and refinement that exists within the necessarily strict rules of the internal fixation method. In this way we seek to contribute to as weIl as to stimulate the search for rational solutions to surgical problems. It is assumed throughout that the reader is fa miliar with the technical fundamentals of internal fixation, and so these details are omitted. Instead, special indications and technical refinements are presented on the basis of case examples. Because an endless variety of situations can arise in orthopedic surgery (a circumstance that is attracting more and more surgeons to the field), we have taken ca re that our examples can readily be applied to novel situations. We now credit, in alphabetic order, those who contributed most to the techniques presented: R. BLATTER, A. BOITZY, C. BRUNNER, O. CECH, A. DEBRUNNER, F. MAGERL, G. SEGMUELLER, G. STUEHMER, and B.G. WEBER. We thus express thanks to those colleagues in our clinic who agreed to having their ideas published. But we are also grateful to our illustrators, H. and K. SCHUMACHER, our photographer, M. SCHAFFNER, and our chief secretary, U. OETLIKER, who contributed so much to the preparation of the manuscript. Finally, we thank Springer-Verlag for their patience with us and especiaUy for their efficient work in bringing the book to press. St. GaU, Fall 1981 CH.F. BRUNNER B.G. WEBER Contents Lag Screws ............. .

In the eight years since the first edition of this book several marvelous technical advances have become available clinically for the care of patients with "failed back syndromes. " High resolution MRI scans, three dimension al CT scans, and percutaneous discectomy are notable technological ad vances. Overall, however, the problem of "the failed back" remains as complex and poorly understood as ever. A discouraging amount of what we claim to be our knowledge of the pathophysiology and appropriate therapy for the complex of disorders that constitute the failed back syndrome re mains unvalidated by careful scientific study. 1 The discussions of patho physiology, diagnosis, and therapy put forth in the first edition for the most part remain equally as valid or as controversial as they were eight years ago. The first edition was well received by numerous physicians and other health care givers from a variety of disciplines and through them the book seems to have contributed usefully to many of those who suffer the unpleasant mal adies of "the failed back. " I hope this second edition will likewise prove to be a positive contribution. The timing of the publication of this second edition is significant in several ways in the context of the current medicolegal climate in the United States."

Pathological conditions affecting the hip and knee joints occupy a particular place amongst the important orthopaedic entities affect ing the extremities. On the one hand they are relatively frequent and on the other they mean for the patient limitation of his ability to walk, because of their considerable detrimental effects. A purposeful basic treatment of these joint diseases (and here osteoarthritis takes pride of place) is only possible if it stems from a reliable biomechanical analysis of the normal and pathological stressing of the joint in question. Whilst the situation in the hip can be considered to be fundamentally clarified, a comprehensive representation of the knee is still lacking, particularly when taking into account the latest knowledge of biomechanics. Recently our concepts of the kinematics of the knee have been completely changed, but the clinically important question of articular stressing remains unanswered. Dr. Maquet has carried out pioneer work in this field for some years in adapting, by analogy, to the knee joint principles already accepted for the hip joint. Since the knee is not a ball and socket joint, a complicated problem arises for which new thoughts are necessary. The results of the numerous operations carried out by Dr. Maquet according to the biomechanical considerations demon strate that his thinking is fundamentally correct. Above all, it is here again proven (as earlier in the case of the hip) that healing of osteoarthritis depends decisively on reducing and evenly dis tributing joint pressure.

The production of a textbook of the pathology of bone work with isotopic markers to refine their classifica- tion. tumours is a hard task to embark upon, but Andre In this book, the author takes up a firm position Mazabraud has certainly succeeded. about the difference between osteoid osteoma and oste- It is the outcome of a very long experience, provided oblastoma, about "tumoral associations" and about the initially by his hospital training, then by his collabora- so-called malignant forms of disorders described as tion with Rutishauser at the Institut de Pathologie at benign. His personal stamp is evident throughout the Geneva and with Dahlin at the Mayo Clinic. The bonds various chapters. he forged then have never been loosened. Certainly, treatment in the area is rapidly changing Subsequently, his duties as head of the department and advancing, but this book does not risk obsoles- of pathology at the Institut Curie directed him finally cence since treatment is not its focus. The extent and towards tumour pathology. At the Institute, he was not nature of the author's experience explain the essentially satisfied with routine examinations but very soon linked anatomo-pathological orientation taken by this semi- up with the research team and worked especially on nal book. It also provides valuable clinical information Ewing's sarcoma and the problems of ultrastructure, and a good radiological study.

