Long-term follow-up of open and endoscopic Hohmann procedures for lateral epicondylitis.

PURPOSE: The long-term outcome of this new endoscopic technique was compared with that of the classical open Hohmann procedure. TYPE OF STUDY: Retrospective cohort study. METHODS: During 1992 and 1995, 37 patients were surgically treated with the Hohmann procedure after failed intensive conservative treatment. At an average of 92 months after the operation, 30 patients (81%) could be clinically re-examined and were evaluated with a standard questionnaire including the scores of Roles and Maudsley and Morrey et al. RESULTS: Twenty of these patients were treated endoscopically and 10 with the open technique. There were no differences in demographic data between the 2 groups. At follow-up in both groups, similar results were seen for the function of the elbow, the scores of Roles and Maudsley and Morrey et al., the subjective rating of pain and function of the elbow, and complication rate. The results in the score of Morrey showed an average scoring of 93.2 for the endoscopic group and 87.5 for the open group (P > .05). CONCLUSIONS: The endoscopic technique showed results comparable to the open technique and can therefore be recommended for wider surgical use so as to learn more details concerning possible complications and results of the new technique. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Anatomical study of preganglionic spinal nerve and disc relation at different lumbar levels: Special aspect for microscopic spine surgery.

BACKGROUND: Lumbar microdiscectomy is a widespread popular method of treatment. One major challenge is the spine level dependent different anatomy and the limited sight on the nerve root during the surgical procedure. OBJECTIVE: The aim was to analyze the specific anatomic relation of nerve root, intervertebral disc and intervertebral ganglion under determination of the specific nerve distances. Furthermore the relation between the disc and the corresponding nerve root was evaluated. METHODS: Regular human lumbar spine specimens of body donors were included in the study. Microscopic assisted dissection was performed. The topographical distances between a defined disc measurement point (DP) and the corresponding nerve root shoulder (NS) were measured. The preganglionic distance from the caudal axilla point (AP) of the spinal nerve root and the center point (CG) of the spinal ganglion in the intervertebral foramen were determined. RESULTS: The AP-CG distance increased gradually in the caudal direction from L1 (7.25 ± 2.72 mm right side, 7.30 ± 2.85 mm left side) to a maximum for L5 (16.00 ± 3.39 mm right side, 16.50 ± 3.58 mm left side, p< 0.05). We found a significant reduction for S1 (14.88 ± 3.42 mm right side, 13.83 ± 2.47 mm, p< 0.05). In contrast the DP-AP distances showed a maximum for L1 (12.75 ± 2.78 mm right side, 13.70 ± 3.87 mm left side) with an increasing shortening in the caudal direction and even negative values for S1 (-2.63 ± 3.31 mm right side, -0.83 ± 2.84 mm left side, p< 0.01). CONCLUSION: The topographical anatomy changes each lumbar segment and demands therefore an exact preoperative planning using this specific knowledge to perform a successful microscopic spine surgery. The results of the study support a better understanding of the relevant anatomy and help to reduce incomplete herniated disc removal and to avoid surgical complications.

Intrathecal volume changes in lumbar spinal canal stenosis following extension and flexion: An experimental cadaver study.

BACKGROUND: The spinal canal stenosis is a common disease in elderly. The thecal sac narrowing is considered as the anatomical cause for the disease. There is evidence that the anatomical proportions of the lumbar spinal canal are influenced by postural changes. The liquor volume shift during these postural changes is a valuable parameter to estimate the dynamic qualities of this disease. OBJECTIVE: The aim of this human cadaver study was the determination of intrathecal fluid volume changes during the lumbar flexion and the extension. A special measuring device was designed and built for the study to investigate this issue under controlled conditions. METHODS: The measuring apparatus fixed the lumbar spine firmly and allowed only flexion and extension. The dural sac was closed water tight. The in vitro changes of the intrathecal volumes during the motion cycle were determined according to the principle of communicating vessels. Thirteen human cadaver spines from the Institute of Anatomy were examined in a test setting with a continuous adjustment of motion. The diagnosis of the lumbar spinal stenosis was confirmed by a positive computer tomography prior testing. The volume changes during flexion and extension cycles were measured stepwise in a 2 degree distance between 18° flexion and 18° extension. Three complete series of measurements were performed for each cadaver. RESULTS: Two specimens were excluded because of fluid leaks from further investigation. The flexion of the lumbar spine resulted in an intrathecal volume increase. The maximum volume effects were seen in the early flexion positions of 2° and 4°. The spine reclination resulted in a volume reduction. The maximum extension effect was seen between 14° and 16°. CONCLUSION: According to our results, remarkable volume effects were seen in the early movements of the lumbar spine especially for the flexion. The results support the concept of the spinal stenosis as a dynamic disease and allow a better understanding of the pathophysiology of this nosological entity. Under clinical aspects our data support the value of a body upright position under avoiding of extended spinal inclination and reclination.

