Mediating Medical Comorbidities in Geriatric Patients Undergoing Surgery for OVCF: From Preoperative Screening to Risk and Outcomes Optimization.

OBJECTIVES: Osteoporotic vertebral compression fractures (OVCF) are a common increasing entity in elderly patients and represent a tremendous economic burden. Surgical treatment is related to high complication rates and little is known about patient-specific and internal risk factors associated with poor clinical results. METHODS: We carried out a comprehensive, systematic literature search according to the PRISMA checklist and algorithm. Risk factors for perioperative complications, for early inpatient readmission, for the duration of the hospital stay, the hospital mortality, the total mortality and the clinical result were analyzed. RESULTS: A total of 739 potentially usable studies were identified. After considering all inclusion and exclusion criteria, 15 studies with 15,515 patients were included. Non-adjustable risk factors were age >90 years (OR 3.27), male gender (OR 1.41), BMI less than 18.5 kg/m2 (OR 3.97), ASA score >3 (OR 2.7), activity of daily live (ADL) (OR 1.52), dependence (OR 5.68), inpatient admission status (OR 3.22), Parkinson disease (OR 3.63) and disseminated cancer (OR 2.98). Adjustable factors were insufficient kidney function (GFR <60 mL/min, and Creatinine Clearance below 60 mg/dl) (OR 4.4), nutrition status (hypalbuminemia (<3.5 g/dl)), liver function (OR 8.9) and further cardiac and pulmonary comorbidities. DISCUSSION: We identified a couple of non-adjustable risk factors, which should be considered preoperatively in terms of risk assessment. However, even more important were adjustable factors that can be influenced preoperatively. In conclusion, we recommend a perioperative interdisciplinary cooperation, especially with geriatricians, to achieve the best possible clinical results in geriatric patients undergoing surgery for OVCF.

OF-Pelvis classification of osteoporotic sacral and pelvic ring fractures.

OBJECTIVES: Osteoporotic fractures of the pelvis (OFP) are an increasing issue in orthopedics. Current classification systems (CS) are mostly CT-based and complex and offer only moderate to substantial inter-rater reliability (interRR) and intra-rater reliability (intraRR). MRI is thus gaining importance as a complement. This study aimed to develop a simple and reliable CT- and MRI-based CS for OFP. METHODS: A structured iterative procedure was conducted to reach a consensus among German-speaking spinal and pelvic trauma experts over 5 years. As a result, the proposed OF-Pelvis CS was developed. To assess its reliability, 28 experienced trauma and orthopedic surgeons categorized 25 anonymized cases using X-ray, CT, and MRI scans twice via online surveys. A period of 4 weeks separated the completion of the first from the second survey, and the cases were presented in an altered order. While 13 of the raters were also involved in developing the CS (developing raters (DR)), 15 user raters (UR) were not deeply involved in the development process. To assess the interRR of the OF-Pelvis categories, Fleiss' kappa (κF) was calculated for each survey. The intraRR for both surveys was calculated for each rater using Kendall's tau (τK). The presence of a modifier was calculated with κF for interRR and Cohen's kappa (κC) for intraRR. RESULTS: The OF-Pelvis consists of five subgroups and three modifiers. Instability increases from subgroups 1 (OF1) to 5 (OF5) and by a given modifier. The three modifiers can be assigned alone or in combination. In both surveys, the interRR for subgroups was substantial: κF = 0.764 (Survey 1) and κF = 0.790 (Survey 2). The interRR of the DR and UR was nearly on par (κF Survey 1/Survey 2: DR 0.776/0.813; UR 0.748/0.766). The agreement for each of the five subgroups was also strong (κF min.-max. Survey 1/Survey 2: 0.708-0.827/0.747-0.852). The existence of at least one modifier was rated with substantial agreement (κF Survey 1/Survey 2: 0.646/0.629). The intraRR for subgroups showed almost perfect agreement (τK = 0.894, DR: τK = 0.901, UR: τK = 0.889). The modifier had an intraRR of κC = 0.684 (DR: κC = 0.723, UR: κC = 0.651), which is also considered substantial. CONCLUSION: The OF-Pelvis is a reliable tool to categorize OFP with substantial interRR and almost perfect intraRR. The similar reliabilities between experienced DRs and URs demonstrate that the training status of the user is not important. However, it may be a reliable basis for an indication of the treatment score.

