfering with the joint. 

There is only one option: surgical treatment. In favorable cases refixation of 

the fragment, otherwise simple removal of the fragment and stimulation of 

self-healing (mostly possible without removal of inner malleolus, but then with 

reduced chances of fast healing). Another promising method is cartilage bone 

transplantation: a healthy cylinder-shaped piece of cartilage bone is taken from 

the knee and transplanted into the defect area of the talus. Here, the inner 

98 



malleolus has to be removed in order to reach the affected area; it is affixed 

with screws afterwards. 

Advantage: load stable condition within 5-6 weeks. Complete surgery possible in 

one session. Public health insurance companies cover the costs of this operation 

method. 

Disadvantage: Transplant has to be extracted from the knee. 

Alternative possibility: autologous chondrocyte transplantation (ACT) = cultivation 

and transplantation of the body’s own cartilage cells (see chapter arthrosis, p. 36). 

Advantage: high-tech procedure with best chances for development of new loadstable 

hyaline cartilage. No additional injury at the donor site. By using recent technologies 

of spheroid ACT even detachment of the inner malleolus can be avoided. 

Disadvantage: expensive (public insurance companies cover the costs only to a limited 

extent; mostly clinics are allowed only a limited number of ACT-operations. 

Surgically challenging. This method is only appropriate for flat defects; otherwise 

the bone defect has to be filled up when removing the cells. Normally, two surgical 

steps are needed (first cell extraction for cultivation and later transplantation). In 

some cases however, after verification of the diagnosis and indication, approval of 

cost transfer has to be obtained from the health insurance company first before 

cell removal and transplantation afterwards can be carried out. Here, bureaucracy 

makes 3 surgical steps inevitable. 


Ellenbogen Foot


Besides the information given, please also note the 

following: 

Prior to operation 

Do not put your joint under unnecessary strain; this might extend your recovery 

period after the operation. If necessary train walking on crutches. 

Arrange treatment dates with your physiotherapist or masseur, beginning about 

1-2 days after the operation. For further information about a planned operation 

please refer to chapter anesthesia from page 18. 

Aftercare 

With most ankle joint surgery patients an extended program for postoperative care 

is arranged. Special details of aftercare are mentioned in the operation record. 

Generally applies: 

Do not put full weight on the foot the first days after surgery and rest your foot 

in an elevated position. Until completed wound healing (5-10 days) support your 

foot by walking on crutches. Cool the joint with dry ice-pack several times a day 

for approx. 15 min. 

Movement and Drainage 

After rest of 2-3 hours get up and walk a few steps. By activating the lower leg musculature 

you can help preventing thrombosis best. In case that the small drainage 

bottle becomes filled, please do not worry and leave it alone. Under no circumstances 

empty the bottle, nothing will happen. 

Dressing Change and Aftercare 

The day after surgery please visit us for change of dressing. The next change after 

2-3 days can be carried out from your referring specialist or family doctor. 

Taking a shower is possible after 1 week; removal of stitches is done approx. 14 days 

after surgery. Full loading is permitted after 5-10 days in most cases. Please carefully 

read the chapter „Aftercare“ of your operation record which serves as information 

for you and for other physicians as well as physiotherapists dealing with the case. 

We kindly ask you to arrange a follow-up examination after 3 weeks and in some 

cases again after 3 months. 

100 


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Ellenbogen Foot



With increasing age occur signs of wear and tear at intervertebral discs and spinal 

joints. Damages of the disc tissue are due to most different reasons as herniated 

discs are usually the result of accidents or other unforeseeable events. The intervertebral 

disc consists of a hard fibrous ring and a softer inner part. The disc tissue is 

not supplied by blood vessels; supply is ensured only through diffusion, a complex 

system of suction- and pressure effect of the vessels surrounding the spinal column 

and the spinal canal. 