Endoprosthetic replacement of the elbow is an operation which is still rarely undertaken. It is indicated in chronic polyarthritic conditions and joint damage due to trauma. A considerable number of different prostheses are commercially available. In this unique collection of papers, the authors discuss methods, implantation techniques, and surgical results and complications. Particular emphasis has been placed on the complications related to the prostheses and surgical revision. In addition, alternative techniques are presented.

Posttraumatic stump formation and replantation of the severed limb are both reconstructive plastic operations which may lead to the improvement or destruction of a patient's lifestyle. For the primary attending surgeon, the decision whether to undertake such an operation depends on the patient's clinical condition, the operational circumstances, the psychological and social aspects and, last but not least, on the surgeon's own abilities. This monograph is designed as a synopsis of the great number of patho-physiological parameters and surgical and rehabilitational aspects which must be considered in the analysis of complications in major limb replantation. In addition, basic information about the key role of ischemic myopathy and microangiopathy is supplied to encourage further experimental investigations.

It is interesting to observe the evolution of medical education over the years. The massive textbooks of the past have almost disappeared except as works of library reference. In their place we now find an increasing number of publications which explore the detail of particular specialities and sub-specialities. Once the young surgeon has acquired his basic knowledge of surgery in general (as it is now called), postgraduate education, whilst seeking to maintain the general scientific and humanistic principles of surgery, is forced to provide specialised reference works in a whole variety of fields, amongst which the postgraduate will choose his own future interest. This tendency emphasises the importance of the Conference on Surgery of the Shoulder organised by Professor Kessel and his colleagues. This first inter national gathering of surgeons and others in related disciplines who are interested in the disorders of the shoulder was self-funded under the aegis of the Institute of Orthopaedics and University of London, and it is to be hoped that other Universities, hospitals and medical foundations will give maximal financial and moral support for further ventures of this kind. This volume places on record the concepts and practices of those interested in the injury and disease of the shoulder joint, and thus becomes a reflection of our knowledge in this field in the second half of the twentieth century."

An introductory text on bone metastases written by experts from various disciplines. It covers the basic principles of surgery in bone cancer, classification, medical treatment, radiotherapy, surgical treatment, incidence and pain relief. The steady progress in diagnosis and treatment of bone cancer in the last decade has dramatically changed the prognosis of cancer patients, improving significantly the overall survival rate and quality of life. Multidisciplinary treatments that combine surgery, radiotherapy and chemotherapy, as described in this book, show significantly improved results and an above average survival rate. Some hematologic malignancies that involve bone may be cured with systemic chemotherapy or radiotherapy, but for most patients with bone metastases, pain relief is the goal of therapy.

Both the diagnosis and the current therapeutic possibilities of the shoulder joint and the subacromial space are described in explicit detail in this book. The anatomy of the shoulder joint from an arthroscopic viewpoint is also briefly described. The diagnostic part of the book gives a description of the individual structures in the glenohumeral joint as well as the subacromial space with regard to their pathologic changes, and special attention is focused on differentiating between healthy and pathologic struc tures. The therapeutic part gives a detailed description of the Bankart refixation methods successfully applied by the authors which include a suturing technique, a refixation technique using absorbable tacks and an extra-articular screw fixation technique; furthermore the techniques of subacromial decompression, the removal of calcium deposits and the resection of the lateral end of the clavicle are described in detail. From the discussion about the indications for arthroscopy and/or arthroscopic therapy, the book then goes on to convey information on positioning, draping, necessary instruments and, finally, the performing the arthroscopic intervention itself. Thus, all the details which are required for arthroscopy of the shoulder are given."

As the incidence of distal radius fractures increases, so too does the importance of this classic volume. Fully revised and expanded, with new illustrations and radiographs and new chapters on the distal radioulnar joint, late complications and future fracture techniques, no orthopaedic surgeon can be without this comprehensive and complete guide to the treatment of what are remarkably complex injuries.

