Comparison of a minimally invasive procedure versus standard microscopic discotomy: a prospective randomised controlled clinical trial.

A Prospective randomised controlled study was done to determine statistical difference between the standard microsurgical discotomy (MC) and a minimally invasive microscopic procedure for disc prolapse surgery by comparing operation duration and clinical outcome. Additionally, the transferability of the results was determined by a bicentric design. The microscopic assisted percutaneous nucleotomy (MAPN) has been advocated as a minimally invasive tubular technique. Proponents have claimed that minimally invasive procedures reduce postoperative pain and accelerate the recovery. In addition, there exist only a limited number of well-designed comparison studies comparing standard microdiscotomy to a tubular minimally invasive technique that support this claim. Furthermore, there are no well-designed studies looking at the transferability of those results and possible learning curve phenomena. We studied 100 patients, who were planned for disc prolapse surgery at two centres [50 patients at the developing centre (index) and 50 patients at the less experienced (transfer) centre]. The randomisation was done separately for each centre, employing a block-randomisation procedure with respect to age and preoperative Oswestry score. Operation duration was chosen as a primary outcome parameter as there was a distinguished shortening observed in a preliminary study at the index centre enabling a sound case number estimation. The following data were compared between the two groups and the centres with a 12-month follow-up: surgical times (operation duration and approach duration), the clinical results, leg and back pain by visual analogue scale, the Oswestry disability index, length of hospital stay, return to work time, and complications. The operation duration was statistically identical for MC (57.8 +/- 20.2 min) at the index centre and for MAPN (50.3 +/- 18.3 min) and MC (54.7 +/- 18.1 min) at the transfer centre. The operation duration was only significantly shorter for the MAPN technique at the index centre with 33.3 min (SD 12.1 min). There was a huge clinical improvement for all patients regardless of centre or method revealed by a repeated measures ANOVA for all follow-up visits Separate post hoc ANOVAs for each centre revealed that there was a significant time-method (MAPN vs. MC) interaction at the index centre (F = 3.75, P = 0.006), whereas this crucial interaction was not present at the transfer centre (F = 0.5, P = 0.7). These results suggest a slightly faster clinical recovery for the MAPN patients only at the index centre. This was due to a greater reduction in VAS score for back pain at discharge, 8-week and 6-month follow up (P < 0.002). The Oswestry-disability scores reached a significant improvement compared to the initial values extending over the complete follow-up at both centres for both methods without revealing any differences for the two methods in either centre. There was no difference regarding complications. The results demonstrate that a shorter operation duration and concomitant quicker recovery is comprehensible at an experienced minimally invasively operating centre. These advantages could not be found at the transfer centre within 25 minimally invasive procedures. In conclusion both procedures show equal mid term clinical results and the same complication rate even if the suggested advantages for the minimally invasive procedure could not be confirmed for the transfer centre within the framework of this study.

[Dislocation as a rare complication of resurfacing of the hip joint. Case report and meta-analysis]. / Die Luxation als seltene Komplikation des Oberflächenersatzes am Hüftgelenk. Fallbeschreibung und Metaanalyse.

Resurfacing of the hip joint experienced a revival in the 1990s. Today metal-on-metal bearing is a therapy option especially for younger, active patients. In comparison to stemmed total hip replacements resurfacing offers advantages, in particular in view of the femoral bone loss. The short-term results are very good. In the current literature revision rates of less than 1% are reported. In comparison to conventional total hip replacement, dislocation is a rare complication. With conventional total hip replacement the dislocation rate is 2-5%. In the international literature the dislocation rate with resurfacing is 0.21%.

Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging.

OBJECTIVES: The aim of this study was to determine whether ultrasound can correctly visualise partial ruptures of the proximal Achilles tendon. METHOD: This was a prospective study in which all chronic Achilles tendon injury patients seen at three centres in Germany from 1998 to 2003 were screened. All patients with clinical and/or sonographic signs of abnormalities in the region of the proximal third of the Achilles tendon and tendomuscular junction were included in the analysis. Each of these cases was evaluated by ultrasound following an assessment protocol. Patients with ambiguous ultrasound findings and/or clinical signs were additionally assessed by magnetic resonance imaging (MRI). RESULTS: Sonomorphologic changes suggestive of an abnormality in the proximal third of the Achilles tendon were detected in 13 out of 320 patients (4.2%) with recurring Achilles tendon complaints. Thirteen patients had clinical signs but no sonographic changes in the tendon. The sonographic diagnosis was correct in 19 cases. In six of the 26 cases studied, MRI was needed to establish the correct diagnosis of partial intratendinous rupture of the proximal Achilles tendon. Sensitivity was 0.5, specificity was 0.81, and the overall agreement of the ultrasound examination was 61.5%. All patients were asymptomatic at follow up at a mean of 14 months (range 12-17 months) after surgery. CONCLUSIONS: Ultrasound is a useful tool for evaluation of proximal Achilles tendon complaints. However, ultrasound is not sufficiently reliable for diagnosis of all pathologies, especially partial ruptures of the Achilles tendon. Thus, the definitive diagnosis must be established by MRI.