If the water content of the intervertebral disc declines, it loses its shock absorbing 

effect and shrinks what can clearly be seen in MRT. Its height is visibly reduced and 

the MRT signal shows lower water content. By increasing wear and tear the disc 

finally loses its elasticity and protrudes; and the fibrous ring is forcefully stretched 

– what causes heavy back pain. Of course, this situation may recede, but in most 

cases the increasing wearing down of the intervertebral disc and the pressure from 

within onto the fibrous ring result in small tears through which the gelatinous 

portion of the disc tissue is being squeezed out (sequestration). By squeezing onto 

nerves or the spinal cord within the spinal canal, this leaked disc tissue can cause 

heavy pain and even neurological deficits such as paralysis, changes in sensation or 

bladder-gastrointestinal disorders. 

A previously damaged disc cannot offer the same shock absorbing effect than a 

healthy one. All these degenerative changes result in the vertebral bodies being 

moved together and stressed excessively. Osteochondrosis as the result of this condition 

is also perfectly visible in MRT. Due to the chronic overload of the vertebral 

bodies with low spondylolisthesis further signs of degeneration occur (facet joint 

arthrosis). Bony and cartilaginous protrusions lead to narrowing of the nerve channels 

(foraminal stenosis) and the spinal channel (spinal stenosis). Both degenerative 

narrowing conditions with chronic pressure lead to stress-dependent pain and after 

longer duration also to neurological deficits. 

102 



Cervical Spine (CS) 

Die Halswirbelsäule (HWS) mit insgesamt 7 Wirbelkörpern ist der beweglichste 

Wirbelsäulenabschnitt und stellt die mobile Verbindung zwischen dem Kopf und 

der restlichen Wirbelsäule her. Aus dieser Bewegungsfunktion resultieren die 

unterschiedlichen Probleme bei degenerativen (verschleißbedingten) und traumatischen 

(verletzungsbedingten) Erkrankungen. In der Halswirbelsäule liegt direkt 

hinter den Bandscheiben das Rückenmark, sodass aus dieser engen Lagebeziehung 

viele Probleme entstehen. Degenerative Halswirbelsäulenerkrankungen kommen 

gehäuft auch bei jüngeren Menschen vor. Klinisch-neurologisch muss man zwischen 

radikulären (Kompression der Nervenwurzeln) und medullären (Kompression des 

Rückenmarks) Symptomen und Defiziten unterscheiden. Ein Druck auf das Rückenmark 

muss nicht immer Schmerzen verursachen, ist jedoch ein langfristiges Problem, 

da die Schädigung der Rückenmarksbahnen langsam fortschreitende Störungen mit 

Gleichgewichtsstörungen, Gangunsicherheit und schleichender Querschnittsymptomatik 

verursachen (cervikale Myelopathie). 

Degenerative Osteochondrosis 

Cause 

Is wear and tear or a gradual restructuring process with degeneration of the intervertebral 

disc and protrusions or extensions of the vertebral bodies. This bone- and 

connective tissue growth results in nerve- or spinal cord compression. Generally it 

can be said that pain cannot be treated satisfactorily with conservative therapy. 

Symptoms 

Are often chronic pain in neck and back of the head or pain radiating to shoulder, 

arm and fingers. Depending on the nerve affected and the dimension of this nerve 

entrapment symptoms may also be lack of force, paralysis and changes in sensation. 

Diagnosis 

Is made by neurologic examinations as well as special examinations of the spinal 

column; in individual cases also by electrophysiological measurements. X-ray images 

of the cervical spine and sometimes so-called functional images are necessary. 

Moreover, a CT and/or a MRT should be carried out. In rare cases even a cervical 

myelography for further invasive diagnostics is necessary. 

Therapy 

In case that no neurologic deficits occur, primary aim should be conservative therapy 

with intensive physiotherapy and pain medication. If no adequate improvement can 

be achieved, indication for operative measures should be checked and discussed new. 

Here, individual advice and definition of the optimally suitable surgery method are 

of decisive importance. 