Burst fractures lead to a fracture-associated intervertebral vacuum phenomenon: a case series of 305 traumatic fractures of the thoracolumbar spine.

PURPOSE: Intervertebral vacuum phenomenon (IVP) is mainly seen as a sign of degenerative disc diseases. Although studies have shown that IVP also occurs after traumatic injuries to the spine, its clinical relevance in spinal fractures remains unknown. Therefore, the aim of this study was to analyse the prevalence, demographic parameters and fracture morphology in patients with fracture-associated IVP (FAVP) of the thoracolumbar spine. METHODS: In this retrospective cohort study, patients with traumatic fractures of the thoracolumbar spine who were admitted between January 2014 and December 2015 were included. CT scans were assessed for the presence of intervertebral areas of gaseous radiolucency, which were defined as IVP. Fractures were classified according to the AOSpine Thoracolumbar Spine Injury Classification System. Demographic and anamnestic data, including age, sex and trauma mechanism, were documented. RESULTS: A total of 201 patients with 305 fractures were included. Seventy-three patients with 98 fractures had follow-up CTs. Sixty-eight patients had IVP, of whom 46 patients had FAVP. On the follow-up CT, a significant correlation was found between A3 fractures and FAVP, while initial FAVP was significantly correlated with age and low-velocity trauma mechanisms. Initial degenerative IVP also showed a significant correlation with age. CONCLUSIONS: FAVP occurred significantly more often in burst fractures and therefore may lead to disc degeneration due to nutritional supply disturbances via the vertebral endplate. As surgical management strategies for burst fractures are intensively discussed, the appearance of FAVP should be taken in consideration.

A Systematic Review on the Value of Infrared Thermography in the Early Detection of Periprosthetic Joint Infections. / Infrarotthermografische Untersuchungen nach endoprothetischem Gelenkersatz ­ ein systematisches Review.

BACKGROUND: Variations in the temperature of body and skin are symptoms of many pathological changes. Although joint replacement surgery of hip and knee has been very successful in recent decades, periprosthetic infection is a growing problem and the number one reason for revision. While many studies have investigated changes in blood levels, investigation of temperature has not been performed on a regular basis. The objective of this work is to determine whether reference literature exists for the infrared thermographic examination in knee and hip arthroplasty and if reference values can be derived for the methodology or if there is a peri- and postoperative benefit. MATERIAL UND METHODS: By means of a systematic online database search and based on the Cochrane, PICOT and PRISMA guidelines, this systematic review retrieved 254 studies. All publications with thermographic examination in arthroplasty of the hip and knee were imbedded. 249 studies were excluded due to the defined inclusion and exclusion criteria and five studies with 251 patients have finally been included in the evaluation process. This was followed by an analysis and discussion of the methodology. RESULTS AND CONCLUSION: Infrared thermography is a useful tool in the perioperative care of patients after arthroplasty of the knee and hip joint. The technology is portable, easy to use and non-invasive. Based only on these few publications, values can be derived, which provide a guidance for the thermographic aftercare in arthroplasty surgery.

Influence of clodronate and compressive force on IL-1ß-stimulated human periodontal ligament fibroblasts.