[Diskography findings and results of percutaneous laser disk decompression (PLDD)]. / Diskographiebefund und Ergebnis der perkutanen Laserdiskusdekompression (PLDD).

AIM: The aim of our study was to find a correlation between discographic findings and the clinical outcome of patients treated by PLDD. METHOD: At our clinic a total of 444 patients was treated by PLDD from 1992 until 1998. Of these, 100 patients were included into this study by chance. All patients had discography. We analysed the discographic results and correlated them with the objective and subjective outcome after PLDD. RESULTS: Best clinical results were found in the group of discographic stages 7 and 8 according to Krämer. In cases of epidural leak of contrast medium and in cases of total degeneration, the clinical results were significantly poor (stages 6 and 9). CONCLUSION: In cases of ruptured posterior longitudinal ligament, i.e., epidural leak of contrast medium in discography, PLDD is not indicated. The indication for an operation first of all depends on the clinical symptoms but the success of the operation depends on the discographic findings.

Vertebral collapse and normal peripheral blood cell count at the onset of acute lymphatic leukemia in childhood.

Acute lymphatic leukemia presenting with bone pain and spine involvement is a recognized clinicopathologic complex that can mimic a wide range of orthopaedic conditions. Bone pain as the presenting complaint is common, with a reported incidence of 27% to 50%. Radiologic abnormalities associated with leukemia in children has been described previously. In the literature, the incidence of spinal involvement is controversial, but there is agreement that the spine is less commonly involved than are the long bones. At the onset of the disease, only 10% of children have normal peripheral blood counts. If the patient has spinal involvement and a normal leukocyte count, the diagnosis is often unclear. Only three of these patients have been described in the literature; this article adds one more patient with acute lymphatic leukemia with back pain as the main symptom, vertebral collapse, and a normal peripheral blood cell count at the time of initial presentation. It illustrates that delay in diagnosis frequently occurs, with the classic features of the disease being uniformly absent.

[Concepts of in-patient gradual diagnostics for patients with lumbar back-pain]. / Das Konzept der stationären Stufendiagnostik bei Patienten mit lumbalem Rückenschmerz : Orthopädische Kompetenz bei der Diagnostik und Behandlung von Rückenschmerzpatienten.

Concepts for treating back pain by considering recent advancements in understanding chronic pain have been increasingly discussed over the last years. In general, any kind of therapy requires a most accurate diagnosis; however, in cases of lumbar back pain matching clinical observations with known structural pathologies is not always straight forward. Here, we suggest a concept of in-patient gradual diagnosis of patients with back pain that includes stepwise structural and functional components. We emphasize that in addition to the specific (classifiable) factors causing back pain (e.g. compression of lumbar nerve roots, facet joint associated pain syndrome, sacroiliacal dysfunction, segmental instability) also unspecific (non-classifiable) causes as well as disease-associated and/or determining bio-psychological or social factors need to be considered. With this study, we aim to introduce the procedure and assess the value of in-patient gradual diagnostics. We will describe different approaches, which we will evaluate for specific indications.

Proximal focal femoral deficiency -- a rare entity in the sonographic differential diagnosis of developmental dysplasia of the hip,.

In the present study, we will describe the differential diagnosis of the rare hip anomaly of proximal focal femoral deficiency (PFFD), based on an analysis of 12,488 ultrasound images of the hips of 6244 neonates, examined in our orthopaedic clinics between 1988 and 1998. The clinical manifestations and ultrasound features of PFFD will be characterised and compared with those of the normal, the mildly dysplastic, and the severely dysplastic hip. Two cases of PFFD (0.032 %) were detected during the investigation period. Both neonates had been referred to the orthopaedic clinic for further evaluation after the initial ultrasound findings suggested an anomaly in the coxal-femoral region. Correct identification of anatomical structures in the acetabular region (acetabular labrum and lower edge of the ilium) was not possible, but the iliac line, femoral head, and greater trochanter could be reliably visualised. Because of these findings, a deformity in the coxal-femoral region was suspected, and further diagnosis was recommended. PFFD was subsequently diagnosed, and specific treatment was initiated. PFFD should be suspected in any neonate with suspicious clinical findings and failure of ultrasound to clearly visualise anatomical landmarks in the region of the acetabulum (acetabular labrum, lower edge of the ilium, cartilage-bone interface) despite the use of a sufficient imaging technique. Radiographs should then be obtained to confirm or refute the tentative diagnosis. Infants with PFFD can then receive proper treatment without unnecessary therapeutic trial and error.

