[Rare combination injury of traumatic spondylolisthesis of the lumbosacral junction and Malgaigne's C3 fracture of the pelvis : Lessons learned]

This article reports on the case of a rare combination injury of a C3 pelvic ring fracture (Malgaigne's fracture) and simultaneous unstable traumatic spondylolisthesis (Meyerding grade 2) of the lumbosacral spine. The patient had pronounced neurological deficits of the lower extremities and tearing of the thecal sac. The selected primary and secondary surgical treatment algorithm of the polytraumatized patient as well as the course are described and critically discussed on the basis of the sparsely available literature.

Migration pattern of cementless press fit cups in the presence of stabilizing screws in total hip arthroplasty

The aim of this study was to evaluate the initial acetabular implant stability and late acetabular implant migration in press fit cups combined with screw fixation of the acetabular component in order to answer the question whether screws are necessary for the fixation of the acetabular component in cementless primary total hip arthroplasty. One hundred and seven hips were available for follow-up after primary THA using a cementless, porous-coated acetabular component. A total of 631 standardized radiographs were analyzed digitally by the "single-film-x-ray-analysis" method (EBRA). One hundred and one (94.4 %) acetabular components did not show significant migration of more than 1 mm. Six (5.6%) implants showed migration of more than 1 mm. Statistical analysis did not reveal preoperative patterns that would identify predictors for future migration. Our findings suggest that the use of screw fixation for cementless porous-coated acetabular components for primary THA does not prevent cup migration.

[Flexion contracture in haemophilic knee arthropathy--10-year follow-up after hamstring release and dorsal capsulotomy]

INTRODUCTION

The aim of this study was to evaluate the long term results of joint preserving surgery with hamstring release and dorsal capsulotomy for the treatment of therapy resistant knee flexion contracture in patients with severe haemophilia.

METHODS

16 patients having undergone hamstring release and dorsal capsulotomy were prospectively observed and clinically evaluated over a period of at least 10 years. Follow-up was on average 16.6 (10-26) years. The average age at the time of surgery was 29.4 (15-40) years and at the last follow-up 43.0 (29-65) years. Clinical assessment of the patients was performed at least twice per year and outcome was evaluated by using the Score of the Orthopaedic Advisory Committee of the World Federation of Haemophilia (WFH).

RESULTS

The preoperative extension deficit of 21.1+/-1.82 degrees (10-40 degrees) was improved to 16+/-3.6 degrees (5-30 degrees; p=0.54) at the last follow-up. In the first 4 years after surgery there was a noticeable and continuous improvement of the preoperative extension deficit. The clinical score improved from 7.6+/-0.4 preoperatively to 3.8+/-0.4 one year after surgery. 14 years after surgery a significant difference to preoperative values was no longer evident for the remaining 10 patients. The first 4 years after surgery average range of movement (ROM) improved, yet these differences were not statistically significant. Based on the clinical outcomes as described by Rodriguez-Merchan, last follow-up showed one patient with a good, 11 patients with a moderate and 4 patients with a poor postoperative result. The Petterson score showed a marked and significant deterioration from 7 (5-10) to 9 (7-12) points at final follow-up.

DISCUSSION

The joint preserving method of hamstring release and dorsal capsulotomy for the treatment of therapy resistant knee flexion contracture in patients with severe hemophilia does not prevent the progression of haemophilic arthropathy. Despite this, improvement of the flexion contracture leads to a better joint function over a number of years postoperatively. Especially for the younger patient suffering from manifest haemarthropathic changes of the knee joint, this management option is a feasible alternative to at least postpone joint replacement.

Osteoporosis in haemophilia - an underestimated comorbidity?

A relationship between haemophilia and osteoporosis has been suggested, leading to the initiative for a larger study assessing this issue. Bone mineral density (BMD) was measured by osteodensitometry using dual energy X-ray absorptiometry (DEXA) in 62 male patients with severe haemophilia A; mean age 41 +/- 13.1 years, mean body mass index (BMI) 23.5 +/- 3.6 kg m(-2). Using the clinical score suggested by the World Federation of Hemophilia, all patients were assessed to determine the severity of their arthropathy. A reduced BMD defined as osteopenia and osteoporosis by World Health Organization criteria was detected in 27/62 (43.5%) and 16/62 (25.8%) patients, respectively. Fifty-five of sixty-two (88.7%) patients suffered from haemophilic arthropathy. An increased number of affected joints and/or an increased severity were associated with lower BMD in the neck of femur. Pronounced muscle atrophy and loss of joint movement were also associated with low BMD. Furthermore, hepatitis C, low BMI and age were found to be additional risk factors for reduced BMD in the haemophiliac. Our data shows that in haemophilic patients osteoporosis represents a frequent concomitant observation. The main cause for reduced bone mass in the haemophiliac is most probably the haemophilic arthropathy being typically associated with chronic pain and loss of joint function subsequently leading to inactivity. Further studies including control groups are necessary to elucidate the impact of comorbidities such as hepatitis C or HIV on the development of osteoporosis in the haemophiliac.

Zusammenhang zwischen Rückenschmerzen und kernspintomografischen LWS-Befunden bei Hochleistungsvoltigierern

INTRODUCTION

A connection between morphologic lesions of the spine and specific sport disciplines incorporating torsional and hyperextension forces has been found. Although vaulting incorporates a significant amount of figures known from gymnastics, little is known about the influence of this sport on the lower back. The aim of our study was to assess to what extent vaulters suffer from back pain and whether these symptoms correlate to findings in magnetic resonance imaging (MRI) of the lumbar spine.

METHODS

20 high level vaulters ( [see text] age 21.95 [15 - 36] years) were included in the study. Using a standardised questionnaire biometric data, training intensity, localisation as well as intensity of back pain (VAS) was assessed. 12 of these vaulters agreed to an MRI scan of their lumbar spine. Scans were evaluated for morphologic changes using a semiquantative score and the results were correlated to clinical symptoms.

RESULTS

17 / 20 (85 %) reported of back pain of which 15 (75 %) had daily pain, the remaining 2 only occasionally. The average pain intensity on the visual analogue scale (VAS) was reported to be 3.76 +/- 0.53. The MRI scans revealed only slight degenerative changes of the lumbar spine. Statistical analysis of the data (Spearman's rank test) could not show a significant correlation between clinical symptoms and morphologic MRI-changes.

CONCLUSION

Vaulters, compared to riders of other disciplines, seem to suffer from recurrent back pain to a greater extent. Despite the fact that the lumbar spine is confronted with repetitive torsional and hyperextension forces, vaulters do not show undue early degenerative changes or marked lesions of the lumbar spine. Recurrent back pain in the vaulter is most likely due to functional problems. It seems unlikely that is based on manifest morphologic changes of the lower back.

[Epidural varicosis as a rare cause of acute radiculopathy with complete foot paresis--case report and literature review]

INTRODUCTION

Lumbar epidural varicosis presenting with radiculopathy is a seldom anticipated condition. An uncommon case of symptomatic enlargement of epidural veins mimicking lumbar disc herniation led us to perform a literature review to elucidate aetiopathological and diagnostic considerations as well as treatment options of this intraspinal pathology.

METHODS

The case of a 40-year-old woman with acute sciatia accompanied by a complete paresis of foot elevation and extension caused by enlarged epidural veins is described. A literature survey (Medline 1960-2005) was conducted to uncover further cases of symptomatic epidural varicosis.

RESULTS

The literature review revealed only 75 published cases of symptomatic epidural varices which is generally judged as a rare cause of radiculopathy. Different models for the origin of enlarged epidural veins have been proposed. Enlargement may occur primary or secondary to a herniated disc or compressive lesions in the spinal cord. In some cases obstruction or occlusion of the inferior vena cava due to pregnancy or deep vein thrombosis are suspected to increase the pressure of the epidural venous plexi via collateral pathways. MRI has been reported to be of high value in demonstrating the dilated epidural vein, but the findings might be misinterpreted as herniated nucleus pulposus material. Coagulative ablation and/or excision of enlarged epidural veins is recommended and produces good long-term results in cases without extraspinal vessel pathology.

