[Magnetic resonance imaging criteria for the differentiation of traumatic and non-traumatic rotator cuff tears]. / Kernspintomographische Kriterien zur Unterscheidung von traumatischen und nicht traumatischen Rotatorenmanscnerrenrupturen.

It is often not easy to classify a rotator cuff tear into traumatic or non-traumatic. For individual medical examinations the classification depends basically on the following four criteria: Case history, analysis of the accident, analysis of the complaints after the accident (or even before) and the pathomorphological findings. The aim of this study was to identify findings in the magnetic resonance imaging of the shoulder joints of patients with rotator cuff tears that could help in the differentiation of traumatic versus non-traumatic. As a result it could be shown that infraspinatus and subscapularis tears, Hill-Sachs lesions and fractures of the tuberculum majus are significantly more detectable among those patients reporting a trauma. In contrast degeneration of the supraspinatus tendon, calcific tendinitis of the supraspinatus tendon, ac-joint degeneration and an absence of the subacromial fat pad are more verifiable in the non-traumatic group. These results can be used as additional important information in the individual medical examination of patients with rotator cuff tears.

Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: sensitive detection of morphologic changes in rheumatoid arthritis.

OBJECTIVE: To evaluate and characterize magnetic resonance imaging (MRI) findings in the metacarpophalangeal (MCP) joints of rheumatoid arthritis (RA) patients macroscopically, using miniarthroscopy (MA; needle arthroscopy). METHODS: The second MCP joint of the dominant hand of 22 RA patients (13 with various RA activities/stages; 9 with early RA [< or = 1.5 years' duration]) was examined by MRI followed by MA. Findings were evaluated by standardized semiquantitative measures of synovial and bony pathologic changes of the MCP joint, and were compared with the clinical and conventional radiologic findings. RESULTS: Erosions and pre-erosions were detected in 17 of 22 patients by MRI; 2 of the other 5 patients (all early RA) displayed bony changes on MA. All 10 joints with pre-erosions on MRI (grade I bony alterations on MRI) exhibited significant cartilaginous and bony pathology on MA. Synovial membrane pathology was detected in all but 1 patient by MRI and in all patients by MA, although findings of plain radiography were normal in 6 of the 22 patients and another 9 patients had a Larsen score of 1. Semiquantitative analysis of synovial findings of MRI revealed gadolinium diethylenetriaminepentaacetic acid enhancement as a significant marker of macroscopically varied synovial vascularity and hyperemia, both of which strongly correlated with clinical activity (as measured by the Disease Activity Score). The extent of synovitis/synovial proliferation shown by MA and MRI were significantly correlated with each other, but not with any other activity or damage parameter analyzed. CONCLUSION: In RA, both MRI and MA findings support early detection and staging of synovial changes. Ongoing longitudinal studies are aimed at evaluating the value of synovial proliferation as visualized by both methods.

Clinical evaluation and computed tomography scan analysis of screw tracts after percutaneous insertion of pedicle screws in the lumbar spine.

STUDY DESIGN: An examination of the accuracy of percutaneous pedicle screw placement in the lumbar spine. Using computed tomography scan analysis after implant removal, the screw tracts could be analyzed regarding the degree and direction of screw dislocation. OBJECTIVES: To investigate the misplacement rate and related clinical complications of percutaneous pedicle screw insertion in the lumbar spine. SUMMARY OF BACKGROUND DATA: The feasibility of the external fixation test has been investigated in several studies. Although pedicle screw misplacement has been reported as one of the main complications, there are no reliable data on the misplacement rate for this difficult surgical procedure. METHODS: In this study, 51 consecutive patients with suspected segmental instability were investigated after external transpedicular screw insertion for the external fixation test. Computed tomography scans of all instrumented pedicles from L2 to S1 were performed after screw removal. The screw tracts were analyzed, and the direction and degree of the pedicle violations were noted. In addition, the screw and pedicle angles were measured. RESULTS: Of 408 percutaneously inserted pedicle screws, only 27 screws (6.6%) were misplaced. There were 19 medial pedicle violations, 6 lateral cortical defects, and only 1 cranial and 1 caudal displacement. With respect to the spinal level, S1 showed the highest misplacement rate, with 11 screw dislocations (12%). After surgery, found two nerve root injuries were found. Only one of the injuries (L4) was related to the malposition of a screw. CONCLUSIONS: This study has shown that percutaneous insertion of pedicle screws in the lumbar spine is a safe and reliable technique. Despite the low misplacement rate of only 6.6%, it should be kept in mind that the surgical procedure is technically demanding and should be performed only by experienced spine surgeons.