Neurosurgery Ellenbogen / Spinal Column


Operation Method 

Minimally-invasive technique (under local anesthesia): 

periradicular infiltration (PRI) – radiologically 

controlled facet infiltration 

When treating with periradicular infiltration (PRI) and the radiologically controlled 

facet infiltration a mixture of local anesthetic and a crystalloid corticoid preparation 

is used. After local anesthesia of the skin a thin cannula is inserted under radiological 

control directly to the point where the nerve exits the foramen and 1 – 2 ml of the 

medication injected. Under x-ray control, this medicine can also be applied into the 

small vertebral bodies near the cervical spine. Its local effectiveness requires only low 

dosages; the medication does only work directly at the site of action and degrades 

very slowly. However, in most cases there are several sessions necessary to achieve 

long-term freedom from pain. 

Microsurgical Operations: 

Ventral discectomy with placeholder 

Here, access is made via the front of the neck with complete removal of the damaged 

disc. Decompression of nerve structures (nerve roots and spinal marrow) is 

made with the operating microscope. At the end a placeholder is inserted instead 

of the damage disc which has a re-erecting effect to the intervertebral disc space 

and relieves the neuroforamen; the development of osteophytes is prevented. 

Different materials such as polymer cement (PMMA) or synthetic cages (PEEK) are 

used. Only in rare and difficult cases with accompanying loosening of the mobile 

segment screwing together of the cervical spine and a titanium plate is necessary. 

Ventral Foraminotomy 

Here, access is also made via the front side of the neck to open up the nerve channel. 

Compared to ventral discectomy however, preservation of the disc is possible. 

Dorsal microsurgical techniques: 

Foraminotomy, Laminectomy, Laminoplastics 

With dorsal foraminotomy, a bony entrapped nerve root can be decompressed by 

removing the osteophytes. A sole laminectomy with complete removal of the vertebral 

arch offers a good possibility to relieve the spinal cord. However there is the 

risk of instability afterwards and so it is used only rarely or in combination with a 

stabilizing procedure. Laminoplastics with dorsal extension and reconstruction of 

the spinal canal is another possibility to treat cervical myelopathy when suffering 

from cervical spinal canal stenosis. This method is especially promising when treating 

an ossification of the posterior longitudinal ligament. 

104 



Aftercare 

Directly after surgery the patient starts with mobilizing exercises. After microsurgical 

operations at the cervical spine there are no noticeable limitations to sitting, 

lying or walking, and even wearing of a neck collar is not necessary. The in-patient 

stay at the hospital normally lasts 2-3 days. The following week start physiotherapy 

and further conservative measures. As regards other activities after a cervical spine 

surgery we would be pleased to give you individual advice. 

Disc Herniation 

Cause 

Due to degeneration of the intervertebral disc there sometimes occur tears in the 

fibrous ring through which the inner gelatinous portion of the disc is squeezed 

out. The possible resulting pressure onto nerves or the spinal cord causes pain and 

neurologic deficits. 

Symptoms 

Acute neck pain and heavily radiating pain to arms and fingers with the feeling of 

weakness and numbness or other abnormal sensations. With severe neurological 

deficits such as paralysis, changes in sensation or bladder-gastrointestinal disorders, 

immediate operation may be necessary in individual cases. 

Diagnosis 

Diagnosis is made with neurologic examinations and special examinations of the 

spinal column; if necessary also electrophysiological measurements. Moreover, Xray 

images of the cervical spine with functional images as well as a current MRT 

are needed. 

Therapy 

Without obvious neurological deficits, conservative therapy should be the first 

choice. Treatment comprises pain medication and if necessary immobilization with 

neck brace. After the acute phase starts intensive physiotherapy. In case that conservative 

therapy does not bring the required result, indication for operative measures 

should be checked and discussed new. Here, individual advice and definition of the 

optimal time of operation as well as the optimally suitable operation method is of 

decisive importance. 