CONCLUSION

Enlargement of epidural veins with compression of lumbar nerve roots can mimic the clinical signs of disc herniation or spinal stenosis, even when accompanied by neurological disorders. Although rare, lumbar epidural varicosis should be appreciated as a possible cause of radiculopathy and diagnosed before surgery. Apart from intraspinal abnormalities causing dilatation of epidural veins, stenosis or occlusion of the extraspinal venous drainage system should be considered.

Einfluss der Reitdisziplin und -intensität auf die Inzidenz von Rückenschmerzen bei Reitsportlern

INTRODUCTION

The connection between morphologic changes of the spine and the intensity of training has been assessed for a number of sport activities. The influence of horseback riding on the spine has only rarely been evaluated. The aim of our study was to evaluate to what degree horseback riders suffer from back pain and whether there is an association between this parameter and the category i. e. the intensity of horseback riding. Furthermore we wanted to judge whether riding may have a positive effect on pre-existent back pain.

METHODS

508 horseback riders (63.2 % females; 36.8 % males) competing in either dressage, showjumping or vaulting were interviewed using a questionnaire. Apart from biometric data, the intensity with which riding was performed and the localisation and intensity (VAS) of back pain was assessed. Furthermore, in the case of existing back pain, riders were asked whether different riding disciplines and paces changed the intensity of pain.

RESULTS

300 dressage riders (59.1 %), 188 showjumpers (37.0 %) and 20 vaulters (3.9 %) with an average age of 33.5 Jahre (12 - 77 years) were questioned. The incidence of back pain was 72.5 %. A significant correlation between back pain and riding discipline respectively gender or riding level could not be found. Discrepancies in VAS-score for dressage riders (3.95 +/- 0.13), show jumpers (4.10 +/- 0.16) and vaulters (3.76 +/- 0.5) were marginal and not significant (p > 0.05). Overall 58.7 % resp. 15.2 % reported to have pain in the lumbar i.e cervical spine. Despite the fact that a large fraction of dressage riders claimed to have problems in these spine areas with 57.7 % resp. 68.8 %, this finding was not significant compared to the other riding disciplines. While 61.6 % of dressage riders reported an improvement of their back pain when riding, this was only the case in 40.9 % of show jumpers.

CONCLUSION

Compared to the general population, a high incidence of back pain is found among riders. A significant correlation between the intensity of riding or the riding discipline and frequency or severity of back pain could not be found. For riders with pre-existent back pain the pace "walk" seems to have a positive influence on pain intensity.

Prävalenz und Stellenwert der Internetnutzung orthopädischer Patienten

AIM

We assessed to what degree orthopaedic patients use the internet as an information platform and how these patients rate the information they obtain over the World Wide Web (WWW).

METHODS

450 consecutive patients consulting the out-patient department of our university clinic for the first time anonymously filled out a three-page questionnaire. Apart from clinical and sociodemographic data, the questionnaire addressed aspects such as the availability of computers and internet. Also, questions concerning the use and interpretation of medical information freely available on the WWW were asked.

RESULTS

402 questionnaires were evaluated. 54 % of the patients stated that they readily had access to the internet. Of the remaining patients without internet access, 19 % planned the installation in the near future. The prevalence of the use of the WWW of patients in the age group up to 40 years was 72 % and in patients over 40 years only 49 %. Compared with internet non-users, internet users were younger (p < 0.001), more frequently men (p < 0.05), and of a higher education level (p < 0.001). 68 % used the internet on a regular basis with regard to queries concerning their health and well being. More than every third patient (38 %) had consulted the internet about the specific orthopaedic ailment prior to seeking advice in our clinic. Almost half of the patients judged the previous treatment to be partially in accordance with the information obtained from the internet. 86 % considered the information obtained over the WWW as helpful or very helpful. 85 % would recommend other patients to use the internet for information concerning their orthopaedic complaint. 65 % of all patients objected to an orthopaedic on-line consultation via internet.

CONCLUSION

The internet seems to be an important source of information for orthopaedic patients. The prevalence concerning the use of the WWW is particularly high in younger, well educated patients.

In-vivo-Analyse zur systemischen Verteilung von metallischen Abriebpartikeln

AIM

The aim of this study was to elucidate whether there is a systemic spread of wear debris from peripherally applied stainless steel and titanium particles into the blood and subsequently to parenchymatous organs. Furthermore, we report on histological findings at the implantation site.

METHOD

In Syrian Gold hamsters we implanted 2 mm3 wear debris of stainless steel and titanium into the dorsal skin fold chamber. Over a period of 2 weeks we took blood samples and afterwards explanted the implant area, the heart, lung, liver and spleen. One half of the organs and the implant area were used for histological analysis. The other half of the organs and the blood samples were analysed by optical emission spectrometer with inductively coupled plasma and graphite furnace atomic absorption spectrophotometry for their contents of chromium, nickel and titanium.

RESULTS

In the group with titanium particles, histological analysis of the implant site showed moderate phagocyted wear in granulocytes but no other pathological findings. Animals treated with stainless steel wear debris had a massive inflammatory reaction, in some cases leading to necrosis. The analysis of the blood and one half of the organs showed increased levels of chromium and, already 24 hours after implantation, raised values for nickel. The result of the hamsters treated with titanium showed significantly elevated levels of titanium ions in the organs, but not in the blood samples. Histology of the organs did not reveal pathological findings.

CONCLUSION

In this study we could show a massive inflammatory reaction for stainless steel wear debris in contrast to titanium wear debris at the implantation site. The elevated blood levels of chromium and increased values of other metals in the organs suggest the haematogenic distribution of ions from the peripherally implanted wear debris.

Successful pain treatment in arthropathic lower extremities by acupuncture in haemophilia patients

Acupuncture is successfully used in the treatment of degenerative osteoarthritis. The treatment of haemophilic arthropathies can require strong painkillers with severe side-effects. Therefore, a special yet simple acupuncture technique was evaluated in the treatment of these joint problems. Twelve patients with a factor VIII activity<1% and at least one painful arthropathy in both lower extremities were included in this single-blinded study. The non-treated side served as a control. Treatment was assessed by a visual analogue scale (VAS) and an orthopaedic clinical examination. Only one needle was inserted at the rear fontanelle once per week and in 15 cycles. Ten of 12 patients showed an improvement of their pain perception. The average VAS could be reduced from 6.8 to 5.0. The side not receiving treatment showed a reduction from 4.1 to 4.0. No side-effects were observed. Even though interpretation of our data are limited due to the small patient numbers, significant improvement of the VAS after treatment suggests that acupuncture has a measurable positive effect in pain management for haemophilic arthropathy of the lower extremities.

[Quality analysis of internet information on epicondylitis radialis humeri]

AIM

By means of conventional internet search engines we assessed the World Wide Web for the topic "epicondylitis radialis humeri" and analysed the content of the listed pages for their quality and transparency.

METHODS

Three of the most frequently used internet search engines were utilised to search the World Wide Web for the terms "tennis arm", "tennis elbow" and "epicondylitis". The first 50 listed internet addresses per search engine were scrutinised in respect to the authors' source, financier of the web page and whether commercial interests were evident. Furthermore, the medical content concerning radial epicondylitis was analysed using a 10-point score.

RESULTS

After elimination of repetitive and not accessible internet pages, as well as web pages only giving links to further web-sites or chat-rooms, we were able to evaluate 137 internet sites. The average content-score of all pages was low with 2.91 +/- 3.27 SD. Web-pages, where authorship could not be identified or where commercial interests were clearly evident, had the lowest content-scores. Sites authored by or associated with orthopaedic surgeons had a significantly higher content-score (6.84 +/- 3.17 SD) in comparison to other initiators of web-pages (p < 0.0001).

CONCLUSION

The facts derived from the World Wide Web when searching for information on epicondylitis radialis humeri are mostly of low professional quality and transparency. Orthopaedic surgeons need to point out this problem to patients who additionally inform themselves on the internet. If the desire for browsing the web for further information concerning musculoskeletal pathology exists, orthopaedic surgeons should tell their patients which web sites are suitable.

Coccygectomy for Coccygodynia: Does Pathogenesis Matter?