OBJECTIVES: The aim of this study was to investigate in vitro the effect of clodronate on interleukin-1ß (IL-1ß)-stimulated human periodontal ligament fibroblasts (HPdLFs) with the focus on inflammatory factors of orthodontic tooth movement with and without compressive force. MATERIALS AND METHODS: HPdLFs were incubated with 5 µM clodronate and 10 ng/mL IL-1ß. After 48 h, cells were exposed to 3 h of compressive force using a centrifuge. The gene expression of cyclooxygenase-2 (COX-2), interleukin-6 (IL-6), matrix metalloproteinase 8 (MMP-8), and the tissue inhibitor of MMP (TIMP-1) was analyzed using RT-PCR. Prostaglandin E2 (PGE-2), IL-6, and TIMP-1 protein syntheses were quantified via ELISA. RESULTS: Compressive force and IL-1ß induced an overexpression of COX-2 gene expression (61.8-fold; p < 0.05 compared with control), diminished by clodronate (41.1-fold; p < 0.05 compared with control). Clodronate slowed down the compression and IL-1ß induced IL-6 gene expression (161-fold vs. 85.6-fold; p < 0.05 compared with control). TNF-α was only slightly affected without statistical significance. Clodronate reduced IL-1ß-stimulated MMP-8 expression with and without compressive force. TIMP-1 on gene and protein level was downregulated in all groups. Analyzing the MMP-8/TIMP-1 ratio, the highest ratio was detected in IL-1ß-stimulated HPdLFs with compressive force (21.2-fold; p < 0.05 compared with control). Clodronate diminished IL-1ß-induced upregulation of MMP-8/TIMP-1 ratio with (11.5-fold; p < 0.05 compared with control) and without (12.5-fold; p < 0.05 compared with control) compressive force. CONCLUSION: Our study demonstrates a slightly anti-inflammatory effect by clodronate under compressive force in vitro. Additionally, the periodontal remodeling presented by the MMP-8/TIMP-1 ratio seems to be diminished by clodronate. CLINICAL RELEVANCE: Reduction of pro-inflammatory factors and reduction of periodontal remodeling might explain reduced orthodontic tooth movement under clodronate intake.

Perception of esthetic orthodontic appliances: An eye tracking and cross-sectional study.

OBJECTIVE: To evaluate the perception of esthetic orthodontic appliances by means of eye-tracking measurements and survey investigation. MATERIALS AND METHODS: En face and close-up images with different orthodontic appliances (aligner appliance [a], aligner appliance and attachments [b], lingual appliance [c], ceramic brackets [d], no appliance [e; control]) were shown to 140 participants. Eye movement and gaze direction was recorded by eye-tracking system. For different anatomical areas and areas of the appliances, time to first fixation and total fixation time were recorded. The questions included in a visual analog scale regarding individual sentiency were answered by the participants. RESULTS: For all groups, the anatomical landmarks were inspected in the following order: (1) eyes, (2) mouth, (3) nose, (4) hair, and (5) ears. Only in group d, first fixation was on the mouth region (1.10 ± 1.05 seconds). All appliances except the lingual appliance (1.87 ± 1.31 seconds) resulted in a longer fixation on the mouth area (a, 2.97 ± 1.32 seconds; b, 3.35 ± 1.38 seconds; d, 3.29 ± 1.36 seconds). For close-up pictures, the fastest (0.58 seconds) and longest (3.14 seconds) fixation was found for group d, followed by group b (1.02 seconds/2.3 seconds), group a (2.57 seconds/0.83 seconds), and group c (3.28 seconds/0.05 seconds). Visual analog scale scoring of questions on visibility were consistent with eye-tracking measurements. With increasing visibility, the feeling of esthetic impairment was considered higher. CONCLUSIONS: Lingual orthodontic appliances do not change how the face is perceived. Other esthetic orthodontic appliances may change the pattern of facial inspection and are different in subjective perception.

An Overview of the Current State of Pediatric Scoliosis Management.

Historically pediatric scoliosis represents a condition deeply rooted within the origins of orthopedic surgery. Today only a few subspecialized surgeons treat pediatric scoliosis patients. In severe cases surgery can hold progression of and correct pathologic spinal curvature. The goal of this article is to provide an overview of the current state of pediatric scoliosis management. It aims to increase the attention of general physicians and orthopedic surgeons to a niched but rather frequently encountered pediatric pathology to facilitate early recognition and diagnosis. A thorough research of literature was conducted to summarize the different scoliosis types, their etiology and presentation. Classification, normal human growth phases and curve progression risk have been further elaborated. Finally, current treatment options with their benefits, shortcomings and complications were laid out and discussed. Among the etiological groups a focus was put on idiopathic scoliosis, in particular adolescent idiopathic scoliosis as the most frequently encountered subtype.