Ventral microsurgical discectomy with placeholder 


disc. Decompression of nerve structures (nerve roots and spinal marrow) is made 

with the operating microscope. At the end a placeholder is inserted instead of the 

damage disc which has a re-erecting effect to the intervertebral disc space and relieves 

the neuroforamen; the development of osteophytes is prevented. Different 

materials such as polymer cement (PMMA) or synthetic cages (PEEK) are used. 




Ventral microsurgical discectomy with artificial intervertebral disc 

With younger patients with a mobile and only slightly damaged disc, preservation 

of the mobile segment can be achieved by implanting a disc prosthesis after microsurgical 

removal of the real disc. 

Dorsal microsurgical foraminotomy 

With dorsal foraminotomy small and outwards situated soft herniated discs can be 

removed and the entrapped nerve root decompressed. 

Aftercare 

Directly after microsurgical operation mobilization is recommended. Drainages are 

only inserted in exceptional cases and the patient normally does not have to wear 

a neck brace. The in-patient stay lasts normally 2-3 days. In the week following the 

surgery physiotherapy and further conservative measures are started. 

Cervical Myelopathy 

Cause 

Cervical myelopathy is a gradual wearing process with degeneration of the disc. 

Developing bony protrusions (osteophytes) narrow the spinal canal at the cervical 

spine and thus lead to compression of the spinal cord. 

Symptoms 

In many cases occurs chronic pain in neck and back of the head, but often this does 

only pose little discomfort. However, even if not very strong - the permanent pressure 

onto the spinal cord results in the medium term in irreversible damages to the 

spinal cord and therefore poses respective risks. 

Diagnosis 


column; in individual cases also by electrophysiological measurements. X-ray images 

of the cervical spine and sometimes so-called functional images are necessary. Moreover, 

a CT and/or a MRT should be carried out whereby assessment of the MRT as 

regards possible signs in the spinal cord for myelopathy is of particular importance. 

Therapy 

With a manifest cervical myelopathy, conservative treatment is relatively promising. 


Microsurgical ventral discectomy with placeholder 


disc. Decompression of nerve structures (nerve roots and spinal marrow) is 

made with the operating microscope. At the end a placeholder is inserted instead 

of the damage disc which has a re-erecting effect to the intervertebral disc space 

and with this prevents the development of new osteophytes. Different materials 

such as polymer cement (PMMA) or synthetic cages (PEEK) are used. 

106 



Microsurgical ventral decompression with removal of vertebral bodies 

and plate osteosynthesis 

Access is made via the front of the neck. By means of an operation microscope the 

vertebral body (or bodies) and the adjacent discs are removed what creates a long 

relieving effect to the spinal cord. In order to re-stabilize the spinal column afterwards, 

implantation of a tricortical iliac crest bone grafting or a metal vertebral 

body replacement is necessary. Additionally a ventral plate osteosynthesis has to be 

carried out in order to ensure sufficient stability. However, this relatively complex 

operation method is rather rare. 

Dorsal microsurgical decompression and laminoplastics 

A microsurgical decompression is carried out in several stages. Here, the ligamenta 

flava and possible osteophytes are removed. Reconstruction of the spinal canal by 

laminoplastics is a preferred surgery method when treating very long cervical stenoses 

especially with elderly patients. 

Aftercare 

Directly after surgery the patient starts with mobilizing exercises. After microsurgical 

operations at the cervical spine there are no noticeable limitations to sitting, lying 

or walking, and even wearing of a neck collar is not necessary. The in-patient stay 

at the hospital normally lasts 3-4 days. Only in rare cases and with previous neurologic 

deficits rehabilitation treatment is necessary. As regards other activities after 

a cervical spine surgery we would be pleased to give you individual advice. 