BACKGROUND

Severity of vertical impact to the coccyx can range from mere contusion to a dislocated fracture of the coccyx. With early conservative management, most patients have a good prognosis and heal within weeks to months after the initial trauma. Occasionally, persisting symptoms make a surgical intervention with coccygectomy necessary.

METHODS

We report on the results of patients surgically managed for traumatically induced, persisting coccygodynia and compare these to patients operatively treated for idiopathic coccygodynia. Sixteen patients with an average follow-up of 7.3 years were evaluated. Of these, eight were surgically treated for traumatic and eight for idiopathic coccygodynia. The clinical results were assessed by means of the Hambly Score and the Oswestry Low Back Pain Disability questionnaire. Patient satisfaction with the postoperative result was assessed by a visual analog scale.

RESULTS

Seven of eight (88%) patients treated for traumatically induced coccygodynia had a good or excellent postoperative result, in contrast to only three of eight (38%) patients with idiopathic coccygodynia. The former group had better results in terms of sitting tolerance and general pain intensity as represented by the Oswestry Low Back Pain Disability questionnaire. According to the significantly better clinical results, personal satisfaction was clearly higher in the traumatic group.

CONCLUSION

These results suggest that, in patients where all conservative treatment methods work to no avail, particularly those with traumatically induced persisting coccygodynia benefit from surgical intervention with coccygectomy.

[Rare differential diagnosis of a degenerative cervical syndrome: an arteriovenous meningeal fistula of the sigmoid sinus]

A 65-year-old patient was referred to our clinic with persisting, severe tinnitus aurium. Due to the facts that prior otolaryngological as well as neurological assessment had been unremarkable and that the patient showed marked degenerative changes in the cervical spine the referring orthopaedic surgeon suggested the cause to be of vertebral origin. Case history showed that the tinnitus had spontaneously occurred and was pulse synchronous. Overall clinical evaluation of the cervical spine was inconspicuous. A brachialgia or other symptoms typically associated with a degenerative cervical syndrome could not be provoked. On the basis of this atypical clinical picture we performed a digital subtraction angiography (DSA) to exclude pathology in the vicinity of the cerebral vessels. This revealed an arteriovenous fistula of the sigmoid sinus which was then, under the auspices of our neurosurgeons, successfully closed by Gugliemo coil embolism. The patient reported that the tinnitus subsided almost immediately. This case demonstrates that despite the manifold pathology that is associated with degenerative cervical syndrome, pulse synchronous tinnitus aurium needs further clarification. Had the case history been taken more accurately and the quality of the tinnitus assessed earlier, the period between onset of symptoms and correct treatment could have been decreased significantly.

Sakrumfraktur als seltene Frühkomplikation nach lumbosakraler Spondylodese

A 57 year old patient with secondary cortisone induced osteoporosis war surgically treated by means of posterior lumbar interbody fusion with internal fixation from L4-S1 for symptomatic instability in the level L4/5 after previous dorsal stabilisation L5/S1. After an unapparent initial postoperative phase, the patient complained of severe pain in the low back and gluteal region 9 day after surgery. Radiographs as well as CT-scans showed a horizontal fracture of the sacrum. After a short period of immobilisation the patient was carefully remobilised with an orthesis and the pain gradually subsided. Conventional radiographs one year later showed complete consolidation of the fracture and a good clinical result. There are only two literature reports with together 3 cases of patients attaining an early sacral fracture after spondylodesis. The main cause seems to be the unphysiological biomechanical stress placed on the osteoporotic sacrum after moresegmental spondylodesis. Further risk factors seem to be adipositas, female gender and age. Despite the rarity of sacral fractures after lumbosacral fusion, this complication should at least be considered in the differential diagnosis in patients who complain of persisting or sudden-onset pain after surgery.

[Invasive chondrosarcoma of the thoracic spine as a rare cause of acute paraplegia]

We report on the case of a invasive chondrosarcoma of the thoracic spine in a 65-year-old woman as a rare cause of acute paraplegia.

[Residual stability of different interbody fusion techniques after pedicle screw loosening]

INTRODUCTION

In spinal surgery, postoperative failure of pedicle screw instrumentation due to loosening of the implant at the bone-screw interface is a clinically relevant problem. While there are numerous biomechanical studies dealing with stability after internal fixation, little is known about the remaining segmental stability after pedicle screw loosening. We hypothesize that, in cases of implant loosening, the remaining stability is dependent on whether the segment received an isolated pedicle screw instrumentation or a 360 degrees instrumentation.

METHODS

Motion analysis was performed under static, damage-free, sagittal strain (preload 100 N) on intact (controls) and posterior monosegmental L5/6 destabilized lumbar spines of sheep. Spine preparations underwent a flectional torque. Changes of spinal profile were radiographically documented, digitalized and then evaluated. Primary insertion of the conical pedicle screws was performed with a torque of 1.4 Nm. Pedicle screw loosening was simulated by turning the inserted screw back either 180 degrees or 540 degrees . Specimens instrumented with screws of differing diameters (5.5 mm and 6.7 mm) as well as non-instrumented pedicles were also compared.

RESULTS

Independent of the type of instrumentation, we found that a loosening of pedicle screws increased remaining segmental motion. In maximal flexion (20 degrees ) and loosening of pedicle screws by 540 degrees, we found a statistically significant increase of remaining segmental motion with sole pedicle instrumentation (- 3.1 degrees ) in contrast to 360 degrees instrumentation (- 1.6 degrees ). For extension, a significant discrepancy between the two stabilization methods could not be shown. In cases where screws were firmly inserted, there was no advantage of using pedicle screws with an increased diameter of 6.7 mm. Independent of the type of fixation method, 5.5 mm screws that were inserted in widened pedicles showed a marked decrease of primary segmental stability.

CONCLUSION

This study suggests that, concerning the remaining stability, 360 degrees instrumentation is superior in cases where pedicle screw loosening has occurred. The screw diameter plays an only subordinate role in primary segmental stability when the pedicle screws are inserted firmly.

[Effectiveness of interscalene plexus block for open subacromion decompression]

AIM

The aim of this study was to assess the influence of interscalene brachial plexus blocks on the functional outcome, subjective pain appraisal and patient satisfaction after open shoulder surgery. These results were compared with patients treated by conventional analgesic measures.

METHOD

23 patients with interscalene brachial plexus block (ISB) and 21 patients without ISB were evaluated preoperatively as well as 1, 7, 12 and 90 days after open surgery of the shoulder. By means of a visual analogue scale (VAS) subjective postoperative pain intensity was assessed. Using the Constant score preoperatively and 6 months after surgery the functional status of the treated shoulder was evaluated. At discharge from hospital patients were asked whether they were satisfied with the analgesic measures taken.

RESULTS

The range of motion of the shoulder of patients treated with an ISB was significantly higher 1 and 7 days after surgery than those without ISB. 12 and 90 days postoperatively the range of motion in the ISB group was still higher, but no longer statistically significant. Assessment of the postoperative subjective pain status showed that patients with an ISB had significantly lower values and required less additional analgesia. In both groups the Constant score was significantly higher 6 months after surgery, compared to the preoperative condition. Compared to the control group, patients treated with ISB were clearly more satisfied with the postoperative pain management.

CONCLUSION

By implementing ISB sufficient analgesia in the early postoperative period after open shoulder surgery is attained, allowing for early physiotherapy. This positively influences convalescence and the outcome of the surgical procedure. Furthermore, patients are visibly more satisfied with the postoperative pain management.

MRT nach Rekonstruktion der Supraspinatussehne: MR-tomographische Befunde

AIM

The value of MRI for pre-operative evaluation of the rotator cuff is proven. In spite of its clinical relevance, there have been only few studies on MR imaging of patients who have already been operated. Thus, the question rises to what extent the post-operative MRI can contribute to the evaluation of the integrity of the rotator cuff.

METHOD

At least 10 months after successful open repair of the supraspinatus tendon, mostly combined with Neer's anterior acromioplasty, an MR scan was performed on 33 shoulders. Only patients satisfied with the outcome of surgery and showing a Constant score of 65 to 100 points were included.