[Postoperative, appositional ossifications after lumbar laminectomy]. / Postoperative, appositionelle Ossifikationen nach lumbaler Laminektomie.

QUESTION: Post-laminectomy segmental hypermobility as well as appositional ossification were suggested by many authors to contribute to the unsatisfactory long-term results of laminectomy. The aim of this study was to find out whether segmental instability, among other factors, influences the degree of appositional ossification following laminectomy. METHODS: 55 out of 72 patients operated upon by laminectomy or hemilaminectomy for degenerative lumbar spinal stenosis were examined by radiography after an average follow-up period of 5.2 years. Appositional ossification at the site of surgery was evaluated in relation to lumbar instability, the number of segments undergoing laminectomy, and whether simultaneous fusion was done. Instability was determined by measuring angulation and translation using lateral flexion and extension views of the lumbar spine, whereas new-bone formation was best evaluated on antero-posterior radiographs. RESULTS: 94% of the patients had appositional ossification at the site of laminectomy. Patients undergoing simultaneous fusion with laminectomy had a significantly lower amount of appositional ossification compared to patients undergoing laminectomy without segmental fusion. Radiographically measured segmental instability, the number of segments undergoing laminectomy, age, and sex of the patients did not influence the extent of ossification. CONCLUSIONS: Postoperative appositional ossification at the posterior site of resection are seen regularly following laminectomy. The extent of appositional ossification does correlate with lumbar fusions, but does not correlate with the extent of radiographically measured lumbar instability, the number of segments undergoing laminectomy, or the age and sex of the patients. CLINICAL RELEVANCE: Simultaneous lumbar fusion with laminectomy is proved to be associated with less appositional ossification. Therefore lumbar fusion should be considered when planning surgery for spinal stenosis.

Miniarthroscopy of metacarpophalangeal joints in rheumatoid arthritis. Rating of diagnostic value in synovitis staging and efficiency of synovial biopsy.

OBJECTIVE: To evaluate miniarthroscopy (MA) (needle arthroscopy) of involved joints in rheumatoid arthritis (RA) in the early detection and staging of synovitis and its application in visual guided synovial biopsies. METHODS: 1.0 and 1.9 mm (0 degree/30 degrees) arthroscopes were used in a 2 portal technique. MA performance was developed and evaluated first on hand cadavers (n = 20) and then transferred to metacarpophalangeal (MCP) joints under local anesthesia conditions. Joints of 20 patients with RA with different disease activity and duration were scoped and rated according to scores adapted from arthroscopy of other joints. RESULTS: In 20/20 cases MA provided visualizing and magnification of intraarticular features of MCP joints in RA and allowed grading of synovial alterations, chondromalacia, and bony alterations. Synovial surface changes, thickness, and fibrosis were related to disease duration, as was damage to cartilage and bone. The degree of acute inflammatory reactions like vascularity and hyperemia varied independently of chronic changes; synovial proliferation was reflected to some extent by C-reactive protein. In 2 patients with early RA, synovitis criteria were found macroscopically and histologically. In 18/20 joints, biopsies were taken under visual control; in the other 2, progression of disease (Larsen score >3) limited arthroscopy to 1.0 scope imaging only. Sampling sizes were sufficient for histologic and molecular analysis. CONCLUSION: The developed standardized procedure of MCP arthroscopy is minimally invasive, practicable, and well tolerated by patients, and may allow synovitis monitoring, staging, and biopsy in patients with early as well as chronic arthritis.

[Bone density and bone metabolism regulated by vitamin D receptor allele polymorphism in a German study sample]. / Knochendichte und Knochenstoffwechsel unter dem Einfluss des Vitamin-D-Rezeptor-Allel-Polymorphismus in einem deutschen Untersuchungskollektiv.