Fractures 

Cause 

Acute or recent physical violence to the cervical spine with rupture of the ligament 

structures and fractures of the vertebral bodies, vertebral arches and vertebral 

joints. But fractures may also be the result of tumors, inflammations of the spinal 

column or osteoporosis. 

Symptoms 

Neck pain, headache and other discomfort near the whole spinal column. Furthermore 

movement restrictions of the spinal column and various degrees of neurological 

deficits. 

Diagnosis 

Is made with a neurological examination and a special examination of the spinal 

column. Furthermore, X-ray images of the cervical spine as well as so-called functional 

images are necessary, and a CT and a MRT should be carried out. In rare cases 

nuclear medicine examinations are needed for further diagnostics. 

Therapy 

FIn case that no obvious instability or neurological deficits can be detected, treatment 

can be done conservatively. This includes stabilization by means of a neck brace and 

pain medication. After the acute phase controlled physiotherapy can be started. 

When treating fractures of the cervical spine offering individual advice regarding 




indication to operation as well as choosing the most appropriate operation method 

is of decisive importance. 


Microsurgical ventral discectomy with removal of vertebral bodies and 

plate osteosynthesis 

Access is made via the front of the neck. By means of an operation microscope 

the damaged parts of the disc and the broken vertebral body are removed what 

enables decompression of the nerves and the spinal cord. Afterwards the cervical 

spine is re-stabilized by implanting a tricortical iliac crest bone or a metal vertebral 

body replacement. Additionally a ventral plate osteosynthesis is needed to ensure 

sufficient stability. 

Dorsal microsurgical decompression with stabilization 

A microsurgical decompression is carried out in several stages by removing ligaments 

and compressed parts of the bone. Stabilization of the cervical spine is carried out 

by dorsal fixation with a screw-rod system. In rare cases and only with severe ruptures 

with massive instability, ventral and dorsal stabilization techniques need to 

be applied both at the same time. 

Aftercare 

Mobilization should follow surgery as soon as possible. After complex stabilization 

operations, the patient should furthermore wear a neck crest during the initial phase. 

Especially with previous neurologic deficits, rehabilitation treatment is necessary. 

108 



Lumbar Spine (LS) 

The lumbar spine (LS) is the lower part of the spinal column with a total of 5 vertebral 

bodies. It connects legs and pelvis with the rest of the spinal column. By walking 

upright, this part of the spinal column is exposed to heavy stress, what often causes 

painful irritations summarized under the generic term “back pain”. Important is here 

differentiation in this wide range of disease patterns which range from simple pain 

symptoms to complex disc herniations with neurological deficits. Degenerative lumbar 

spine disorders are very common symptoms and may also affect younger patients. 

Disc Herniation 

Cause 

The degeneration process of a disc results in loss of liquid, reduction of height and 

finally in laceration of the fibrous ring. The leaked disc tissue exerts pressure on the 

nerves what causes pain and also may lead to neurological deficits. 

Symptoms 

Acute and chronic, stress-dependent back pain which radiates to the leg. Movement 

restrictions of the spinal column, weakness and loss of power of legs and feet. The 

sensation of tingling, warmth and cold in the legs. Gait disorder with the feeling of 

insecurity when walking. Impairment of the rolling movements of the foot when 

walking. Bladder- and bowel voiding dysfunctions. 

Diagnosis 

Is made with a neurological examination and a special examination of the spinal 

column. Furthermore, X-ray images and functional images of the lumbar spine are 

needed and a MRT should be carried out as it offers optimal view on the herniated 

disc. 

Therapy 

Cases without obvious neurological deficits should be treated conservatively first. 

This comprises intensive physiotherapy and pain medication; in some cases also local 

infiltrations. However, if these measures do not bring adequate improvement, indication 

for operative treatment should be assessed and discussed. Here, individual 

advice and definition of the best strategy and the optimal operation method are 

of decisive importance. Herniated discs which cause acute high levels of paralysis or 

bladder-colon disturbances need to be treated in an emergency operation. 