Sonographic imaging of the distal biceps tendon -- an experimental and clinical study.

AIM: With this study we aimed to determine the reliability of ultrasound imaging in depicting the normal anatomy of the distal biceps tendon in human cadaver specimens and to provide an accurate visualisation of ruptures of the distal biceps tendon in healthy volunteers. METHOD: The distal biceps tendons of six whole-arm human cadaver specimens were investigated. The tendons were subsequently marked with a biopsy needle and re-examined. In addition, ultrasound imaging of the distal biceps tendon was performed in 25 healthy volunteers (50 sonograms). All examinations were carried out using linear ultrasonic transducers of various frequencies (5 - 13.5 MHz). The sonographic images were submitted to two experienced examiners for analysis. RESULTS: Positive identification of the tendon was achieved in all cases. The best results were achieved using 7.5 MHz transducers. Our study also suggests that the medial longitudinal scan and the articular transversal scan are a definite prerequisite for a correct diagnosis in the region of the distal biceps tendon. The dynamic examination is very useful to visualise the tendon with sufficient accuracy. CONCLUSION: Based on this study, ultrasound imaging is recommended as the method of choice for visualisation of the distal biceps tendon if performed with the necessary accuracy.

Ultrasonography as a reliable diagnostic tool in old quadriceps tendon ruptures: a prospective multicentre study.

Quadriceps tendon rupture is an uncommon injury. In the majority of cases, predispositions as recurrent microtrauma or degenerative changes are present. The diagnosis of acute quadriceps tendon ruptures can usually be made by clinical examination. Ultrasonography has been shown as a reliable, inexpensive and easily available diagnostic tool to confirm the diagnosis. In this study, we evaluated the clinical value of ultrasonography for establishing diagnosis of old quadriceps tendon ruptures. In the prospective time period of 6 years (01/1998-12/2003), the delayed diagnosis of quadriceps tendon rupture was established in six patients with seven cases of old ruptures (one bilateral rupture). The mean age was 50.2 (SD+/-16.9) years in one woman and five men. The mean interval from trauma until diagnosis was 15.2 (SD+/-7.1; range 8-24) weeks. In all cases, ultrasonography represented a reliable and sensitive tool for establishing diagnosis of old quadriceps tendon rupture. We therefore recommend the use of ultrasonography in the diagnostic work up of cases with knee trauma and potential involvement of tendon injuries.

[Results after resection of juxta-facet-cysts - Which role does a segmental instability play?]. / Ergebnisse nach Resektion von lumbalen Juxta-Facett-Zysten - Welche Rolle spielt die segmentale Instabilität?

This study demonstrates the results after operative treatment of patients suffering from a lumbar Juxta-Facet-Cyst. We point out diagnostical aspects, possible concomitant problems and deriving therapeutical consequences. Between 01. 01. 1998 and 31. 03. 2001 9 patients were operated on a synovial cyst or a ganglion of the facet joint at our department. 5 patients were female, 4 patients male with a mean age of 61 (45-70) years. The average clinical and radiological follow up was 11 (5-18) months postoperatively. The clinical examination revealed in 5 out of 9 patients a sensible deficit, in 3 out of 9 patients motoric disturbances. There was no positive sign of Lasegue. The resection of the cyst or ganglion was performed in all cases via a dorsal approach. 8 patients underwent for a spinal stenosis and/or an existing instability a laminectomy and a spondylodesis with an internal fixateur. The histological findings showed a synovial cyst in 6 cases and a ganglion cyst in 3 cases. At the follow up all preoperative sensible or motorical deficits had resolved. Juxta-Facet-Cysts are discovered in some cases intraoperatively by chance, the radiological methods (CT, MRT) are especially in case of a concomitant spinal stenosis uncertain. During all operations, which are performed for a spinal stenosis, one should look for a cyst. The resection of the cyst leads to good functional results, a possible instability should by addressed by a spondylodesis.

[Ultrasonographic visualization of a Baker-cyst as cause of a peroneal nerve palsy in a patient with rheumatoid arthritis]. / Sonographische Diagnosestellung einer Baker-Zyste als Ursache einer Peroneusparese bei einem Patienten mit Rheumatoidarthritis.