Soft Tissue Sarcoma - a Current Review of the Diagnostic and Treatment Strategies. / Weichteilsarkome ­ eine Übersicht aktueller evidenzbasierter Behandlungskonzepte.

Soft tissue sarcomas are a heterogeneous group of neoplasias that due to their often clinically silent appearance often remain undetected or experience delayed treatment. Especially soft tissue swelling is often misinterpreted by patients and doctors and trivialized or verified with an incorrect biopsy technique. The hereby evoked complications for the patients are serious and may be reduced by simply following the available guidelines. The treatment of soft tissue sarcomas requires a close interdisciplinary coordination between specialists in tumor orthopedics, oncology, radiology, pathology and radiotherapy. On the basis of a selective literature review, the following article points out the current evidence on the treatment and illustrates a treatment algorithm.

Laser-based Techniques for Microcirculatory Assessment in Orthopedics and Trauma Surgery: Past, Present, and Future.

: Microcirculatory integrity and proper function are the cornerstones to tissue nourishment and viability. In the clinical environment extended immobility, injuries, and inflammatory reactions demand local microcirculatory adaption to provide adequate supply. Assessment of endothelial adjustment capability and microcirculatory perfusion status, as direct or surrogate markers of disease, are therefore of uttermost interest to the treating physician. Given the simple, noninvasive, nonradiating nature of laser-based techniques for bedside or intraoperative microcirculatory perfusion assessment, this article's objective is to present a comprehensive overview of available techniques, their technological aspects, and current application. Advantages of individual methods are pointed out and compared with each other. The areas of medical utilization relevant to orthopedics and trauma surgery are exemplified and their available evidence elaborated. A particular focus is put on laser speckle contrast imaging, with its current and future influence on medical practice.

Bone Metastases - Pathophysiology, Diagnostic Testing and Therapy (Part 2). / Knochenmetastasen ­ Pathophysiologie, Diagnostik und Therapie (Teil 2).

The second part of this review deals with the several options for the surgical therapy of bone metastases according to their anatomical site and the patient's individual prognosis. Although metastases to the bone - with few exceptions - are normally given palliative therapy, patients nowadays reach survival times of several months to years, depending on the underlying tumour entity. Scoring systems are suitable to estimate the patient's prognosis and fracture risk. The indication for operation has to be adapted to these parameters. In order to preserve a high quality of life, a limb saving procedure has to be aimed at. The options include the resection of the metastasis with stabilisation, the sole stabilisation of the affected bone, and wide resection with limb reconstruction using a modular tumor endoprosthesis. With today's anaesthesiological peri- and intraoperative care, a vast number of surgical implants and bone augmentations are available. However, what is important is not the practicability of the procedure, but the oncological justification and patient-adapted selection of surgical therapy.

Who profits from three-dimensional optics in endoscopic surgery? Analysis of manual tasks under two-dimensional/three-dimensional optic vision using a pelvic trainer model.

Background: In endoscopic operations, direct binocular view, tissue sensation and depth perception get lost. It is still unclear whether the novel three-dimensional (3D) high-definition (HD) cameras are able to compensate the limited senses and how this affects the skill set of users with different endoscopic experience. This study aimed first to evaluate if the 3D technology improves depth perception, precision and space orientation as compared to conventional two-dimensional (2D) HD technology. The second aim was to determine the 3D influence on participants with different endoscopic experience. Methods: A total of 24 participants of different experience levels performed three different tasks on a pelvic trainer using the same thoracoscopic unit in 2D and 3D modes. Results were statistically analysed using Student's t-test and Pearson's product-moment correlation. Results: Across all the participants, we found that 3D optic vision significantly reduced the needed time to perform a defined difficult task in comparison to 2D. This difference was less pronounced in participants with higher experience level. Participants with eyeglasses performed slower in both 2D and 3D in comparison to participants with normal vision. Only participants with normal vision could significantly improve their completion times with 3D optic vision. Conclusions: By testing the novel generation of 3D HD cameras, we could demonstrate that the 3D optic of these systems improves depth perception and space orientation for novices and experienced users and especially inexperienced users benefit from 3D optic.