Endoscopic neurosurgical interventions gain in importance. This book gives adetailed description of the recent indi- cations of endoscopic procedures inmodern neurosurgery. They include endoscopic stereotaxy, endoscopic evacuations of intracerebral hematomas, cysts and abscesses as well as endoscopic interventions on brain tumors. An extended over- view about the usable endoscopes and the operative equipment is pointed out

Up until two decades ago, clinical interest in the etiopathogenetic interpretation of lumbo-radicular syndromes was prevalently concentrated on the pathology of the inter vertebral disc. This vision gradually changed and grew as a result of the affirmation of the concept of pathological narrowing of the osteoligamentous vertebral canal as a cause of compression of the lumbar nervous structures. Finally, in the last ten years, lumbar stenosis has become more and more a subject of current interest not only as a result of problems related to nosography, diagnosis, and therapy, but also as a result of the increasing frequency with which vertebral canal or nerve root canal stenosis syndromes are recognized and treated. At the same time there was a tendency to include in stenotic pathology other pathological conditions responsible for lumbo-radicular syndromes. This led to dilation of the concept of stenosis, which perhaps no longer responded to reality, and which was not useful from a practical point of view. The need to define stenotic pathology and to correctly locate it within the vast field of lumbar pathology inspired the writing of this volume. This monograph gathers many diagnostic and therapeutic concepts matured at our In stitution over the years. Some of these concepts have already been defined in scientific meet ings or in publications."

Joint replacement surgery has seen remarkable progress and development in recent years both in prostheses and in surgical technique. A prime concern has been improved durability, for which a major factor is reduction of the polyethylene wear that leads to osteolysis. This book presents an update on the means by which the problems of wear and loosening are being addressed in total hip arthroplasty (THA) and total knee arthroplasty (TKA). Included are chapters on new surgical techniques for difficult cases, nonpolyethylene interfaces for THA, custom hip prostheses, and computer-assisted surgery. Arthroplasty 2000 also takes up current controversial issues such as posterior cruciate substitution versus retention in TKA. With contributions by eminent specialists in total joint replacement in Asia, Europe, and North America, this volume is a valuable reference for all orthopedic surgeons.

Rapid developments in this successful diagnostic and operative technique have called for a new edition of "Arthroscopy of the Knee Joint." This second edition has been completely revised and retains very little material from the first edition. The diagnostic section has been considerably expanded and elucidated and the operative section adapted to modern technology. The first part of the book presents the external conditions and pre-requisites for diagnostic arthroscopy. The endoscopic anatomy and pathology of the knee joint are covered in detail. Particular emphasis is placed on practical hints for accurate arthroscopic procedures. The second part then discusses operative techniques. The reader discovers step-by-step how and which pathological findings should, in the author's opinion, be treated. Here, too, the problems and possible complications of arthroscopic surgery relevant to the individual techniques are dealt with in detail. Equipped with this book, the reader will be thoroughly informed on all current arthroscopic methods and possibilities.

A different kind of book! The clivus of skull base is an area difficult to reach in neurosurgery, otorhinolaryngolo- gy, maxillo-facial surgery, plastic surgery, reconstructive surgery, and orthopedic surgery. It is for this reason that the various specialities gave found different approaches for different operations.

In response to the great demand for an English edition of the standard German handbook, Systematic Musculoskeletal Examination will soon be available. This comprehensive book contains up-to-date information for the orthopedic examination of the locomotor apparatus. In addition to the well-known techniques of the musculoskeletal examination, it also describes in detail the diagnostic techniques used in manual medicine. The numerous examinations are carried out according to five clearly defined examination stages which are the same for each joint and allow a systematic examination of the individual joint structures for functional disorders or disruptive effects (functional structural analysis). The examination is thus logically organized according to an outline, and the indications for each stage are based on the results of the previous stage and the summary of the functionally related body regions. The functions tests take into account the state of the art in biomechanics, and the symptoms requiring radiologic functional diagnosis are depicted. The systematized and streamlined examination procedure makes it possible to obtain and document results in a uniform manner. The all-inclusive nature of the text, guided by a well-designed systematic and methodical approach, will make it attractive to anyone dealing with the musculoskeletal system.