RESULTS

More than half the patients had positive direct diagnostic criteria for a full- or partial-thickness tear of the supraspinatus tendon, in the form of signal intensity or morphological alterations. In addition, the indirect diagnostic criteria described by Zlatkin, such as the absence of the subacromial-subdeltoid fat or the appearance of subacromial-subdeltoid fluid, were often positive. Atrophy of the supraspinatus muscle, as a further indirect diagnostic criterion of a rupture, was also frequently noted.

CONCLUSION

Taking the excellent clinical outcome of our patients into consideration, this study shows that caution should be taken in evaluating postoperative MR images. There is a high risk of over-interpreting MR findings.

[Value of sonography after rotator cuff repair: a comparison with MRI and clinical results]

AIM

How well do ultrasound- and MRI-results after rotator cuff reconstruction correlate with postoperative clinical findings?

METHODS

Ultrasound- and MR-imaging of the afflicted shoulder on 40 patients who were surgically managed for isolated tear of the tendon of supraspinatus was performed at least 24 months after intervention. Patients were also clinically assessed. Based on the clinical result, sensitivity and specificity for the two imaging procedures was determined.

RESULTS

Only 11 (27.5%) patients had a completely inconspicuous ultrasonography. By ignoring the sonographic parameter "echogenicity" this number was raised to 29 (72.5%) patients. Without the above mentioned parameter ultrasonography demonstrated a good specificity (90.3%) yet a poor sensitivity (33.3%). Incorporation of "echogenicity" markedly weakened both values. MR-imaging showed an intact cuff in 32 (80%) patients, 5 (12.5%) had signs for a partial tear and in 3 (7.5%) a recurrent tear was diagnosed. Based on the clinical result, MR-imaging showed sufficient specificity (87.1%), yet also a poor sensitivity (44.4%).

CONCLUSION

After rotator cuff repair MRI- and ultrasound-findings frequently stand in distinct discrepancy to clinical results. Based on clinical findings, postoperative MR-imaging shows a slightly higher sensitivity than ultrasonography. Despite this, both radiographic methods do not allow deductions concerning the clinical outcome. The postoperative shoulder-scan and MRI should therefore be interpreted with utmost care. Symptoms and functional results are of high clinical relevance in the assessment of the postoperative shoulder.

Die Steißbeinresektion in der Behandlung der Kokzygodynie

AIM

Excision of the coccyx for the treatment of therapy-resistant coccygodynia is a disputable management option. Due to the low morbidity only few studies concerning the long-term follow-up after coccygectomy exist. The aim of this study is a retrospective analysis of our patients surgically managed for coccygodynia and a critical review of the results obtained in comparison to the literature.

METHOD

12 patients with complete radiographic and clinical data were included in the study. The average age of patients at the time of surgery was 43.3 years (11 - 75 years). The average follow-up was 9.8 years (2 - 16 years). As suggested by Hambly (1989) the clinical result was assessed according to postoperative pain status and subjective patient satisfaction.

RESULTS

9 of 12 patients regarded the surgical intervention as a success and claimed that they would repeat the procedure (75 %). Three patients did not show marked improvement after coccygectomy. All patients (n = 6) surgically managed for traumatically induced coccygodynia had a positive result, while only 3/6 patients treated for idiopathic coccygodynia reported that symptoms were postoperatively reduced.

CONCLUSION

According to our results and review of those documented in the literature, excision of the coccyx for the treatment of coccygodynia, after all conservative treatment options have been exhausted, seems a justifiable alternative. Patients with a history suggestive of traumatically induced coccygodynia are more likely to benefit from coccygectomy.

Fu�verletzung als seltene Ursache einer Scedosporiose mit letalem Ausgang

After an attempted suicide with a fall from a height of 5 m, a 33 year old male suffered a subarachnoidal haemorrhage, an instable fracture of the second lumbar vertebra as well as a soft-tissue decollément in the vicinity of the right heel. Despite surgical management, the comatose patient showed slow wound-healing of the heel, making revision-surgery necessary 10 days after the first treatment. Fungi were histologically recognised, and subsequent culturing identified Scedosporium apiospermum. Systemic antimycotic therapy with itraconazol (800 mg/d) was immediately initiated. Despite this, S. apiospermum was repeatedly found in wound swabs over the following 2 weeks. After 4 weeks, a radiographically verified osteomyelitis of the calcaneus was diagnosed and local debridement was once again performed. After 5 days, an MRI of the cranium suggested an abscess in the posterior horn of the left lateral ventricle. Itraconazol was altered to voriconazol (4 mg/kg body weight). Neurosurgical opening of the abscess and subsequent culturing once again showed S. apiospermum. CT-scans performed over the following period showed an increase in lesions in the brain suggestive for numerous abscesses. At 78 days after the initial trauma, the still comatose patient died due to a massive cerebral haemorrhage. Microbiological assessment of the soil at the site of injury revealed S. apiospermum.

[Effect of posterior lumbar interbody fusion on the lumbar sagittal spinal profile]

AIM

To determine the effect of different cage geometries and posterior instrumentation on the sagittal spinal profile after monosegmental lumbar interbody fusion.

METHOD

The study is based on a retrospective analysis of 119 patients with segmental instability, who were surgically managed by monosegmental PLIF with PEEK-Cages and dorsal instrumentation.

RESULTS

At radiographic follow-up after surgery we found a significant improvement of the lumbar sagittal spinal profile, independent of the cage geometry utilised. A marked discrepancy between 0 degrees -standard and 4 degrees -trapezoid implants concerning the radiographic parameters lumbar lordosis, disc height, correction of spondylolisthesis and sacral inclination was not found. With the use of 4 degrees optimised cages in segment L4/5 slightly better results for segmental lordosis were obtained. Reliability of the radiographic evaluation, expressed as intra-observer error, was satisfactory. Cage geometry did not have an effect on the clinical result. By combining interbody fusion with pedicular instrumentation the reposition of slipped vertebra and distraction of the interbody space could more effectively be achieved. Patients without dorsal instrumentation had a higher rate of pseudarthrosis as well as a less satisfactory clinical outcome.

CONCLUSION

These results show that normal sagittal alignment after single-level lumbar fusion can be achieved with rectangular and 4 degrees -wedged cages. Although results after utilization of 4 degrees -wedged cages do not significantly differ, these implants offer the surgeon one more sizing variation with which physiological lumbar lordosis may be attained. The combination of intersomatic implants with dorsal instrumentation achieves a more precise realignment and has a lower rate of cage-associated complications. It therefore seems prudent that an interbody fusion for the surgical management of lumbar segmental instability should be combined with pedicular instrumentation.

Haemophilic arthropathy of the hip in children--prognosis and long-term follow-up

The aim of this study was to report on the long-term follow-up of haemophilic children with avascular femoral head necrosis and to determine whether radiographic findings at initial diagnosis have any prognostic value. Seven patients with avascular necrosis of the femoral head were clinically and radiographically observed over a period of 5-50 years. The average age of patients at first diagnosis was 7.1 years. At follow-up, three of seven patients claimed to have occasional mild pain in the affected hip, four of seven showed loss of range of motion in the hip joint and two of seven patients showed a limp. Only one patient was clinically completely inconspicuous. The radiographically measured caput-collum-diaphysis angle at follow-up was pathologic in four cases and in one case a lateral subluxation of the femoral head was found. There was marked deformation of the femoral head in three of seven cases and a further two hips showing slight incongruency. Owing to the small patient-number, a statement concerning the prognostic value of defined radiographic signs cannot be made. As expected, the more 'risk signs' radiographically found, the higher the likelihood that patients will suffer arthrosis at a later stage. We propose that a clear distinction between haemophilic arthropathy of the hip and Legg-Calvé-Perthes disease should be made. In cases where radiographic changes are also found in the vicinity of the acetabulum, it is indicative for haemophilic arthropathy.