3-D Optics for Thoracoscopic Vertebral Body Replacement - Essential Technical Progress or Just Nice to Have? / Die dreidimensionale Optik für den thorakoskopischen ventralen Wirbelkörperersatz ­ notwendiger Fortschritt oder nur "nice to have"?

BACKGROUND: Three-dimensional (3-D) endoscopic optics use 2 cameras to simulate the different perspectives of the right and left eye, creating the illusion of spatial depth. Optimised orientation as well as improved hand-eye coordination compared to 2-D-optics could be proven in standardised test setups (black box) and in laparoscopic use. This retrospective study examines whether these results can also be applied to thoracoscopic vertebral body replacement at the thoracolumbar junction. HYPOTHESES: 1. Ventral vertebral body replacement using 3-D-thoracoscopy results in a shorter operation time than with 2-D-thoracoscopy. 2. Perioperative blood loss is less, due to better spatial orientation (faster haemostasis) and reduced tissue laceration. MATERIAL AND METHODS: 29 patients met the inclusion criteria of this retrospective study. Between 08 - 2012 and 08 - 2017, all of these received ventral thoracoscopic vertebral replacement at the thoracolumbar junction (Th11 to L2). Patients with additional anterior procedures (e.g. anterolateral plate) were excluded. Perioperative data such as blood loss, duration of surgery and length of hospital stay were analysed. Conventional 2-D-optics were used in n = 14 patients and 3-D-optics in 15 patients. Aesculap EinsteinVision® 2.0 was used as the 3-D-optics. Statistical significance was calculated using Student's t-test. RESULTS: The most common diagnosis was a L1 fracture (n = 18, 62%). Mean OR time was 24 minutes shorter in the 3-D group (149 ± 29, 107 - 198 min) than in the 2-D group (173 ± 39, 125 - 260 min), but this difference was not significant. Total perioperative blood loss in the 3-D group was significantly lower than in the 2-D group (**p = 0.043). Proportional intraoperative blood loss in the 3-D group was also lower (mean around 115 ml), but not significantly so. Significantly lower values were found for the delivery rate of the thoracic drainage in the 3-D group (248 vs. 560 ml, *p = 0.195). Inpatient stay with the 3-D group was on average 1.5 days (d) shorter (8.7 d for the 3-D group, 10.2 d for the 2-D group) but this difference was not significant (p = 0.27). CONCLUSION: Thoracoscopic-assisted vertebral body replacement at the thoracolumbar junction is a safe and reliable surgical procedure using conventional 2-D-optics or the new 3-D-optics. Both methods allow thoracoscopic vertebral body replacement in comparable operation times but in our study the 3-D group presented with significantly lower postoperative blood loss. Due to the small number of cases and because of the retrospective design, the present study is considered to be a pilot study only.

Heterotopic Ossification - Complication or Chance? / Heterotope Ossifikation ­ Komplikation oder Chance?

So far, there has been no clear explanation of the pathophysiological relationships in the development of HO. There is little experimental data dealing with the post-traumatic inflammatory response in terms of a balance between the repair of damaged muscle cells and the opposite response in its development. There are numerous indications regarding possible predisposing factors, such as existence of surrounding tissue hypoxia or the function of pro-angiogenic (VEGF e.g.) and osteoinductive (BMP e.g.) factors. These different scientific approaches offer the opportunity to clinically intervene. In our opinion, early intervention seems to make the most sense in terms of effectiveness and recurrence of HO. An important pathomechanism seems to be chronic inflammation. Currently, non-steroidal anti-inflammatory drugs are the most commonly prescribed prophylaxis drugs. The effectiveness and efficacy of non-steroidal anti-inflammatory drugs is limited by the time-limited release and the side effect potential. Therefore, it is interesting to focus future research towards the cross-talks between immunosuppressive downregulation of the inflammatory response and its effect on the balance between muscle regeneration and the development of HO.