The related outcome and complication rate in primary lumbar microscopic disc surgery depending on the surgeon's experience: comparative studies.

BACKGROUND CONTEXT: Studies concerning intraoperative complications and their influence on the clinical outcome of microscopic disc surgery are quite rare. Complication rates vary between 1.5% and 15.8%. A correlation between the surgeon's experience and the complication rate may be expected. PURPOSE: To determine the influence of the surgeon's experience on the intraoperative complication rate in lumbar microscopic disc surgery. STUDY DESIGN: Three studies are included: 1) retrospective analysis of intraoperative complications in microscopic disc surgery (N=1,872); 2) prospective follow-up study of microscopic disc surgery (N=583); 3) prospective evaluation of complication rates in microscopic disc surgery (N=90). PATIENT SAMPLE: Patient data sets from 1,872 lumbar microscopic disc surgeries performed between January 7, 1981, and June 31, 2000, were examined in a retrospective study. A total of 463 patients, operated on between 1991 and 1996, were followed up by a questionnaire. Finally, a prospective controlled trial (N=90) was performed. OUTCOME MEASURES: Such complications as incidental durotomy, wrong level exposure, or bleeding were analyzed based on the patient data sets by a blinded external evaluator. The rates of lower back pain and ischiatic pain were measured on a visual analogue scale at follow-up in Study 2 and Study 3. To measure the outcome of surgery in daily life activities and functional capacity, the Tegner activity level was calculated. In addition, a questionnaire with the Hannover score was used. The patient's social and economic status was also recorded. METHODS: A total of 1,872 lumbar microscopic disc surgeries, performed between January 7, 1981 and June 31, 2000, were examined in a retrospective study. Intra- and perioperative complications were evaluated and related to the surgeons' level of experience. Patients in the first group (XL) were operated on by the most experienced surgeon (more than 500 microscopic discectomies before the beginning of the study). The L-group surgeons performed between 50 and 100 microscopic disc surgeries before the study. This group included a total number of seven surgeons during the 1981-2000 time frame. None of this group reached the experience level of 500 surgeries during the course of the study. A total of 463 patients, operated on between 1991 and 1996, were followed up. Finally, a prospective controlled trial (N=90) was performed. Injuries of the dura, nerve root, ventral structures and wrong level exposure, which had been detected and corrected during surgery, were analyzed. In the second and third study, the outcome was correlated to surgery and complications during surgery. RESULTS: The rate of intraoperative complications showed a statistically significant difference between the groups. The comparison of both groups (n=1,872) with regard to the rate of intraoperative complications showed a statistically significant difference between 2.2% in the XL group and 10.7% in the L group (p< or =.001). Regarding work-related and socioeconomic factors, no significant difference in the outcome was seen. CONCLUSIONS: Microscopic disc surgery requires a course of instruction and a considerable number of surgeries under supervision by experienced surgeons. To shorten the learning curve, a number of standardized surgery steps to clearly identify anatomical landmarks are helpful. During training, these landmarks can be checked by an experienced surgeon to minimize the rate of intraoperative complications. Initial postoperative ischiatic pain was correlated to an incidental durotomy with p<.001. For long-term results after disc surgery, however, socioeconomic and work-related factors are of greater importance in spinal disc surgery than the incidence of intraoperative complications.

Misinterpretation of cup anteversion in total hip arthroplasty using planar radiography.

INTRODUCTION: Anteroposterior pelvic radiographs are routinely used to monitor cup orientation in total hip arthroplasty (THA). Analysis of planar radiographs leads to a certain degree of measurement error for the cup anteversion (AV). With the current study, we wanted to clarify whether planar radiography can be used for accurate evaluation of the THA position. MATERIALS AND METHODS: The postoperative orientation of pelvic implants in 42 patients was analyzed according to five documented mathematical algorithms using planar radiographs. Postoperative computed tomography (CT) pelvis scans were available for all patients. A CT-based navigation system was used to determine AV. RESULTS: The comparison showed that all five formulas presented substantial variations for the AV angle. Of these, Widmer's algorithm presented the smallest difference compared to the CT. Misinterpretation of postoperative planar radiographs is a common problem in THA. CONCLUSION: Planar radiographs are too imprecise for exact evaluation of the correct cup AV after THA. CT-based analysis may be necessary if exact values are required.

Anatomic referencing of cup orientation in total hip arthroplasty.