Minimally-invasive percutaneous nucleotomy 

DThis procedure is carried out under local anesthesia. Under radiologic control a 

cannula is inserted sideways into the disc space to inject contrast medium. Then the 

respective disc tissue is removed by means of a pneumatically operated suction- and 

cutter mechanism. This technique is especially suitable for patients with subligamental 

disc herniation. Patients with relevant bony narrowing of the nerve exit canals 

(foraminal stenosis), in an advanced stage of degeneration with resulting reduction 

of disc height (osteochondrosis), or a definitely sequestered disc do not benefit from 

this operation method in the long term. 




Transforaminal endoscopic discectomy 

This operation method can be carried out under local- or general anesthesia. Access 

is made via an 8-10 cm long incision from the side next to the spinal column. Through 

this incision the endoscope is inserted to the nerve exit canal (foramen) to remove 

the sequestered disc under endoscopic control. This minimally-invasive technique is 

especially suitable for patients with extremely outside-lying disc herniation (lateral 

sequester). 

Microsurgical sequestrectomy 

This microsurgical operation is carried out under local anesthesia. Access is made 

through a 2 – 3 cm long incision, whereby a special speculum is used to retract the 

back muscles to the side. The spinal canal and the nerves lying inside are reached via 

the natural bone window. After preparation by means of the operation microscope 

the leaked disc material can be removed with a special miniature forceps. The disc 

itself is preserved and only degeneratively changed material is removed; this helps 

to maintain the function of the disc. Entrapped nerves are immediately relieved and 

the radicular radiating pain eases. Disturbances in sensation and paralysis however 

need some time for complete regression. 

Aftercare 

With microsurgical operations, mobilization is started immediately after surgery. 

Getting up and walking is already possible the day of surgery. Also wearing a girdle 

is not necessary as statics and biomechanics of the lumbar spine are not impaired 

by this gentle microscopic treatment. The in-patient stay normally lasts 2 – 3 days, 

physiotherapy and other conservative therapies are started the week after surgery. 

Although patients feel recovered after a very short time, carrying heavy load or undertaking 

strenuous sporting activities should be avoided during the first 3 – 4 weeks. 

Duration of disability varies individually and depends on many different factors. 

Facet Syndrome 

Cause 

Excessive strain on the spinal column not only causes damages to the discs but also 

leads to mechanical wear and tear on the vertebral joints, or more precisely on the 

inner surfaces – the so-called facets. Thus the term facet syndrome stands for wear 

and tear (arthrosis) of the small vertebral joints. Due to signs of wear or degenerative 

spondylolisthesis occurs excessive strain on the joints and with this continuous 

wear and damage of the joint cartilage. Exuberant bone formation and extension 

of joint facets are the result. 

Symptoms 

Back pain after periods of long standing, sitting or lying and when getting up. Most 

common complaints are back pain radiating to the buttock and the groin to the 

thigh. Rotating movements of the spinal column are painful, especially getting up 

in the morning can be very difficult. 

110 



Diagnosis 

Is made with a neurologic examination and a special examination of the spinal column. 

Moreover, X-ray images of the lumbar spine with functional images as well 

as images of CT and MRI help proving the diagnosis. Also helpful may be testinfiltrations 

of the vertebral joints. 

Therapy 

Conservative measures and pain medication can be successful when treating the facet 

syndrome. With many patients, sling table therapy is very successful in the short 

term. All in all however, success of conservative therapies when treating advanced 

stages of facet degeneration. 


Radiologically controlled facet infiltration (diagnostic and 

therapeutic) 

Radiologically controlled facet infiltrations are carried out under local anesthesia. 

