[Rare combination injury of traumatic spondylolisthesis of the lumbosacral junction and Malgaigne's C3 fracture of the pelvis : Lessons learned]. / Seltene Kombinationsverletzung einer traumatischen Spondylolisthese des lumbosakralen Übergangs und C3-Beckenfraktur (Malgaigne-Verletzung) : "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.

[Algorithm for treatment of deep spinal infections and spondylodiscitis with in situ instrumentation]. / Algorithmus zur Behandlung tiefer Wirbelsäuleninfektionen und der Spondylodiszitis bei einliegender Instrumentierung.

Due to a significant increase in spinal interventions and in particular spinal fusion procedures, also in elderly and immunocompromised patients, spinal surgeons are increasingly confronted with deep wound infections and/or spondylodiscitis with in situ instrumentation. This occasionally life-threatening complication can be a challenge for even the most experienced physician, not only in the initial diagnosis but also when determining the operative treatment strategy. It is not uncommon that patients must undergo several operations before a deep infection is finally under control. The aim of this article is to suggest an algorithm for the diagnostics and management of this very troubling complication.

[Therapy of isolated arthritis in the patellofemoral joint: are there evidence-based options?]. / Therapie der isolierten Femoropatellararthrose : Gibt es evidenzbasierte Verfahren?

BACKGROUND: Isolated osteoarthritis of the patellofemoral joint occurs in 9% of patients over 40 years of age and women are more often affected. Options of treatment are varied and not sufficiently justified by the literature. MATERIALS AND METHODS: A literature research with keywords in the field of femoropatellar osteoarthritis was carried out in the relevant databases. Studies were categorized into different treatment options and analyzed. RESULTS: There are almost no level I studies comparing the different treatment options. In the literature there are indications that relief of pain can be achieved by conservative treatment, arthroscopic surgery, cartilage conserving surgery and isolated arthroplasty. CONCLUSION: In view of the fact that there are almost no prospective randomized controlled trials, none of the options for treatment can be highly recommended. There is still no gold standard for the treatment of isolated patellofemoral osteoarthritis.

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.

[Endoprosthesis for the fractured elbow: uni- and bicompartmental alloarthroplasty of the humero-ulnar joint]. / Frakturendoprothetik am ellenbogen: uni- und bikompartimentelle alloarthroplastik am humeroulnaren gelenk.

Posttraumatic arthrosis or rheumatoid arthritis located at the elbow, in particular at the humero-ulnar joint will probably not occur in increasing numbers in the future due to new antirheumatic medications and modern implants. However, the demographic development with an increase of the geriatric population and the typical physical changes is evident. Due to osteoporosis with a resulting poor bone quality severe fracture patterns may occur at the site of the distal humerus after a simple collapse. The usual surgical aim consisting of an exact anatomic reduction may be impossible to achieve by applying the standard operative treatment. Several studies have proven that a prosthetic replacement of such a severely damaged elbow is a viable solution for elderly people. A mobile, pain-free and stable elbow joint promotes a fast recovery of the patient with a quick return to former activities. Nevertheless, elbow prostheses cannot withstand great strains and the surgeon has to identify those fractures which require a prosthetic replacement. The surgical implantation procedure requires an adequate knowledge of both elbow anatomy and prosthetic options.

[3-Tesla MRI vs. arthroscopy for diagnostics of degenerative knee cartilage diseases: preliminary clinical results]. / 3-Tesla-MRT vs. Arthroskopie bei der Diagnostik degenerativer Knorpelschäden des Kniegelenkes : Erste klinische Ergebnisse.

BACKGROUND: The literature contains only a few studies investigating the magnetic resonance imaging (MRI) diagnostics of degenerative cartilage diseases. Studies on MRI diagnostics of the cartilage using field strengths of 3-Tesla demonstrate promising results. To assess the value of 3-Tesla MRI for decision making regarding conservative or operative treatment possibilities, this study focused on patients with degenerative cartilage diseases. METHODS: Thirty-two patients with chronic knee pain, a minimum age of 40 years, a negative history of trauma, and at least grade II degenerative cartilage disease were included. Cartilage abnormalities detected at preoperative 3-Tesla MRI (axial/koronar/sagittal PD-TSE-SPAIR, axial/sagittal 3D-T1-FFE, axial T2-FFE; Intera 3.0T, Philips Medical Systems) were classified (grades I-IV) and compared with arthroscopic findings. RESULTS: Thirty-six percent (70/192) of the examined cartilage surfaces demonstrated no agreement between MRI and arthroscopic grading. In most of these cases, grades II and III cartilage lesions were confounded with each other. Regarding the positive predictive values, the probability that a positive finding in MRI would be exactly confirmed by arthroscopy was 39-72%. In contrast, specificities and negative predictive values of different grades of cartilage diseases were 85-95%. CONCLUSIONS: Regarding the high specificities and negative predictive values, 3-Tesla MRI is a reliable method for excluding even slight cartilage degeneration. In summary, in degenerative cartilage diseases, 3-Tesla MRI is a supportive, noninvasive method for clinical decision making regarding conservative or operative treatment possibilities. However, the value of diagnostic arthroscopy for a definitive assessment of the articular surfaces and for therapeutic planning currently cannot be replaced by 3-Tesla MRI. This applies especially to treatment options in which a differentiation between grade II and III cartilage lesions is of interest.

[Correlation of back pain and magnetic resonance imaging of the lumbar spine in elite horse vaulters]. / 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.

[Flexion contracture in haemophilic knee arthropathy--10-year follow-up after hamstring release and dorsal capsulotomy]. / Flexionskontraktur bei hämophiler Kniearthropathie--10-Jahres-Follow-up nach Hamstring-Release und dorsaler Kapsulotomie.

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.

[Epidural varicosis as a rare cause of acute radiculopathy with complete foot paresis--case report and literature review]. / Epidurale Varikose als seltene Ursache eines akuten radikulären Lumbalsyndroms mit kompletter Fussheber- und Fusssenkerparese--Kasuistik und Literaturübersicht.

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.

[Influence of the riding discipline and riding intensity on the incidence of back pain in competitive horseback riders]. / 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.

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.

[Frequency and utility of internet use by orthopaedic patients]. / 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.

[Systemic spread of wear debris--an in-vivo study]. / 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]. / Analyse der Informationsqualität im Internet zur 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.

[Sacral fracture as a rare early complication of lumbosacral spondylodesis]. / 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.

[Rare differential diagnosis of a degenerative cervical syndrome: an arteriovenous meningeal fistula of the sigmoid sinus]. / Seltene Differenzialdiagnose eines degenerativen HWS-Syndroms: Dura-AV-Fistel im Bereich des Sinus Sigmoideus.

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.

[Residual stability of different interbody fusion techniques after pedicle screw loosening]. / Reststabilität differierender Spondylodesetechniken bei Pedikelschraubenlockerung.

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.

[Invasive chondrosarcoma of the thoracic spine as a rare cause of acute paraplegia]. / Invasives Chondrosarkom der Brustwirbelsäule als seltene Ursache einer akuten Querschnittssymptomatik.

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.

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.