With this report we present a patient with rheumatoid arthritis in whom a popliteal cyst could be diagnosed quickly and conclusively by ultrasonography as the possible reason for peroneal palsy. The sonographic investigation of the knee joint revealed an effusion. Within the popliteal fossa (dorsal longitudinal and transverse section) a cyst measuring 54 x 21 x 51 mm in a typical dorsomedial position in between the heads of the gastrocnemius muscles was found. Besides extensive synovectomy, we completely removed the cyst. The common peroneal nerve was entrapped by the Baker's cyst. The complete palsy of the nerve improved postoperatively (grade 4 according to Janda). Ultrasonography is an excellent diagnostic procedure for easy, quick, and reliable differential diagnostic evaluation of a swelling within the popliteal fossa region.

[Vertebral Langerhans-cell histiocytosis in childhood--a differential diagnosis of spinal osteomyelitis]. / Die Langerhanszell-Granulomatose der Wirbelsäule im Kindesalter als Differentialdiagnose zur spinalen Osteomyelitis.

BACKGROUND: The Langerhans cell histiocytosis has lots of different manifestations. Symptoms are not specific enough to identify the disease. In cases of vertebral Langerhans cell histiocytosis it is sometimes difficult to differentiate the lesions from spinal osteomyelitis. PATIENTS: Six children with Langerhans cell histiocytosis who had an operative treatment at our clinic in 1981 to 1995 have been reviewed. All patients had a localised vertebral presentation at the onset of the disease. METHODS: In this study we have been showed the clinical, radiological, histological and laboratory findings of our patients with Langerhans cell histiocytosis for an average of six years. Especially the use of diagnostic tools has been examined. RESULTS: Diagnostic tools such as radiogram, computerised tomography, bone scan and MRI and their value in finding the correct diagnosis have been described. Especially the use of MRI in early diagnosing has been discussed. Early changes in MRI have been presented as well as the useful radiological signs and MRI signs to differentiate Langerhans cell histiocytosis and spinal osteomyelitis. CONCLUSIONS: Vertebral Langerhans cell histiocytosis in childhood is a possible differential diagnosis to spinal osteomyelitis.

[Spondylitis due to Salmonella typhimurium]. / Spondylodiszitis durch Salmonella typhimurium.

Very little is known about Salmonella typhimurium as an agent of spondylitis. Only single cases have been described in the international literature over the last years. We report on three patients suffering from spondylitis with Salmonella typhimurium being isolated as the triggering agent and point out the subtly differentiated diagnostic and therapeutic procedures, especially the possible complications of a Salmonella spondylitis. For one of the patients, we diagnosed a concomitant abdominal aortic aneurysm. Another patient sustained an infection of a known aortic aneurysm, which had been operated on 3 years ago. The source of the infection could be either the aneurysm or the spine, with the other structure being infected subsequently. We also discuss possible pathogenesis.

[Value of ultrasound diagnosis in Legg-Calvé-Perthes disease]. / Wert der Sonographie bei Morbus Legg-Calvé-Perthes.

Ultrasound examination of the hip joints in cases of the painful hip in childhood is routinely performed according to the advised standard sections of the German Society for Ultrasound in Medicine (DEGUM) at the special surgery of paediatric orthopaedics of the Orthopaedic University Clinic Magdeburg. Between 1993 and 2000 we performed 418 sonographic examinations of painful hip joints in 153 children. We identified 53 children (159 sonograms) with coxitis fugax, 47 children (188 sonograms) with Morbus Perthes, 28 children with epiphysiolysis capitis femoris, and three children with septic arthritis. In 15 cases (30 sonograms) no sonopathologic changes were observed. However, only in seven cases where ultrasound examination failed to reveal pathological changes, the cause of painful hip was identified by means of radiation depending X-ray or MRI. Sonograms of children with Morbus Perthes were further used to evaluate for stage differentiation and potential surgical treatment. Thus, we could show that ultrasound examination is a powerful tool for identifying the variety of underlying causes of painful hip in childhood and should be used as method-of-choice especially in children to avoid unnecessary radiation exposure.

[Results of surgically managed acromioclavicular joint rupture in adults]. / Ergebnisse operativ versorgter Acromioclavicularsprengungen im Erwachsenenalter.

60 out of 69 (87%) patients were reexaminated after operation for a trauma of the actomioclavicular articulation of type TOSSY III. The evaluation includes functional, radiological and cosmetical-subjective criterions. The surgical treatment consists of fixation of the clavicula to the coracoid with screw figure-of-eight suture and suture or plastic of the ligament. The results correspond to those of other surgical techniques.

[Vertebragenic dysphagia]. / Vertebragenbedingte Dysphagien.