UNLABELLED: Pelvic tilt and rotation can drastically affect the apparent cup orientation on conventional anteroposterior pelvic radiographs. It was hypothesized that nonstandardized radiographic cup version and abduction can differ significantly from the corresponding anatomic angles if not measured to the anterior pelvic plane, defined by the pubic tubercles and the anterior superior iliac spine. Differences in preoperative and postoperative pelvic orientation and their influence on radiographic measurements of the two angles were analyzed. Conventional radiographs and preoperative and postoperative computed tomography scans of 37 total hip arthroplasties were compared. Calculations were made with the preoperative planning station of a computer navigation system. Significantly smaller values of cup version were seen on nonstandardized radiographs, whereas abduction could be measured reliably when referenced to horizontal pelvic landmarks seen on radiographs. The underlying cause for this difference was the variation of pelvic tilt that ranged 27 degrees (range, -7 degrees -20 degrees). Influence of pelvic tilt on the apparent cup orientation can be seen with simple nomograms. The orientation of the anterior pelvic plane before and after surgery did not differ. We think that version measurement on nonstandardized radiographs without anatomic referencing is highly inaccurate. LEVEL OF EVIDENCE: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients--with universally applied reference "gold" standard). See Guidelines for Authors for a complete description of levels of evidence.

Prospective randomized surgical treatments for calcifying tendinopathy.

Thirty-eight patients with chronic calcifying tendinopathy of the shoulder were randomized prospectively into two groups: 19 patients had endoscopic decompression and 19 had open decompression. Thirty-three patients (19 with open and 14 with endoscopic decompression) were available for followup. Clinical and ultrasonographic investigations were done at followup. The purpose of the current study was to evaluate prospectively the clinical and sonographic results after open decompression and after endoscopic decompression. Apportionment of age and gender was similar in both groups. The followup was 15.7 months for patients after open decompression and 17.1 months for patients after endoscopic decompression. The average Patte score was 84.5 points (84.4 for patients who had endoscopic decompression and 84.6 for patients who had open decompression). Corresponding results were found with a Constant and Murley score of 96.6 points (97.6 for patients who had endoscopic decompression and 95.8 for patients who had open decompression). In the endoscopic group physiotherapy was recommended for 5 weeks more than in the open surgery group. Similar results were seen for the incapacity to work in both groups with 4.6 weeks for the patients who had endoscopic surgery and 5 weeks for the patients who had open surgery. No nerve injuries, wound infections, or other postoperative complications were found. Comparison of both surgical methods showed good clinical and score results. Endoscopic and open surgery are equally effective in the treatment of chronic calcifying tendinopathy.

Early results of endoscopic trochanter bursectomy.

Between 1995 and 2000, we performed 45 endoscopic bursectomies in 42 patients (average age 51, range 17-61 years). All patients had at least 6 months of failed conservative treatment, and all responded positively to a sonographic-guided injection with Mepivacaine 0.5%. The bursa was removed using a synovial resector. An additional tractopexie was performed in four cases. We followed 37 patients for 12-48 months. Pre-operatively, the mean modified Japanese Orthopaedic Association (JOA) disability hip score was 40.5 points. It improved to 72.6 points after a mean of 25 months. Severe complications did not occur. The minimally invasive technique requires only stab incisions, and immobilisation and hospitalisation are minimal.

Participation of cyclooxygenase-1 in prostaglandin E2 release from synovitis tissue in primary osteoarthritis in vitro.

OBJECTIVES: To investigate the relative contribution of the cyclooxygenase (COX) isoenzymes COX-1 and COX-2 to prostaglandin E2 (PGE2) release from inflamed synovial tissue in N=10 patients with primary osteoarthritis (OA) in vitro and to determine possible effects of COX inhibitors on the gene expression of synovial COX-1 and COX-2. DESIGN: The effects of a COX-unspecific nonsteroidal anti-inflammatory drug (NSAID; diclofenac), a selective COX-1 inhibitor (SC-560) and a selective COX-2 inhibitor (SC-58125) on PGE2 release from inflamed synovial tissue (0.1-10 microM, 3 and 6 h incubation time) were compared. Release of PGE2 into the incubation media was measured by means of the enzyme-linked immunosorbent assay. Expression of synovial COX-1/-2 was quantified by means of real-time reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: All agents inhibited synovial PGE2 release dose-dependently. Compared to short-term incubations, the inhibitory potency of diclofenac, SC-58125 and SC-560 was increased (0.1-10 microM) and decreased (0.1-1 microM), respectively, during 6 h: At 10 microM, SC-560 and SC-58125 had obviously lost their specificity for COX-1 and COX-2, respectively, indicated by a comparable inhibitory potency of the selective COX-1 inhibitor (86.6%) and the selective COX-2 inhibitor (96.6%) within identical tissue specimens. In contrast, at 1 microM, 83% and 62.8% inhibition was seen for diclofenac and SC-58125, respectively. SC-560 showed 30.6% inhibition (P<0.05). In contrast to synovial COX-1, RT-PCR revealed a significant induction of COX-2 through PGE2. CONCLUSIONS: With respect to the concentrations studied, the data suggest that in inflamed synovial tissue in OA, up to 30% of PGE2 might be generated via the COX-1 pathway. In therapy of OA, the relative contribution of COX-1 in synovial inflammation should be considered, weighing the potency of COX-unspecific NSAID against the assumed superior gastrointestinal safety profile of selective COX-2 inhibitors.