BACKGROUND: It has been reported that the spinal bone density is associated with vitamin-D-receptor (VDR) gene polymorphisms. The results of recent studies have been contradictory concerning the predictive power for low bone mineral density (BMD). Regional population-specific influences have been found to affect the vitamin-D-endocrinologic-system, diminishing the influence of VDR polymorphism on BMD and on bone turnover. We have examined the association of bone density, fracture predictivity and biochemical markers of bone turnover with VDR polymorphism in a German population. METHODS: Blood and urine were collected from a heterogeneous subset of 164 caucasian subjects with ethnic German background. Polymerase chain reaction and subsequent digestion with Bsm I were used to examine variations of VDR genotypes. The morning following initial specimen collections, both urinary excretion rate of pyridinoline crosslinks (Pyr) and serum levels of bone alkaline phosphatase (BAP) were determined. For determination of the bone mineral density, the well-established method of dual X-ray absorptiometry was used. FINDINGS: The VDR BB-genotype was associated with low bone mineral density for age-matched subjects (90.1 +/- 15.5%) versus the bb-genotype (100.8 +/- 10.8%) at the lumbar spine and at the Ward's triangle (91.8 +/- 17.9% versus 101.9 +/- 12.1%). 34.2% of BB-genotype subjects, 14.2% of bB-genotype subjects and 12.6% of bb-genotype subjects had Z-score related bone mineral density < 85%. The fracture rate at typical osteoporotic fracture sites was 23.6% for the BB-, 10.8% for the bB- and 0.0% for the bb-genotype. The urinary excretion rate of free pyridinoline crosslinks was higher for the BB-genotype than for the bB- or the bb-, however the difference was not significant. No genotype specific variations were seen for bone alkaline phosphatase. INTERPRETATION: The authors conclude from this study that bone mineral density at the axial skeleton is associated with the vitamin-D-receptor allele polymorphism and that there is an influence on bone turnover and fracture rate in a German subset. CLINICAL RELEVANCE: The analysis of the VDR-genotype can be considered as a new piece in the puzzle of the diagnostic of osteoporosis for we get prognostic hints concerning the rate of fracture.

Current status of gene therapy for rheumatoid arthritis.

Despite the high prevalence of the disease, at present little effective pharmacological treatment of rheumatoid arthritis is available. Novel approaches utilising biological agents have resulted in the development of new antiarthritic and antiinflammatory agents, such as tumour necrosis factor-alpha (TNFalpha)-specific antibodies and interleukin-1 receptor antagonist (IL-1ra). Local gene therapy not only allows the pharmaceutical use of these biologicals, but also allows for continuous drug supply, which is necessary for chronic diseases like rheumatoid arthritis. We discuss the basics of rheumatoid arthritis therapy, candidate genes and possible gene transfer methods. A current clinical gene therapy trial is focusing on the IL-1 system using IL-1ra as a transgene. The transfer system, clinical protocol and preliminary results are described. After treatment of 11 patients we feel that gene therapy will offer potential as a new avenue to treat rheumatoid arthritis.

Hemarthrosis as a major complication after arthroscopic subcutaneous lateral retinacular release: a prospective study.

The use of arthroscopic lateral release and medial imbrication of the vastus medialis obliquus for recurrent dislocation of the patella was evaluated prospectively in 31 patients. Patients were examined clinically as well as radiologically; the average length of follow-up was 34.4 months. Seventy-one percent of the patients were satisfied with the operative result. Seven patients experienced redislocation of the patella. Postoperative effusion occurred in 13 (42%) patients, with 4 patients requiring aspiration and 3 patients requiring open revision because of hemarthrosis. Seven patients developed a long-lasting stiffness of the joint following a 3-week period of immobilization with a dorsal plaster splint of the whole leg.

Transfer of genes to chondrocytic cells of the lumbar spine. Proposal for a treatment strategy of spinal disorders by local gene therapy.

STUDY DESIGN: In the current study, chondrocytic cells from bovine intervertebral end plates were cultivated in vitro and modified genetically. OBJECTIVE: The authors intended to perform isolation and cultivation of cells from bovine end plates of the spine. They also intended to show, in principle, the feasibility of introducing exogenous genes into chondrocytic cells from bovine intervertebral end plates by way of retroviral vectors. SUMMARY OF BACKGROUND DATA: The involvement of cytokines in the destruction of articular cartilage is established. It appears possible that similar mechanisms may play a role in intervertebral disc degeneration and other spinal disorders. Conventional medication and surgery of intervertebral disc degeneration addresses neither the pathophysiology nor the chronicity of the disease. Therapeutic proteins carry great potential as locally produced drugs after transfer of their cognate genes to the sites of interest. METHODS: Vertebral end plate tissue was obtained from bovine os coccygis. Chondrocytic cells were isolated and cultured in vitro. The bacterial beta-galactosidase (LacZ) gene and, alternatively, the complementary DNA (DNA copy of the mRNA) of the human interleukin-1 receptor antagonist were introduced into the isolated cells by retrovirus mediated gene transfer. beta-galactosidase activity was determined by staining, and interleukin-1 receptor antagonist protein was quantitated by enzyme-linked immunosorbent assay. RESULTS: Isolation and cultivation of chondrocytic end plate cells is possible. Native cells continue to grow in culture for more than 2 months. Transfer of the beta-galactosidase gene to cultured cells resulted in approximately 1% beta-galactosidase positive cells. Transfer of the interleukin-1 receptor antagonist complementary DNA resulted in the production of 24 ng/ml/10(6) cells interleukin-1 receptor antagonist protein in 48 hours. CONCLUSIONS: The introduction of exogenous therapeutic genes into cells from the intervertebral end plate opens the possibility for a local gene-based treatment of intervertebral disc degeneration. This approach avoids some of the shortcomings of conventional drug- and surgery-based treatments and has the potential to be specific, effective, and appropriate to the chronicity of the disease.