We shall not, and those who come after us must not, accept the goals that were not reached yesterday as unsurmountable today or tomorrow. We will strive to render the world of the paralyzed-on-wheels but a transitory stop, and settle for nothing short of optimal recovery. N. Eric Naftchi In man, the process of "encephalization" culminates in almost complete control of the brain over the lower centers. Transection of the spinal cord severs the extensions of its nerve fiber tracts running to and from various brain centers. Although there is some confusion on the meaning of spinal shock, it is supposed to last from two to three weeks or longer in man, compared with less than a few minutes in the frog. This is a testimony to the complexity of the suprasegmental control in higher animals. Since the brain exerts its control over the internal environment through several monoamine, amino acids, and peptide neurotransmitters, it should not be surprising if the metabolism of these transmitters is found to be drastically altered along with other physical and metabolic dysfunctions which ensue following the spinal cord section. In spite of the major strides in rehabilitation of traumatic spinal cord injury, our knowledge of the etiology underlying the diverse neurophysiologic derangements remains limited. For instance, we are just becoming aware of some of the changes in the "milieu interieur.

The question facing anyone contemplating a book on low back pain is: Why write another book? It is certainly true that there are many books on this topic addressing a wide variety of audiences. Some books are all inclusive and scholarly in nature, others are personal descriptions of diagnostic and treat ment philosophies. This book is a combination of these two extremes. It represents our views on the low back problem, supported by scientific data. Most aspects on back pain presented in this book can be found in other texts. The organization of the material is unique, however. Our approach is to start by listening to and looking at the patient. It becomes apparent, then, that patients can be classified into one of the syn dromes described in chapters 4 through 13. We believe that this syndrome classification, which is quite simple to make clinically, will allow you to diagnose and treat your patients more effectively. To set the stage for the syndrome chapters the first three chapters of the book are generic to the remaining chapters. They reviewe the epidemiology, pathology, biomechan ics, etiologic theory, diagnostic methods, and treatment modalities applicable to the low back syndromes. They should be read before the syndrome chap ters. At the end of the book you will find four chapters that are specific to disease entities."

..". I would recommend this book for an in-depth analysis of the lumbar spine and its degenerative states ... extremely beneficial for the resident early in trainings as he or she attempts to correlate the complex anatomy of the lumbosacral region with associated pathological states ... Journal of Neurosurgery"

Following a presentation of basic principles of fracture fixation and biomechanical principles the book turns to practical problemsolving areas, namely, the hand, wrist, elbow, shoulder, hip, knee, ankle and foot, and spine, and special problems in children. Internal fixation, including intramedullary nailing and the use of external fixation are described.
Compound fractures are everyday problems, and the principles of their management and practical solutions deserve separate discussion. The value of microsurgical techniques has been underestimated by orthopaedic experts and the indications, choices, and procedures need to be put into proper perspectives.

th This book contains most of the papers presented at the Iy Inter- national Symposium on Bone Circulation which was held in Tou- louse, France, in September of1987. The symposium was attended by over 200 specialists from 17 different countries. Some of them were in Toulouse for the fourth time to discuss their favourite topic of study and research: bone circulation, its exploration, its pathol- ogy. Many, including a group of Japanese orthopaedic surgeons, were present for the first time, delighted to meet the authors of papers they had read. There were more than 100 oral presentations and posters, but many meaningful informal discussions took place both in and outside of the auditorium, in the hall and during meals. The organizers wished to maintain a balance between funda- mental themes and subjects of clinical and practical interest. This balance was accomplished: recent developments including scintig- raphy, magnetic resonance imaging and bone grafts played just as important a part as more sophisticated topics such as the evalua- tion of the blood flow rate in animal bone tissue. Thus, as did the previous symposia, this book aims to present a progress report on developments during the last 5 years in the study of bone circulation. We wish to thank all those who helped and encouraged us throughout the organization of the congress, especially C. Ar- noldi, M. Brookes, R. Burkhardt, L. Coutelier, S.P.F. Hughes, P. Kehr, J.P. Jones, A. Trias, K.Ono, T. Yizkelety and G.J.