After local anesthesia of the skin a thin cannula is inserted directly into the facet joint 

at the lumbar spine and a small amount of local anesthetic (approx. 2 ml) injected 

under radiologic control. For diagnosis it initially is helpful to perform injections 

from both sides of the mobile segment. When therapeutically treating a facet block 

which can also be combined with a periradicular infiltration (PRI), a mixture of a local 

anesthetic and a crystalloid corticoid compound is injected. Here, too, a thin cannula 

is inserted into the skin after local anesthesia and a small amount of the mixture 

(2 – 3 ml) injected directly into the small vertebral joints. This medicine can also be 

injected directly into the tissue surrounding the nerve exit at the foramen. The local 

effectiveness needs only small dosages and the mixture has a long-lasting effect. 

Nevertheless several sessions are necessary to achieve long term freeness of pain. 

Interspinous Retractor 

This low invasive operation can be carried out optionally under local anesthesia or 

short-acting anesthesia. Under x-ray control the retractor is inserted through an approx. 

4 cm long incision at the back and then positioned between the bony spinous 

processes to relieve the vertebral joints. The operation is normally carried out on 

in-patient basis but patients can already walk the day after surgery. This in-patient 

stay lasts about 1 – 2 days. 

Aftercare 

There is no special aftercase necessary after radiologically controlled facet infiltration 

or the PRI. The therapy can lead to comprehensive reduction or even complete elimination 

of discomfort. After implantation of an interspinous retractor, progression 

is controlled via x-ray and clinical check-ups. Complementary conservative therapy 

measures are in most cases very helpful. 




Spinal Canal Stenosis 

Cause 

Narrowing of the verterbral canal occurs mostly with elderly patients due to chronic 

wear as well as exuberant bone formation, vertebral joint arthrosis, disc protrusions, 

ligament thickenings and vertebral body dislocations. The spinal canal with the 

nerves inside becomes increasingly narrow and the continuous pressure results in 

pain and neurological deficits. 

Symptoms 

In most cases stress-dependent back pain which radiates to the legs. Other symptoms 

are weakness or loss of muscle power in legs and feet or the sensation of tingling, 

warmth and cold in the legs. Furthermore gait disorder with the feeling of insecurity 

when walking. Characteristic are also the symptoms of spinal intermittent claudication 

(claudicatio spinalis). Here, walking distances have to be more and more reduced. 

Diagnosis 


column. X-ray images of the lumbar spine and so-called functional images are necessary. 

Moreover, a CT and/or a MRT should be carried out. In rare cases even a lumbar 

function myelography for further invasive diagnostics is necessary. 

Therapy 

With a severe spinal canal stenosis, conservative treatment has little prospect of success 

as it is nearly impossible to have influence on the bony narrowing of the lumbar 

spinal canal i.e. the mechanical compression of the nerves. In the case of massive 

instability of the lumbar spine, even microsurgical decompression is not sufficient. 

In these individual cases, stabilization has to be considered. Here, individual advice 

and choice of the optimal surgery method are of essential importance. 


Microsurgical Decompression 

This microsurgical operation is performed under general anesthesia. Access is made 

through a 2 – 3 cm long incision, whereby a special speculum is used to retract the 

back muscles to the side. The spinal canal and the nerves lying inside are reached 

via the natural bone window. Under microscopic control the enlarged facet joint 

segments are undermined by means of diamond micro milling cutters and small 

punches what extends the nerve exit canal and the spinal canal. Thanks to an operation 

method newly developed some years ago (Spetzger, et al) the spinal canal 

can be decompressed from both sides through only one access. This method has by 

now already become one of the standard procedures for microsurgical treatment of 

spinal canal stenoses (Spetzger, et al). The disc itself is preserved if no obvious disc 

herniation can be detected. In many cases, the facet joint is heated up with special 

forceps and treated with bipolar coagulation. This has a positive effect on local pain. 

Trapped nerves are relieved and the radiating pain eases quickly. With following 

conservative therapy extending the walking distance is achieved very soon. 

112 



Aftercare 

With microsurgical operations, mobilization is started immediately after surgery. 