Growth changes of solidly fused kyphotic bloc after surgery for tuberculosis. Comparison of four procedures.

STUDY DESIGN: A study to analyze the changes of the spinal deformity during the growth period, with regard to different operations for spinal tuberculosis in children. OBJECTIVES: To quantify the changes in the kyphotic angle and the growth ratio of the fusion bloc during spinal growth for different fusion techniques. SUMMARY OF BACKGROUND DATA: Most of the publications dealing with spinal tuberculosis in children focused on the clinical outcome with regard to different conservative and operative treatments. There is little reliable information concerning the growth of the solidly fused kyphotic bone bloc and its influence on the changes of the kyphotic deformity after different operative procedures. METHODS: The study included 117 children operated on for spinal tuberculosis at the age of 2-6 years at the Ruttonjee Sanatorium in Hong Kong during the 1950s and 1960s. Lateral radiographs obtained postoperatively and 5 and 10 years after the operation were analyzed for the growth changes of the solidly fused bone bloc. These results were compared with the different operation techniques (e.g., anterior fusion, posterior fusion, combined anterior and posterior fusion, and anterior debridement without fusion). RESULTS: The patients treated by anterior fusion showed the worst results with respect to the kyphotic angle. This was especially true when the lesion was located in the thoracic spine and several segments were involved. Regarding the growth ratio of the fusion bloc, only the combined fusion and the anterior debridement guaranteed an equal growth of the anterior and posterior height. CONCLUSIONS: Radical anterior surgery for spinal tuberculosis destroys the anterior growth and limits the capacity for spinal remodeling. Therefore, it should be avoided, if it is not absolutely necessary, for the healing of the infection or the primary correction of the tuberculous deformity.

Recurrent dislocation of the patella and the Goldthwait operation.

In this study 17 patients with recurrent dislocation of the patella were followed up 10 years after their Goldthwait operation. The subjective and clinical findings were excellent or good in 70%. X-radiographs indicated osteoarthritis of the femoropatellar joint in 60%. Concerning the aetiopathological factors, we found an increased external torsion of the afflicted extremity (measured by computed tomography).

Comparison of surgical procedures for degenerative lumbar spinal stenosis: a meta-analysis of the literature from 1975 to 1995.

Therapy for spinal stenosis remains difficult. The possibilities for conservative management are limited and not satisfactory in the more severe cases. Various surgical procedures are possible, such as decompression, decompression and fusion without instrumentation and decompression and fusion with instrumentation. The aim of our meta-analysis was to compare the postoperative results of these three surgical techniques in the literature and, thus, to establish a treatment of choice for degenerative lumbar spinal stenosis. Via Medline, 30 articles met the inclusion criteria for our study, leading to a total number of 1668 cases being included in the meta-analysis. The evaluation was made according to our own definition of outcomes, based on criteria most commonly used in the studies reviewed. We found that in patients suffering degenerative spinal stenosis for up to 8 years, decompression without fusion showed the best results. For a duration of symptoms of 15 years or more, decompression with instrumented fusion had the best results. Analysing all postoperative outcomes, decompression is the surgical procedure with the highest rate of success and the fewest complications, followed by decompression with instrumented fusion. In surgery for degenerative lumbar spinal stenosis, decompression and fusion without instrumentation was the least successful procedure. As patients suffering from a degenerative spinal stenosis often are elderly, operations are risky and place a strain on them. This review of the literature shows that the least invasive surgical procedure can obtain the best results if the correct diagnosis is made and if the operation is carried out within the first years of the disease.

[Effect of social status on occupational reintegration after lumbar discotomy]. / Einfluss des sozialen Status auf die berufliche Reintegration nach lumbalen Diskotomien.