Medial patellofemoral ligament reconstruction fails to correct mild patella alta in cases of patellofemoral instability-a case-control study.

PURPOSE: Medial patellofemoral ligament reconstruction (MPFL-R) is the gold standard in patella soft tissue surgery for patellofemoral instability. Although claimed, recent reports indicate that MPFL-R may fail to distalize the patella in mild cases of patella alta. The present study is a retrospective case-control study to compare radiographic patella height between MPFL-R and historical Insall's proximal realignment (IPR) pre- and post-operatively with respect to distalization and assess redislocation rates at a mid-term follow-up. METHODS: Sixty-four patients were age/sex matched (1:1), yielding 32 patients for group 1 MPFL-R (cases) and 32 patients for group 2 IPR (controls). Insall-Salvati, Blackburne-Peel and Caton-Deschamps indices were analyzed for differences pre- and post-operatively. An additional inter-rater reliability analysis was performed by means of intra-class correlation (ICC). Redislocation rates were considered as treatment failures in this study. RESULTS: ICC was excellent for all three patella indices. MPFL-R failed to show significant differences if compared to IPR with respect to distalization in mild stages of patella alta. Moreover, redislocation rates significantly favored MPFL-R (3.1%) over IPR (12.5%; p < 0.0001). CONCLUSIONS: MPFL-R has become a popular option to restore native patellofemoral biomechanics after ligament rupture. However, the procedure's potential to correct concomitant patella alta should not be overestimated and indications considered carefully.

Systematic Reviews and Meta-analyses. / Systematische Reviews und Metaanalysen.

The rising number of medical publications makes it difficult to keep up-to-date on scientific knowledge. In recent years, reviews in the form of narrative or systematic publications and meta-analyses have increased. These can only be interpreted and evaluated if the reader understands the techniques used. This review article describes the differences between narrative and systematic reviews, together with the characteristics of meta-analysis, and discusses their interpretation. The concept of systematic reviews and meta-analysis includes a systematic literature search and summary, together with an appraisal of the quality of the publications. Systematic reviews are often considered to be original studies due to their structure and ability to reduce bias.

Relative radiographic bone density measurement in revision hip arthroplasty and its correlation with qualitative subjective assessment by experienced surgeons.

BACKGROUND: Conventional radiography (CR) is the imaging method of choice in monitoring bone remodelling and other stability parameters after total hip arthroplasty (THA). Quantitative roentgen- or computed-tomography-based methods to determine bone density are prone to metal artifacts and often very costly, which is why they are not used as standard in a clinical setting. Since subjective assessment of bone remodelling in CR also has a certain susceptibility to errors, semi-quantitative methods have been developed to help approximate periprosthetic bone density development via CR to open up an additional tool for documentation of radiographic THA follow-up. OBJECTIVE: Proof-of-principle of a newly designed imaging-software-aided method to measure relative bone density around the femoral stem in a series of conventional radiographs following THA. METHODS: Eighty-six patients with hip modular tapered, fluted titanium stems were selected from the clinical database and series of baseline and postoperative follow-up radiographs were obtained after 24 and 48 weeks. Relative bone densities were measured per Gruen zones G1-7 with the use of an open-source image analysis package (ImageJ) by means of greyscale histograms. In addition, subjective evaluation of selected cases was performed by three independent, blinded orthopedic surgeons. Besides descriptive and nonparametric analyses, intra-class correlation (ICC) was performed and objective and subjective results were compared by linear regression analysis. RESULTS: Two individual cases are presented as a proof-of-principle. Increase or decrease of bone density could be measured correctly over time in each case. In a collective analysis there were no significant differences in mean relative bone densities between groups after 24 and 48 weeks, although a positive tendency was visible towards increased bone formation over time. Individual analyses by Gruen zones revealed that some zones, namely the proximal ones (e.g. G6), exhibit a broader scattering than others over time. This could be explained by the design of the evaluated tapered revision stem that achieves distal fixation and allows for proximal micromotion. Correlation analysis with subjective ratings (inter-rater reliability ICC = 0.71) showed a positive correlation with objective results, suggesting a feasibility of the method for clinical use. CONCLUSIONS: In conclusion the presented method is an easy and accessible tool to quantify relative bone density changes during THA follow-up. It shows a positive correlation to established subjective assessment of bone remodelling and may therefore serve as a quantitative supplement in clinical documentation.