Long-term follow-up after osteotomy for haemophilic arthropathy of the knee

In this study the long-term value of corrective osteotomy around the knee was evaluated by means of clinical and radiographic parameters. Between 1974 and 1984 we performed 52 corrective osteotomies in the vicinity of the knee on patients affected by haemophilic arthropathy. Forty-two patients (45 osteotomies) were adequately followed-up at an average 11.6 years postoperatively. Using the clinical score of the Advisory Committee of the World Federation of Haemophilia, 38 patients showed a postoperative improvement, five remained clinically unchanged and two showed deterioration. Range of motion of the knee joint did not significantly improve postoperatively. The radiographic Pettersson score showed only a marginal decrease by an average 0.003 points at the time of follow-up. Only one patient needed subsequent joint replacement of both knees, on the left side 13 years after osteotomy and on the right side 8 years after osteotomy. Even in cases of marked radiographic joint destruction, corrective osteotomy shows acceptable long-term clinical results, underlining the feasibility of this management option in the treatment of haemophilic arthropathy of the knee. Although moderate cartilage degenerations in the femoropatellar complex and in the contralateral compartment can be tolerated, this therapy should primarily be contemplated for those patients where damage is unicompartmental and a corresponding axial deviation is found. Particularly the younger patient can benefit from this treatment option in that joint replacement may possibly wholly be avoided or at least postponed to a later stage of life.

Microvascular response of striated muscle to metal debris. A comparative in vivo study with titanium and stainless steel

Wear products of metal implants are known to induce biological events which may have profound consequences for the microcirculation of skeletal muscle. Using the skinfold chamber model and intravital microscopy we assessed microcirculatory parameters in skeletal muscle after confrontation with titanium and stainless-steel wear debris, comparing the results with those of bulk materials. Implantation of stainless-steel bulk and debris led to a distinct activation of leukocytes combined with a disruption of the microvascular endothelial integrity and massive leukocyte extravasation. While animals with bulk stainless steel showed a tendency to recuperation, stainless-steel wear debris induced such severe inflammation and massive oedema that the microcirculation broke down within 24 hours after implantation. Titanium bulk caused only a transient increase in leukocyte-endothelial cell interaction within the first 120 minutes and no significant change in macromolecular leakage, leukocyte extravasation or venular diameter. Titanium wear debris produced a markedly lower inflammatory reaction than stainless-steel bulk, indicating that a general benefit of bulk versus debris could not be claimed. Depending on its constituents, wear debris is capable of eliciting acute inflammation which may result in endothelial damage and subsequent failure of microperfusion. Our results indicate that not only the bulk properties of orthopaedic implants but also the microcirculatory implications of inevitable wear debris play a pivotal role in determining the biocompatibility of an implant.

Clinical and radiographic scores in haemophilic arthropathies: how well do these correlate to subjective pain status and daily activities?

Haemophilic patients who reached adulthood before the establishment of prophylactic treatment frequently show multiple and substantial arthropathies. The aim of this study was to determine to what extent haemophiliac's subjective impairment due to arthropathies correlates with objective clinical and radiographic parameters. By means of a questionnaire and a visual analogue scale, we consulted 79 haemophiliacs concerning their joint-pain status, how these were treated and to what extent their daily activities had been affected. Using a scoring system suggested by the Advisory Committee of the World Federation of Haemophilia, clinical evaluation was performed. Radiographs of 60 patients were assessed by means of the Petterson scale. The results were statistically compared. We found a significant correlation between pain intensity and clinical pathology as well as between pain intensity and radiographic joint damage for both knees and for the right ankle. The number of painful joints correlated well with the number of clinically/radiographically affected joints. The more pronounced the objective damage to joints, the more frequently patients claimed to have constant pain, depressive episodes and a dependency on pain-relieving medication. The more pronounced the objectively assessed damage to the knee and ankle joint, the higher the likelihood that the patient suffers from severe joint pain and reduction of activity. Treatment of painful symptoms from arthropathies is often insufficient. Scores and questionnaires may help to define the haemophiliacs pain status more clearly, thereby offering a possibility of assessment and long-term observation.

[Striated muscle microvascular response to implants with sol-gel calcium phosphate coating. A comparative in vivo study]

AIM

Local microvascular perfusion plays an important role in reparative processes and the pathogenesis of infection. The impairment of skeletal muscle microcirculation by a biomaterial may therefore have profound consequences. The aim of our study was to determine whether the biological acceptance of the widely utilised implant material stainless steel can be improved by a coating of sol-gel calcium phosphate.

METHODS

Using the hamster dorsal skinfold chamber preparation and intravital microscopy, we quantified nutritive perfusion and leukocyte-endothelium interaction in skeletal muscle after implantation of sol-gel calcium phosphate-coated stainless steel- and commercial pure titanium implants, and compared these results to those obtained with uncoated stainless steel and titanium.

RESULTS

Within the first 24 h after implantation, animals with calcium phosphate coated stainless steel showed a significantly lower inflammatory response than did those with an uncoated stainless steel implant. After 24 h the quantified microcirculatory parameters deteriorated for animals with a calcium phosphate-coated stainless steel plate, indicating that, for as yet unknown reasons, the shielding mechanism of the calcium phosphate seems to deteriorate. Although not as inert as pure titanium, we found a relatively low inflammatory response for calcium phosphate coated titanium over the whole observation period, suggesting that the coating as such is well tolerated by the skeletal muscle microcirculation.

CONCLUSIONS

Our in vivo results suggest that the biological acceptance of a conventional stainless steel implant can be improved over a short term by a sol-gel coating of calcium phosphate. Concerning tolerance by the local vascular system, commercially pure titanium currently remains unsurpassed.

Long-term observation and management of resolving infantile idiopathic scoliosis a 25-year follow-up

Of 42 patients with resolving infantile idiopathic scoliosis, 34 were followed up for more than 25 years. Twenty had been primarily treated in a plaster bed and 14 by physiotherapy. The mean angle of the curve at presentation was 17 degrees and at follow-up it was 5 degrees. No patient had significant progression of the scoliosis during the growth spurt. When adults few had back pain or an increased disability score and there was no interference with work or social activities. The rib-vertebra angle difference proved to be an essential radiological sign when distinguishing resolving from progressive infantile idiopathic scoliosis. There was no advantage of plaster over physiotherapy with regard to either the time to resolution or the functional outcome. Treatment of resolving infantile idiopathic scoliosis in a plaster bed is therefore now outdated.

[Rare differential diagnosis of disk prolapse with foot-lifting pareses: Spontaneous intramedullary hemorrhage]

We report on a case of spontaneous intramedullary hemorrhage initially misdiagnosed as a lumbar nucleus pulposus prolapse due to the clinical appearance and findings on CT-scan.

Long-term observation and management of resolving infantile idiopathic scoliosis

Of 42 patients with resolvingscoliosis, 34 were followed up for more than 25 infantile idiopathicyears. Twenty had been primarily treated in a plaster bed and 14 by physiotherapy. The mean angle of the curve at presentation was 17° and at follow-up it was 5°. No patient had significant progression of the scoliosis during the growth spurt. When adults few had back pain or an increased disability score and there was no interference with work or social activities. The rib-vertebra angle difference proved to be an essential radiological sign when distinguishing resolving from progressive infantile idiopathic scoliosis. There was no advantage of plaster over physiotherapy with regard to either the time to resolution or the functional outcome. Treatment of resolving infantile idiopathic scoliosis in a plaster bed is therefore now outdated.

[Primary subcutaneous hematogenous osteomyelitis in childhood]

The most frequent form of bone infection is haematogenous osteomyelitis (HOM), typically affecting infants and children. Dependent on the virulence of the pathogen and the patients immune response, one can distinguish between the acute (AHOM) and primary subacute haematogenous osteomyelitis (PSHO). In contrast to AHOM, diagnosis of PSHO is severely impeded in that clinical and blood-chemistry findings usually do not enable differentiation from primary malignant bone tumors. With a comparable age predilection and clinical symptoms, as well as very similar conventional radiographic, MRI- and bone-scan-findings, the most important differential diagnosis is Ewing's-sarcoma. The here demonstrated case of a 12 year-old girl shows that PSHA may imitate a sarcoma very closely, even concerning such usually fairly reliable radiographic aspects like osteolysis and lamellar periostal bone reaction. Despite the use of MRI, the diagnosis initially remained uncertain and a malignant bony lesion could only be ruled out after open biopsy and histopathological evaluation.