Tradi tionally, the International lTV - Conferences on Biomate rials are focussing on problems in Biomedical Engineering, problems, which are still unsolved, of main interest, and which are of interdisciplinary character. In 1983, the Division of Biomedical Engineering of the Institute of Textile Technology and Chemical Engineering, Denkendorf, started wi th a conference about the use of polyurethanes in biomedicine. Three years later, . in 1986, progress in development and use of polyurethanes was selected as conference topic. It had to be realized that degradation problems were still dominating the discussions. The main discussion topics were: What are the causes for the degradation? How can one prevent them? What are the degradation products, and do they affect the human body? How can one simu late the degradation? How can one accelerate the in vitro tests and how can the results predict the in vivo behaviour of the material? How do in vitro tests correlate with animal tests and the behaviour in the human body? At the third conference in 1989, the speakers focused on the use of textiles in medicine. Again the problem of degradation was discussed intensively and demonstrated by the failure of textile implants, the degradation of aramide polymers or the degradation of resorbable suture materials. The examples make clear, that degradation may be a desired or undesired property of an implant."

Many advances have occurred in the last 5 years especially in understanding genetic susceptibility factors, the role of immune response in chronic arthritis and the relationship between cellular processes that underlie inflammation and tissue damage. All these are dealt with in depth in the individual contributions. Genetics studies included illustrate how studies of HLA genes and genes controlling the autoantibody repertoire may be involved. Environmental factors are believed to be important and studies both in humans and in experimental models on the role of viral and bacterial agents are covered. The fascinating relationship between microbes, dysregulated immune responses and oncogenes are also examined. Since autoimmunity is the key aspect of the immunological response in rheumatoid arthritis, the role of antigens is re-examined as is the part played by immune T and B cells. New areas of clinical application of basic science is well presented in this book, forexample, in examining how markers of cartilage destruction may become important in monitoring disease activity. A chapter reviewing possible future novel therapies is included.

The most frequently requested investigation in any nuclear medicine department remains the technetium-99m (99mTc)-labelled diphosphonate bone scan. Despite rapid advances in all imaging modalities. there has been no serious challenge to the role of bone scanning in the evaluation of the skeleton. The main reason for this is the exquisite sensitivity of the bone scan for lesion detection. combined with clear visualisation of the whole skeleton. In recent years several new diphosphonate agents have become available with claims for superior imaging of the skeleton. Essentially. they all have higher affinity for bone. thus allowing the normal skeleton to be visualised all the more clearly. However. as will be dis cussed. this may occur at some cost to the principal role of bone scanning. lesion detection. The major strength of nuclear medicine is its ability to provide functional and physiological information. With bone scanning this leads to high sensitivity for focal disease if there has been any disturbance of skeletal metabolism. However. in many other clinical situations. and particularly in metabolic bone disease. more generalised alteration in skeletal turnover may occur. and quantitation of diphosphonate uptake by the skeleton can provide valuable clinical information."

A major part of orthopedics is the treatment of musculoskeletal diseases caused by structural disorders and mechanical breakdown of living tissue. Therefore, biomechanical consideration of static structures and dynamic mechanisms is compulsory for both diagnosis and treatment of orthopedic diseases. Previous biomechanical studies have enabled great advances in orthopedic implant technology, such as artificial joint replacement and instrumentation for spinal fusion. Consequently the importance of biomechanics is increasing more and more in daily clinical practice and development. In addition, biomaterial research into mechanical properties and tissue reactions of implant materials is certainly an important area of related study. This book is comprised of 22 papers presented at the International Seminar on Biomechanics in Orthopedics and the 17th Annual Meeting of the Japanese Society for Orthopedic Biomechanics, held in Nagoya in 1990. The volume contains full descriptions of both conventional and updated knowledge of the spine, ligaments, artificial joint replacement in the hip and knee, fracture treatment, and gait analysis, as well as biomaterials. I earnestly hope that this book will be of benefit to readers in daily clinical work and research. To close, I would like to thank profoundly the two coeditors, Prof. S.M. Perren and Mr. T. Hattori, and also a quiet supporter Mrs. J. Buchanan in Davos, for their cooperation in producing this book.