Spondylitis - Spondylodiscitis - an Update. / Spondylitis ­ Spondylodiszitis ­ ein aktuelles Update.

Spondylodiscitis is an infection of the intervertebral disc with subsequent infection of the adjacent vertebral bodies. The main causes are 3 pathogen groups: bacteria, particularly tuberculosis pathogens, fungi and parasites. In pyogenic spondylodiscitis, infections with Staphylococcus aureus are the most common, with an incidence of up to 80%. Mortality is around 2 - 3%. Infections with tuberculosis are often associated with psoas and paravertebral abscesses. Neurological deficits are registered in up to 50% of patients. For microbiological diagnostic testing, blood cultures are used for aerobic and anaerobic bacteria. However, histological examination leads significantly more frequently to positive pathogen detection. In tissue samples, results with 16S rRNA PCR results are clearly superior to results from microbiological examination. The MRI exhibits high sensitivity and specificity and is therefore superior to other radiological methods. Elimination of the infection, pain reduction and stabilisation of the spine are the main objectives of any treatment. A standardised antibiotic therapy for spondylodiscitis has not been clearly defined. Pathogen detection is important, with focused antibiotic therapy. Antibiotic therapy should initially be administered intravenously for 2 - 4 weeks. This should be followed by oral administration for 6 - 12 weeks. In the case of antibiotic-resistant infections with neurological deficiencies, it is recommended to perform a surgical procedure, with careful debridement and instrumentation as well as i. v. administered antibiotics for 3 weeks followed by three month oral antibiotic treatment. Surgical procedures are indicated with neurological deficits, progressive increase in spinal deformities, failure of conservative therapy with insufficient pain relief and unreliable pathogen identification. The selection of the surgical procedure should mainly be based on the extent and localisation of bone destruction and the individual circumstances of the patients. The prognosis is good if there is a clear reduction in CRP and ESR in the first few weeks.

Predictors for secondary patellar resurfacing after primary total knee arthroplasty using a "patella-friendly" total knee arthroplasty system.

PURPOSE: Patellar resurfacing (PR) in total knee arthroplasty (TKA) is still one of the major controversies in orthopaedic surgery today. The aim of the present retrospective case-control study was to identify predictors for secondary patellar resurfacing (SPR) after initial TKA to create a rationale for surgeons to decide which patients to resurface primarily. It was hypothesized that proper TKA implantation and component positioning as well as a maintained physiological patellar geometry will lead to a reduced risk of SPR. Overmore, it was hypothesized that intrinsic factors like overweight might also have an influence on the need for SPR. METHODS: After identification of suitable patients and age/sex matching in a 1:2 fashion, 29 cases (TKA/SPR) and 58 controls (TKA) were included and screened for available clinical and epidemiological data as well as for radiographic data after primary TKA. Pearson's correlation analysis as well as logistic regression modeling was performed to identify possible predictors for SPR following TKA. RESULTS: Binary logistic regression was able to correctly classify 88.5% of patients into case or control groups. It indicated that patella tilt, patella height, and thickness as well as the delta angle were significant predictors of a need for SPR following primary TKA. An increase in patellar width by 1 mm will increase the risk of SPR, while an increase in patellar thickness by 1 mm will reduce it. An increase in patellar tilt by 1° will also increase the risk of SPR. Finally, an increase in delta angle by 1° will again reduce the risk of SPR. CONCLUSIONS: Easy and accessible radiographic measurements have been identified as possible predictors of SPR following primary TKA. Although indication for primary PR may still remain a controversial topic, a rationale has been proposed in this study to support surgeons in objectively estimating an individual patient's risk for SPR prior to primary TKA measuring the patella tilt, width, and thickness. Overmore, regarding surgical aspects of TKA, tibial component positioning has also been shown to be of importance to reduce the risk of SPR.