[The posterior lumbar interbody fusion with cages (PLIF) and transpedicular stabilization]

The development of intervertebral cages has significantly innovated the original technique of posterior lumbar interbody fusion (PLIF). In this study we present the results of patients treated for degenerative or postoperative segmental spinal instabilities by PLIF with cages and pedicular stabilisation (360 degrees-instrumentation). Between 1992 and 1999 we implanted either CFRP-, PEEK- or Titanium-cages in 86 patients. 78 patients were adequately followed up over a period of at least 12 months (average 2,6 years). 5 patients were stabilised over 2 segments, so that ultimately 83 fused segments were evaluated.15% of all patients had an excellent, 51% a good, 28% a moderate and 5% an insufficient clinical result. Degenerative instabilities had a better outcome with 73% good or excellent clinical results, compared to postoperative instabilities (56%). Based on stringent radiographic fusion criteria we found true bony fusion in 52% of all segments after 12 months, 63% after 24 months, 72% after 36 months, and 78% after 48 months. In 21 segments cage packing was performed with autologous spongiosa, while in 62 segments a combination of cortical bone and spongiosa obtained from osseous structures at the operation-site were used as packing material. At the 24 month radiographic control we found a slightly higher fusion rate for those segments treated with autologous spongiosa obtained from the iliac crest. Neither for cages nor for pedicular screws was implant failure or material fatigue found. Serious entero-, pulmo-, cardio- or urological complications were not observed. Nonetheless the necessity for operative revision was 9%. A postoperative semiquantitative evaluation of segments neighbouring the fused vertebra revealed in 28% an increase in degenerative changes. Particularly after 360 degrees-instrumentation, interpretation of the fusion-status should be based on structural and not on functional criteria. The modification of PLIF with cages compared to the use of only autologous spongiosa has the advantage of a high primary stability. Long-term studies are necessary to determine the implications of a radiographically evident uncertain fusion-status.

[Extracorporal shock wave treatment of the achilles tendinitis: Experimental and preliminary clinical results]

OBJECTIVE

Various studies have shown the benefit of extracorporal shock wave therapy (ESWT) in the treatment of soft tissue pathologies. The aim of this prospective study was to compare the results of ESWT with the operative treatment for achilleus tendopathy. Furthermore mechanical effects of the shock waves on the achilleus tendon were analysed by an in-vitro model.

METHOD

The achilleus tendons of common pigs treated with 1500 impulses twice using an energy varying from 0.23 - 0.54 mJ/mm (2) were histologically examined. The clinical results of two patient groups of which the first (n = 28) was treated with 2000 impulses (0.23 mJ/mm (2)) once and the second (n = 26) underwent surgery for achilleus tendopathy were compared.

RESULTS

The in-vitro model demonstrated that an EFD of 0.42 and 0.54 mJ/mm (2) can lead to tendon lesions. One year follow-up showed good and excellent results in 69 % and satisfactory results in 15 % of the operated group and good and excellent results in 29 % and satisfactory results in 43 % of the ESWT group. We could show a time-dependent effect of the shock wave treatment on the clinical outcome.

CONCLUSIONS

Follow-ups show acceptable results with little side effects when an energy flow density (EFD) under 0.23 mJ/mm (2) is used. ESWT offers a non-invasive therapeutic concept that can seriously be contemplated before operative treatment, but lower success rates in comparison to the operative results can be expected.

Long-term follow-up after intertrochanteric varus osteotomy for haemophilic arthropathy of the hip

In view of an increasing tendency in prosthetic management of haemophilic arthropathy, we intended to evaluate the efficacy of corrective osteotomy of the hip, specifically taking long-term clinical and radiographic results into consideration. Eleven hips affected by haemarthropathy in nine patients suffering from severe haemophilia A were treated with an intertrochanteric varus osteotomy. The average follow-up period was 15 small middle dot4 years. The preoperative clinical score of the Advisory Committee of the World Federation of Haemophilia was 5 small middle dot3 points (range 4-7) and the Pettersson score was 6 small middle dot4 points (range 2-10). The average WFH score at follow-up had increased to 3 small middle dot6 points. Seven hips showed clinical improvement, two hips showed a postoperative deterioration while a further two hips remained unchanged. The Petterson score increased to an average of 7 small middle dot7 points. Here the radiographs of six patients indicated postoperative deterioration, three remained unaltered and two showed improvement. Our study cannot conclusively answer whether intertrochanteric varus osteotomy for haemophilic arthropathy of the hip is always a feasible alternative to joint arthroplasty. The decision for or against this procedure must be individually assessed and the patient must be thoroughly informed about the advantages and disadvantages of both procedures.

Impact of a nickel-reduced stainless steel implant on striated muscle microcirculation: a comparative in vivo study

The impairment of skeletal muscle microcirculation by a biomaterial may have profound consequences. With moderately good physical and corrosion characteristics, implant-quality stainless steel is particularly popular in orthopedic surgery. However, due to the presence of a considerable amount of nickel in the alloy, concern has been voiced in respect to local tissue responses. More recently a stainless steel alloy with a significant reduction of nickel has become commercially available. We, therefore, studied in vivo nutritive perfusion and leukocytic response of striated muscle to this nickel-reduced alloy, and compared these results with those of the materials conventional stainless steel and titanium. Using the hamster dorsal skinfold chamber preparation and intravital microscopy, we could demonstrate that reduction of the nickel quantity in a stainless steel implant has a positive effect on local microvascular parameters. Although the implantation of a conventional stainless steel sample led to a distinct and persistent activation of leukocytes combined with disruption of the microvascular endothelial integrity, marked leukocyte extravasation, and considerable venular dilation, animals with a nickel-reduced stainless steel implant showed only a moderate increase of these parameters, with a clear tendency of recuperation. Titanium implants merely caused a transient increase of leukocyte-endothelial cell interaction within the first 120 min, and no significant change in macromolecular leakage, leukocyte extravasation, or venular diameter. Pending biomechanical and corrosion testing, nickel-reduced stainless steel may be a viable alternative to conventional implant-quality stainless steel for biomedical applications. Concerning tolerance by the local vascular system, titanium currently remains unsurpassed.

Radiographic characteristics on conventional radiographs after posterior lumbar interbody fusion: comparative study between radiotranslucent and radiopaque cages

The problem of determining solidity of a fused spinal segment still remains. Our purpose is to evaluate radiographic findings after posterior lumbar interbody fusion (PLIF) with cages and estimate their relative value in judging fusion status. Radiographic follow-up was performed in patients after PLIF with cages of either radiotranslucent or radiopaque material. Conventional radiographs were obtained 6 weeks, 3 and 6 months, and then yearly after surgery for spinal instability for 64 patients. We differentiated between uncertain (increased density within the cage, increase of sclerotic endplates, and posterolateral fusion) and definite (trabecular continuous bone bridging within the implant and periimplant new bone formation with bridging of the intervertebral space) fusion signs. A fusion rate of 51.5% after 12 months, 61.4% after 24 months, 66.7% after 36 months, and 77.8% after 48 months postoperatively was found. We found only a slight, nonsignificant correlation between radiographic fusion and patient-assessed clinical outcome. There is evidence that radiographic fusion criteria occur in a specific chronologic order. The interpretation of fusion status is notably impaired by the use of radiopaque cages. Criteria to standardize the interpretation and evaluation of radiographic findings after PLIF are discussed.

Implications of orthopedic fretting corrosion particles on skeletal muscle microcirculation

Particulate corrosion and wear products of metal implants are increasingly becoming topics of interest, due to the cascade of biological and biomechanical events they induce. The impairment of skeletal muscle microcirculation by fretting corrosion particles may have profound consequences. We therefore studied in vivo leukocyte-endothelial cell interaction in skeletal muscle after confrontation with characterized titanium and stainless steel fretting corrosion particles, and compared these results with those of the bulk materials. Using the hamster dorsal skinfold chamber preparation and intravital microscopy, we could demonstrate that stainless steel induces a more pronounced inflammatory answer in contrast to the implant material titanium. However, we were not able to show a general benefit of bulk vs. debris. Overall, the study suggests that not only the bulk properties of orthopaedic implants, but also the microcirculatory implications of inevitable wear debris, may play a role in determining biocompatibility and ultimately longevity of an implant. The skinfold chamber is a feasible and versatile model for observation of the dynamic process of microvascular response after foreign-body implantation, and offers much perspective.