QUESTION: The influence of non somatic factors, especially the social status of the patients' profession on postoperative reintegration following lumbar discectomy is investigated. METHODS: In 511 patients postoperative loss of working time and time till return-to-work after lumbar discectomy were investigated. Patients were interviewed by questionnaire at an average of 7.6 years postoperatively. RESULTS: Patients returned to work at an average of 10.5 weeks after operation. Looking at the social status of the patients we found an average time of 5.4 weeks until return to full work for self employed people. Civil servants took on average 10.2 weeks and regular employees returned to work after 14.0 weeks. The longest time to return to work was seen in workers with 17.2 weeks. Somatic risk factor profile for nucleus pulposus prolaps was identical in the group of self employed and employees. There was a different risk profile in the other two groups. CONCLUSION: We could show a correlation between the length of the return-to-work period and long-term clinical outcome with the social status of the patient. This correlation was most clearly shown in the group of self employed and employees. CLINICAL RELEVANCE: For judgement of the postoperative rehabilitation period, the social status may indicate the pain level and duration of pain that has to be expected.

[Segmental hypermobility of the spine before and following discectomy]. / Die segmentale Hypermobilität der LWS vor und nach Diskektomie.

In 145 patients with open dissectomies (virgin back) preoperative functional x-rays (flexion/extension) were available. 80 patients out of this group could be used for additional postoperative functional x-rays. The mean follow-up was 28 +/- 18 months. The segmental mobility was measured using the translation in the z- and the angular rotation about the x-axis (methods of Morgan/ King and Dupuis et al.). The patients were divided in 3 groups in respect to the level of operation. For each patient 3 segments (L3/4 to L5/S1) were analyzed. Segmental hypermobility was defined with a translation of more than 4 mm respectively a rotation of more than 18 degrees (ROM flexion/extension). In patients operated at the level of L4/5 (n = 62) segmental hypermobility was found in 12.9% at L3/4, in 8.1% at L4/5 and in 17.7% at L5/S1. Patients with a discectomy at the level of L5/S1 (n = 79) showed preoperative hypermobility in 10.1% at L3/4, in 15.1% at L4/5 and in 12.6% at L5/S1. In postoperative x-rays patients with discectomy at L4/5 (n = 34) showed no significant differences after operation, neither in translation nor in rotation. In the L5/S1-discectomy group (n = 45) the mobility for rotation at the level L4/5 increased significantly from 6.7 degrees to 10.2 degrees and in the level L5/S1 from 5.2 degrees to 8.4 degrees. There was no significant difference for the translation in all 3 segments. In both discectomy groups the number of segments with hypermobility didn't change significantly after operation.

[Is instrumented pedicle fixation of the lumbar vertebrae used on too large a scale?--thoughts on indication]. / Wird die instrumentierte Pedikelfixation an der Lendenwirbelsäule zu grosszügig eingesetzt?--Gedanken zur Indikation.

The use of pedicle screw fixation can be considered as a mile-stone in developments in spinal surgery in the past decade because of its benefits in the field of correction of spinal deformities due to scoliosis, following fractures, in the treatment of spinal tumours and in some cases of spondylolisthesis. Their widest use, however, has been in the treatment of degenerative disc disease for which its continued use--not only because of a higher morbidity--must be brought into question.

[Proton spin tomographic changes of the femoral shaft in patients with kidney transplantation]. / Kernspintomographische Veränderungen des Femurschaftes bei nierentransplantierten Patienten.

In a prospective study 43 patients were reviewed 3 and 12 months after renal transplantation. The patients had MRI examinations and plain x-rays of the hips as well as punch biopsies of the iliac crest. In 9 patients diffuse, inhomogeneous bilateral changes of the MRI-signal patterns of the femoral diaphysis were seen. They were hypointense in the T1-weighted images and hyperintense in the STIR-images. All plain x-rays were inconspicuous. These changes of the femoral shaft were significantly more frequent in patients with renal osteodystrophy of the histological type Delling Ila. We conclude that these changes of MRI-signals patterns might be connected with an osteoidosis.

[Genetic determination of bone density]. / Genetische Determinierung der Knochendichte.

Osteoporosis is a very common disease that concerns every forth postmenopausal white woman. The loss of bone density leads to fractures, mainly to fractures of the neck of the femur. A hereditary genesis of the idiopathic osteoporosis seems to be sure. The vitamin D receptor (VDR) has an important role for the mineralisation of the bones. His allelic variants can be used for a prediction of bone density. These alleles are correlated with endonuclease restriction areas for Bsm-1, Apa-1 and Taq-1. Among these Bsm-1 has the highest incidence for prediction. In this study the allelic variants of the VDR gene correlated with the bone density of the lumbar spine (p < 0.009).