UNLABELLED: Dysphagia due to external compression by anterior hyperostosis of the cervical spine is rare. The diagnosis may be established by conventional X-ray of the spine, oesophagogram, CT or MRI. CASES: We operated on one patient with an exostosis on the axis and another patient with large anterior osteophytes from C3 to C7 in Forestiers's disease. Postoperatively the patients were asymptomatic. CONCLUSIONS: Painful dysphagia due to anterior hyperostosis of the cervical spine is an indication for surgery. The anterolateral extrapharyngeal approach from C3 to C7 and the transoral intrapharyngeal approach to the vertebra C2 are preferred. In cooperation between orthopaedics and ENT the surgical treatment has no major complications and gives good functional results.

[Ultrasound diagnosis of sternum fractures]. / Sonographische Diagnostik von Sternumfrakturen.

AIM: With the present study we wanted to examine the value of ultrasonography in the diagnosis of fractures of the sternum. METHOD: Included in this study were 11 patients with pain in the sternal region and suspected fracture of this area according to case history and clinical examination. We exclusively used a 7.5 MHZ linear scanner. RESULTS: In all 11 cases the fracture was free of doubts diagnosed using ultrasound. A fragment dislocation could be visualized in 10 cases and 1 case showed a fissure of the sternum. The standard lateral X-ray as our reference method confirmed the sonographical diagnosis in all cases. CONCLUSIONS: The diagnostical value of ultrasonography of the sternum is at least as high as that of standard lateral X-ray. When a hypoechoic area over the sternum together with a hematoma, a disruption of the cortical bone or a step in the bony outline as a sign for fragment dislocation are found, sternal fracture is the definite diagnosis. Ultrasonography is quickly feasible, non-invasive and gives sufficient information in these cases without side effects.

[Spondylodiscitis in childhood]. / Spondylodiszitis im Kindesalter.

Spondylitis is a rare disease in childhood and atypical symptoms frequently retard the diagnosis. From 1968 to 1988, 25 children with a diagnosis of spondylitis were treated in our orthopedic hospital. Anamneses, clinical symptoms, roentgenograms, and differential diagnoses are described for these cases. Spondylodiskitis represents a mild course of the disease in childhood. Tuberculous spondylitis was not present in any of the cases. The prognosis of childhood spondylitis is favorable, and surgical interventions were not necessary in our patients. Spondylitis healed with an ankylosis of one segment of the spine without essential disturbance of spinal function.

[Transabdominal ultrasonography in the diagnosis of lumbar disc herniation]. / Die transabdominale Sonographie in der Diagnostik des lumbalen Bandscheibenprolaps.

AIM: The aim of our study was to assess the value of transabdominal ultrasonography in the diagnosis of a lumbar herniated disc and to investigate the influence of the quality of the ultrasonography investigation on detection of pathological changes in lumbar intervertebral disc. METHOD: 119 patients (55 female, 64 male, mean age 41 years) were included in our study. Patients were suffering from lower back pain and were investigated by transabdominal ultrasonography, using a 3.5 MHz scanner. The results of the ultrasonography investigation were compared with MRI and intraoperative findings RESULTS: The quality of the ultrasonography documentation shows distinct differences between the segments of the lower lumbar spine (L3/4 86.6 %, L4/5 85.7 %, L5/S1 70.6 %). The sonographic evaluations were correct in 75.4 % of cases. Sensitivity of ultrasonography for the detection of an intradiscal lesion was 0.46 for L3/4, 0.83 for L4/5 and 0.78 for L5/S1. Specificity was 0.91 for L3/4, 0.65 for L4/5 and 0.67 for L5/S1. CONCLUSION: Compared to MRI investigation transabdominal ultrasonography of the lumbar herniated disc proved to be distinctly inferior because of methodical limitations and lower diagnostic accuracy. This method, however, can be used as a preliminary diagnostic procedure.

[Modification of patella alta, patella ventralization en patella lateralization in patellar pain syndrome following implantation of total GSB endoprosthesis]. / Beeinflussen Patellahoschstand, Patellaventralisation und Patellatateralisation das patellare Schmerzsyndrom nach Implantation von GSB-Totalendoprothesen?

We examined the degree of retropatellar pain related to biomechanical factors of the implantation in 31 cases of GSB-endoprostheses without retropatellar alloarthroplasty, loosening or infection. Postoperative patella alta and lateralisation of the patella extended the retropatellar pain syndrom but not tibiaventralisation. These results indicate that certain unfavourable patella positions may be responsible for the retropatellar pain syndrom in patients with a GSB-endoprosthesis.