Soft-tissue angioleiomyoma of the hand as a rare differential diagnosis of haemophilic pseudotumour

The benign vascular tumours known as angioleiomyomas, which originate from smooth muscle cells of arterial or venous walls are rare, particularly in the region of the hand. Frequently, the diagnosis is only made after surgical extirpation and histological assessment. The occurrence of an angioleiomyoma in a haemophiliac has not yet been reported, to our knowledge. A 62-year-old patient with a haemophilia B complained of increasing pain in the vicinity of the soft tissue covering the carpo-metacarpophalangeal joint of his left palm. In the T1-weighted magnetic resonance images a hypointense well-demarcated mass was found, showing a homogeneous enhancement after intravenous application of contrast medium. T2-weighted images showed a hyperintense signal. Based on clinical and radiographic findings, the tumour was initially thought to be a haemophilic pseudotumour arising from a prior local haematoma. Intraoperatively, the mass was found to be solid, and histological assessment diagnosed an angioleiomyoma, without signs of malignant transformation. Descriptions of the clinical symptoms of angioleiomyoma in an extremity vary considerably in the literature. Although rare, the vascular leiomyoma should therefore be contemplated in the differential diagnosis in patients with a solid nodular lesion of unclear aetiology in arms or legs. Especially in a haemophiliac patient, the growth can easily be mistaken for a pseudotumour because of its clinical and radiological similarities.

Pain status of patients with severe haemophilic arthropathy

Patients with severe haemophilia A growing up before the establishment of prophylactic treatment frequently developed significant haemarthropathies. The goal of the following study was to clarify the role of haemarthropathic pain for haemophilic patients. Furthermore, we aimed to determine to what degree daily activities are influenced by the impairment and which therapeutic modalities are used in pain management. Using a questionnaire we consulted 71 haemophiliacs concerning their complaints and how they were treated in 1999 (average age 43 years; range 21-63 years). The pain in the large joints and spine and the effect of specific treatment was estimated by a visual analogue scale. On average, there were four joints with major pain and 0.5 with minor pain. The most frequent sources of pain were the ankle joints (45%), followed by the knee (39%), spine (14%) and elbow (7%). Fifty percent of all patients complained of pain throughout the day if no treatment was applied. In 29% of patients, pain persisted after application of factor VIII (FVIII), while 12% claimed that pain still remained after use of FVIII and pain killers. Restriction in activities of daily life was reported by 89% of the group and 85% reported on an impact of pain on their mood. Patients primarily used FVIII to decrease pain, followed in frequency by use of anti-inflammatory drugs, orthopaedic footwear, liniments and bandages. Haemophilic patients with haemarthropathy are chronic pain patients. By means of the questionnaire, it is possible to reveal the 'silent' sufferers. Sufficient pain treatment is essential so as to increase the patient's quality of life and avoid inadvertent abnormal postures possibly resulting in increased loading of joints and subsequent bleeding episodes.

Radiographic spinal profile changes induced by cage design after posterior lumbar interbody fusion preliminary report of a study with wedged implants

STUDY DESIGN

A prospective comparative radiographic study between two geometrically varying implants utilized in single-level posterior lumbar interbody fusion (PLIF) was performed.

OBJECTIVE

The aim of this study was to determine the influence of 4 degrees wedged cages on postoperative lateral lumbar spinal profile.

SUMMARY OF BACKGROUND DATA

The biomechanical and clinical importance of realigning the sagittal lumbar profile in surgical management of spinal instabilities is known. Wedged cages are therefore increasingly attaining popularity in PLIF. As yet the significance of wedged implants on postoperative sagittal spinal profile has not been assessed.

METHODS

Forty patients were randomly assigned to two equal-sized groups. In one group rectangular cages and in the second group cages with a wedged design and an inclination of 4 degrees were implanted. Quantitative assessment of the lumbar spinal profile on standing neutral lateral radiographs was performed before surgery as well as 6 weeks and 12 months after surgery. Results were statistically compared.

RESULTS

A significant improvement of lumbar sagittal profile after use of 4 degrees wedged compared with nonwedged cages was not found. The greatest effect on lumbar profile and segmental lordosis was observed in fusion of segment L4-L5 with 4 degrees wedged cages.

CONCLUSIONS

These results show that normal sagittal alignment after single-level lumbar fusion can be achieved with rectangular and 4 degrees wedged cages. Although results after utilization of 4 degrees wedged cages do not significantly differ, these implants offer the surgeon one more sizing variation with which physiologic lumbar lordosis may be attained. The biomechanical implications of wedged implants on the rigidity of a fused segment remain to be analyzed.

Radiological signs of osteitis around extramedullary metal implants. A radiographic-microbiological correlative analysis in rabbit tibiae after local inoculation of Staphylococcus aureus

Radiographic changes in the early stages of osteomyelitis may be subtle and, especially after plate osteosynthesis, frequently missed. A previously described experimental model of local bacterial infection was used in an attempt to determine the reliability of specific changes on conventional radiographs for the diagnosis of osteitis after metal-plate implantation and subsequent inoculation of Staphylococcus aureus in rabbit tibiae. Roentgenograms of the treated limbs were evaluated, and seven radiographic parameters, to which numerical scores were assigned, were determined for each bone. Our results substantiate the conclusion that a radiographically verified periosteal reaction is a constant and early skeletal feature of acute osteomyelitis and has the strongest association to the microbiological results (P < 0.05), emphasising its high predictive value. Plate implantation does not notably impede the diagnosis of osteomyelitis. An association between the amount of inoculated bacteria and the extent of radiographic changes could be found. The results of this present study closely resemble those described in man and suggest that this model may be useful for future experimental investigations in determining a score judging the severity of osseous involvement in local bacterial infection after plate osteosynthesis.

Three-dimensional ultrasonography in the diagnosis of rotator cuff lesions

Two-dimensional (2-D) ultrasound (US) of rotator cuff lesions is a well-established tool. The aim of this study was to elucidate if the use of 3-D sonography can increase the diagnostic yield of US. A total of 40 patients were preoperatively evaluated using 2-D and 3-D sonography, and these results were compared to intraoperative findings. Ultrasound was performed on a 530D US machine (Kretztechnik, Zipf, Austria) with a 10-MHz transducer. We found an increased validity of 3-D imaging, mainly based on the higher reliability in the diagnosis of partial-thickness cuff lesions. Sensitivity and specificity were found to be 91% and 82% for 3-D sonography and 74% and 82% for 2-D sonography, respectively. With 3-D US partial-tear rotator cuff lesions can be predicted more accurately.

[Orthopedic aspects of osseous echinococcosis--radiologic diagnosis, current surgery and drug therapy aspects]

PURPOSE

Skeletal manifestation of alveolar (E. multilocularis) or cystic (E. granulosus) echinococcosis is seldom, with an incidence of less than 2% of all cases. By reporting on a rare case of bony manifestation of E. granulosus, we intend to emphasize current standards in surgical and drug management of the disease. Typical radiographic and blood-chemistry findings are highlighted on a 62-year-old Arabiqu female suffering from a cystic echinococcosis with skeletal manifestation in the left ileum and lower lumbar spine.

RESULTS

Radiographically typical are fine zones of osteolysis which, at a later stage, show confluence. Due to the rigid structure of cortical bone, cysts tend to grow slowly, and seldom exceed 2 cm in diameter. Only after having broken through the cortical bone, may a massive increase in size be observed. By means of serological tests, it is postoperatively possible to evaluate how successful radical surgery with removal of larvae was. Furthermore, serological tests can be used as a screening method, offering a diagnostic tool that can also utilized in detecting a recurrence.

CONCLUSION

The surgical aim in the treatment of osseous echinococcosis should be in accordance to curative tumor surgery. Even after radical removal of the parasites, the WHO suggests an adjuvant chemotherapy with mebendazole or albendazole for at least two years after surgery. In cases where only a palliative treatment is possible, the antihelminthic drug administration can be continuous.