Getting up and walking is already possible the day of surgery. Also wearing a girdle 

is not necessary as statics and biomechanics of the lumbar spine are not impaired 

by this gentle microscopic treatment. The in-patient stay normally lasts 3 - 4 days, 

physiotherapy and other conservative therapies are started the week after surgery. 

Fractures 

Cause 

Fractures are often caused by acute violence on the thoracic- or lumbar spine or 

are the result of an accident in the past with rupture of ligament structures and 

fractures of vertebral bodies, vertebral arches and vertebral joints. But fractures 

can also occur in connection with tumors, inflammations of the spinal column or as 

sign of osteoporosis. 

Symptoms 

Severe diffuse back pain and discomfort throughout the whole spinal column with 

movement restrictions up to neurologic deficits. Especially with elderly patients or 

as a result of certain diseases, fractures may occur as a result of minor falls. 

Diagnosis 

Is made with a neurologic examination as well as a special examination of the spinal 

column. Furthermore, X-ray images with functional images as well as a CT and a 

MRI are necessary; in some cases even nuclear medicine examinations are needed 

for more precise diagnostics. Important is here differentiation and consideration 

of the actual cause. 

Therapy 

If there is neither obvious instability nor any neurological deficit detectable, treatment 

can be done conservatively. Adjustment of an individual girdle as well as 

stabilization by means of special physiotherapeutic measures together with pain 

medication bring often complete healing. When treating fractures of the thoracic- 

and lumbar spine, individual advice as well as discussion of the indication and 

most appropriate operation technique is of decisive importance. With osteoporotic 

fractures or vertebral body metastases, minimally-invasive techniques with injection 

of PMMA-cement show very good results. 


Vertebroplasty and Kyphoplasty 

Minimally-invasive surgery can be performed optionally under local- or general 

anesthesia. In prone position and under permanent x-ray control, one or two cannulae 

are inserted through the pedicle of the affected vertebrae. Then the vertebral 

body is re-erected by inflating a balloon (kyphoplasty). In case that this special 

positioning has already caused this re-erection, polymer cement (PMMA) is directly 

injected into the vertebral body (vertebroplasty). This pasty cement fills the broken 

vertebrae from the inside and hardens within several minutes so that immediate 

stabilization is achieved. 




Aftercare 

Mobilization is possible directly after surgery what enables the patient to get up 

and walk already the day of operation. Girdles are only necessary in individual cases. 

The in-patient stay normally lasts 1 – 2 days and in the week following the surgery 

physiotherapy and other conservative treatments can be started. 

114 


Directions 

Directions via the A8 motorway Karlsruhe-Stuttgart 

• Leave the A8 motorway at exit 43 junction Pforzheim West with direction to 

Pforzheim-Zentrum (city center). 

• Stay in the left hand lane and turn into the Karlsruher Straße (B10). Follow the 

road for about 400 m. 

• Leave the Karlsruher Straße (B10) and turn right into the Stuttgarter Straße. 

• Follow the road for about 600 m. Then turn right into the Rastatter Straße. 

FRANKFURT 

KARLSRUHE 

B10 

A8 

AS PFORZHEIM WEST 

Stuttgarter Str. 

INDUSTRIEGEBIET 

WILFERDINGERHÖHE 

B10 / Karlsruher Str. 

Raststatter Str. 

Wilhelm-Becker Str. 

Rastatter Str. 17-19 • 75179 Pforzheim • Germany 

Phone +49 7231- 60556- 0 • Fax +49 7231- 60556- 3044 

www.sportklinik.de • info@sportklinik.de 

STUTTGART 

MÜNCHEN 

ZENTRUM 

Ellenbogen 

115

ARCUS Kliniken 

Rastatter Str. 17-19 

75179 Pforzheim 

Germany 

Phone +49 7231 605560 

Fax +49 7231 60556 3044 

www.sportklinik.de 

info@sportklinik.de

ortema pforzheim - Arcus Sportklinik

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