Delayed and incomplete treatment may result in dural fistula development in children with Vein of Galen malformation.

The association of dural arteriovenous fistulas (DAVF) in children with Vein of Galen malformation (VGM) has recently been reported for the first time. In a larger series of cases treated with transarterial NBCA embolization, 30% had DAVF. We wanted to analyze the development of DAVF in our cohort of children with VGM and to evaluate whether their occurrence depends on different treatment timing and embolic materials. We analyzed 43 VGM cases treated with a combined transarterial and transvenous approach between 2003 and 2016. In our early series until 2011, we used coils solely in 21 children. Since 2012, 22 children were treated with the combination of coils and Onyx. In the early series treated with coils solely, no case presented initially with or developed DAVF over time on follow-up angiograms. In our recent series we found four cases (9%) with DAVF. In two patients (5%), DAVF were found on the initial angiogram. Both patients presented at our department at age >2 years and were not treated elsewhere before. One patient (2%) presented at our department with too proximal occlusion of arterial feeders performed at another institution before. Only one patient (2%) developed DAVF in our department after the transarterial use of Onyx. Interestingly, this child did not develop DAVF as long as we used coils solely and his DAVF was localized exactly where an Onyx cast was identified. In conclusion, delayed and incomplete treatment may have a considerable impact on the occurrence of DAVF in VGM.

Mechanical loading increases pro-inflammatory effects of nitrogen-containing bisphosphonate in human periodontal fibroblasts.

OBJECTIVES: There is increasing evidence that inflammation and biomechanical loading can influence the effects of bisphosphonates (BP). The aim of this study was to investigate the influence of tensile strain application combined with IL-1ß and clodronate or zoledronate on human periodontal ligament fibroblasts (HPdLF) in vitro. MATERIALS AND METHODS: HPdLF were cultured with 10 nM IL-1ß and 5 µM clodronate or zoledronate for 48 h. Cells were applied to cyclic tensile strain (CTS; 3% elongation) for 12 h in vitro. Cell number was analyzed directly after CTS by MTT assay. Gene expression of receptor activator of cyclooxygenase-2 (COX-2) was investigated using real-time PCR. MMP-8, TIMP-1, and PGE2 were measured by ELISA. Statistics were performed with SPSS (ANOVA, p < 0.05). RESULTS: Zoledronate reduced the cell number of HPdLF (60.3 vs. 100%), which was significant when combined with IL-1ß. Combined with 3% CTS, this effect was voided and cell number increased over the level of the control cells. IL-1ß led to a 10-fold increase of COX-2 gene expression. Combined with CTS and zoledronate, this increase was enhanced to a gene expression 70-fold that of control cells with related PGE2 synthesis. Clodronate neither reduce the cell number nor enhanced the COX-2 gene expression. CTS increased MMP-8 protein synthesis. Combined with BP, this increase was voided. TIMP-1 protein synthesis was increased at all conditions under CTS. CONCLUSIONS: Mechanical loading might activate cell metabolism and abolish BP- and inflammation-induced reduction of viability. Combination of mechanical loading, inflammation, and nitrogen-containing bisphosphonates can cause pro-inflammatory effects. CLINICAL RELEVANCE: Periodontal inflammation should be treated initially before BP intake to prevent decreased cell viability of the periodontium and increased inflammation, which might be enhanced by the addition of mastication forces.