[Differential diagnosis of osteoarthropathia hypertrophicans]

PURPOSE

Chief clinical symptoms of HOA are bone and joint plain, nearly always coupled with finger and toe clubbing. The classification of HOA distinguishes between a very seldom primary (PHOA) and the more frequent secondary hypertrophic osteoarthropathy (SHOA). The pathogenesis of the disease is as yet not wholly understood, but there is a tendency that it may be a bony manifestation of a paraneoplastic syndrome.

RESULTS

By means of two cases, one a 72-year old patient with pulmonary carcinoma, the second a 48-year-old patient with a long standing history of COPD, we demonstrate and discuss typical clinical, laboratory, radiographic, and scintigraphic findings associated with SHOA. Primarily the patients consulted an orthopaedic surgeon due to persisting, localised osseous pain. Clubbing of fingers and toes as well as soft tissue swelling usually remain asymptomatic. Characteristically a symmetrical diaphyseal accumulation of periosteal calcification in the vicinity of short and long cortical bones becomes radiographically apparent. Early diagnosis is best facilitated by means of a bone scan, where the symmetrical increase in bone activity and the typical "double stripe sign" can be observed.

CONCLUSION

In patients in whom unexplained periosteal reaction is found and phalangeal clubbing becomes evident, the diagnosis of SHOA should be contemplated and further tests performed, so as to rule out a paraneoplastic syndrome.

[Non-cerebrovascular complication in chirotherapy manipulation of the cervical vertebrae]

PURPOSE

Chirotherapy is a popular and successful management option for reversible functional disorders of the cervical spine. Though rarely observed, complications do occur, mainly involving the cerebrovascular system. By means of the here described case and a literature survey, we aim to highlight non-cerebrovascular complications of chirotherapeutic cervical spine manipulation.

RESULTS

A 43-year-old male initially consulted an ENT specialist, suffering from tinnitus aurium and loss of hearing ability. His hearing significantly increased after intravenous drug therapy, but the tinnitus remained. During chiropractic manipulation of the cervical spine by an orthopaedic surgeon for the tinnitus, the patient described severe neck pain following a clearly audible clicking sound. Scans of the cervical spine prior to and after manipulation showed an intracapsular/intraosseus oedema of the facet joints C2/C3 with lesion of the nerve root C3, most probably induced by chirotherapy.

CONCLUSION

Although complications after chiropractic manipulation are extremely rare, treatment of the spine, especially the cervical spine, is not wholly harmless. An adequate history taking followed by clinical and radiographic patient evaluation is necessary to keep the risk of iatrogenic trauma at a minimum. Above all, the chiropractic manipulation of the cervical spine belongs in the hands of a qualified and experienced medical practitioner.

[Secondary hypertrophic osteoarthropathy. Differential diagnosis of post-traumatic ossification of the interosseous crural membrane]

The case of a 48-year-old patient is presented, suffering from persisting pain in the right lower leg for more than a year following a distortion of the ankle. The patient was known to have a history of severe asthmatic disease. Conventional X-rays showed a periostitis of the lower tibia and fibula. To exclude a malignant process, an open biopsy was performed. Neither tumor nor any histological signs of chronic inflammation were found. The patient claimed to have a similar pain in the contralateral lower leg 5 months after initial biopsy. X-rays again showed signs of a periostitis of the tibia and fibula. Furthermore, an increase in isotopes in this area was found in a performed bone scan. Diagnosis of osteoarthropathia hypertrophicans was confirmed 2 years after onset of the first symptoms. Pathogenetic variables both of the primary and secondary forms of hypertrophic osteoarthropathy (HOA) are as yet not completely clarified. Secondary hypertrophic osteoarthropathy (SHOA) may be defined as a syndrome of the long bones with clubbing of the fingers and toes, and occurs in the process of chronic lung and mediastinal disease. We conclude that HAO detection may contribute to early detection of lung disease, especially bronchopulmonary cancer, before it becomes clinically and radiographically manifest.

[Differential diagnostic considerations in microcephalic dwarfism]

PURPOSE

While the rare Seckel-Syndrome is defined by clear criteria, clinical and radiologic findings for microcephalic osteodysplastic primordial dwarfism (MOPD) make an exact diagnosis and classification difficult. By comparing our patients to previously described cases of MOPD we evaluate the hypothesis that this disorder has a greater heterogeneity than has been believed up until now. Furthermore the differential diagnosis of the MOPD-complex is discussed.

RESULTS

Two cases that show typical growth retardation, microcephalus and facial anomalies as well as osteodysplastic deformities including hip dysplasia are presented. The parents of both children are consanguineous and of Arabic race. In one of the children growth hormone levels were noticeably decreased. In discrepancy to the Seckel-syndrome both children showed no signs of mental retardation, therefore the classification into the heterogeneous group of microcephalic osteodysplastic primordial dwarfism (MOPD) is the most likely diagnosis.

CONCLUSION

It is suggested that microcephalic osteodysplastic primordial dwarfism (MOPD) has a greater clinical and radiological expression than has been assumed up until now. Whether our results are merely a variant or suggest a new subtype of the MOPD can only be resolved by further cases. The exact pathogenesis of the disease currently remains unknown but the most probable cause is an autosomal recessive inheritance.

[Dorsal lumbar interbody implantation of cages for stabilizing segmental spinal instabilities]

PURPOSE

The technique of posterior lumbar interbody fusion (PLIF) has been critically discussed due to a high degree of complications, including the development of pseudarthrosis. With the recent establishment of intercorporeal implants new aspects have to be contemplated in surgical techniques, especially concerning the posterior approach. In this study we present our first results after intercorporeal stabilisation of segmental spinal instabilities utilising carbon and titanium cages.

METHOD

45 spinal instabilities were surgically stabilised in 42 patients who were evaluated on average for 2.8 years post-operatively. 12 patients had isthmic and 19 patients degenerative instabilities while 11 patients suffered from instabilities resulting from prior spinal surgery.

RESULTS

Assessed according to the Hambly-score, 69% of the patients had an excellent or good result; 2 (4.8%) patients were subjectively worse off than before surgical treatment. After implantation of cages precise radiological evaluation of bony ingrowth is frequently impaired by artefacts. We found that three months after implantation of a titanium cage, which had to be removed after incorrect placement, no bony consolidation was visible. Persisting or recurrent instabilities in fused segments were not recorded.

CONCLUSION

By means of PLIF and implantation of cages the interbody space is reconstructed and jeopardized neural structures are decompressed. In addition to this, the frequently osteochondrotically degenerated segment is immobilized. The posterior approach allows decompression of neural structures and, with comparable results concerning stability, the considerable risks of the ventral approach are avoided.

Striated muscle microvascular response to silver implants: A comparative in vivo study with titanium and stainless steel

Local microvascular perfusion is the primary line of defense of tissue against microorganisms and plays a considerable role in reparative processes. The impairment of the microcirculation by a biomaterial may therefore have profound consequences. Silver is known to have excellent antimicrobial activity and, although regional and systemic toxic effects have been described, silver is regularly discussed as an implant material in bone surgery. Because little is known about the influence of silver implants on the adjacent host tissue microvasculature, we studied in vivo nutritive perfusion and leukocytic response, and compared these results with those of the conventionally used materials titanium and stainless steel. Using the hamster dorsal skinfold chamber preparation and intravital microscopy, the implantation of a commercially pure silver sample led to a distinct and persistent activation of leukocytes combined with a marked disruption of the microvascular endothelial integrity, massive leukocyte extravasation, and considerable venular dilation. Whereas animals with stainless-steel implants showed a moderate increase in these parameters with a tendency to recuperate, titanium implants caused only a transient increase of leukocyte-endothelial cell interaction within the first 120 min and no significant change in macromolecular leakage, leukocyte extravasation and venular diameter. After 3 days, five of six preparations with silver samples showed severe inflammation and massive edema. Thus, the use of silver as an implant material should be critically judged despite its bactericidal properties. The implant material titanium seems to be well tolerated by the local vascular system and currently represents the golden standard.