[Manual medicine and osteopathic methods on the growing spine]. / Manuelle Medizin und osteopathische Verfahren an der wachsenden Wirbelsäule.

The application of various techniques in manual medicine on infants, toddlers and adolescents enjoys widespread acknowledgement not only in the musculoskeletal field but also beyond that. For a long time, the seminars of the DGMM have been trying to structure the advanced training of doctors and the vocational training of physiotherapists and to adjust it according to the latest clinical and scientific findings (in this subject matter). Considering the controversial debates, this seems particularly necessary and meaningful. This article aims to identify the current state of discussion and the consensus between medical associations but it also means to provide assistance in daily routine.

An economic analysis of aseptic revision hip arthroplasty: calculation of partial hospital costs in relation to reimbursement.

INTRODUCTION: Aseptic loosening is one of the most common intermediate and long-term complications after total hip replacement (THR). These complications cause suffering and require expensive revision surgery. Little concrete data on direct costs are available from the hospital's, moreover operating department's perspective. We here provide a detailed analysis of the costs of THR revision and relate them to reimbursement underlying the German diagnosis-related groups (DRG) system. MATERIALS AND METHODS: Major cost parameters were identified using for orientation the cost matrix of the German Institute for Hospital Reimbursement (InEK GmbH). We then retrospectively analysed the major direct costs of aseptic revision THR in terms of contribution margins I and II. The analysis included a total of 114 patients who underwent aseptic revision from 1 January 2009 to 31 March 2012. Data were retrieved from the hospital information system and patient records. All costs of surgery, diagnostic tests, and other treatments were calculated as purchase prices in EUR. The comparative analysis of direct costs and reimbursements was done for DRG I46A and I46B from the hospital's, especially treating department's rather than the society or healthcare insurance's perspective. RESULTS: The average direct cost incurred by the hospital for a THR revision was 4,380.0. The largest share was accounted for surgical costs (62.7 % of total). Implant and staff costs were identified as the most important factors that can be influenced. The proportion of the daily contribution margin that was left to cover the hospital's indirect cost decreased with the relative cost weight of the DRG to which a patient was assigned. CONCLUSION: Our study for the first time provides a detailed analysis of the major direct case costs of THR revision for aseptic loosening from the provider's perspective. Our findings suggest that these revision operations could be performed cost-beneficially by the operating unit. From an economic perspective, cases with higher cost weights are more favorable for a hospital. These results need to be confirmed in multicenter studies.

[Learning and teaching abilities of a newly inaugurated operation technique. Analysis of learning curves and transferability exemplified by Kypho-IORT]. / Lehrfähigkeit und Erlernbarkeit einer neu inaugurierten Operationsmethode. Analyse der eigenen Erfahrungskurve und des Weitergabeerfolgs am Beispiel der Kypho-IORT.

The Kypho-IORT procedure is a recently developed surgical technique to combine intraoperative radiotherapy with cement augmentation of the vertebra for spinal metastases. The technical feasibility and the operation principle of this new method have been described. In the following article the refinement of the standard operation procedure and the technical development of the method are described. Not only the procedural improvements but also the learning curves of the inaugurators are pointed out. Moreover, the article presents the measures which were necessary to educate trainees during surgical master classes in this new method and to transfer the method. The learning success was quantified by recording the accuracy reached by the trainees in the key procedure during hands-on cadaver exercises. Improvements of the standard operation procedure could be successfully transferred in a second master class. The method of Kypho-IORT and the demonstrated way of postgraduate education is feasible to instruct trainees. The Kypho-IORT procedure can be learnt and performed safely by running through the surgical master class.

[Kyphoplasty in combination with intraoperative radiotherapy. Technical and regulatory characteristics of a concept for treatment of vertebral metastases]. / Kyphoplastie in Kombination mit intraoperativer Radiotherapie. Technische und regulatorische Besonderheiten eines Konzepts zur Behandlung von Wirbelkörpermetastasen.

BACKGROUND: Operative and radiotherapeutic procedures are available for the treatment of symptomatic vertebral metastases. The method for treatment of vertebral metastases presented in this article involves a combination of intraoperative radiotherapy (IORT) and kyphoplasty. METHODS AND RESULTS: Kyphoplasty-IORT allows treatment of symptomatic vertebral metastases between vertebrae T3 and L5. With the patient under intubation narcosis an extrapedicular or bipedicular access to the vertebra is selected as for conventional kyphoplasty. This is followed by insertion of special sheaths of the radiation applicator and radiation therapy is intraoperatively administered via a radiation generator (Intrabeam®, Carl Zeiss Surgical, Oberkochen, Germany). The radiation dose is 8 Gy at a depth of 5-10 mm depending on the study protocol (50 kV X-radiation). Following radiation a conventional kyphoplasty procedure (Medtronic, USA) is carried out and the vertebra stabilized with cement. CONCLUSIONS: The procedure presented demonstrates a new approach to treatment of vertebral metastases and represents a valuable alternative to previously established methods.

[Manual medicine]. / Manuelle medizin.

The techniques of manual medicine provide the basis for the palpatory recognition of dysfunction, primarily in the musculoskeletal system. The essential criterion of manual medicine is inclusion of the segmental level of function. One criterion of evaluation is, most notably, segmental hypomobility. The purpose of manual diagnostics is to determine segmental blockage. Manual therapy techniques lead first to improved function of the segment and, consequently, to improved function of the whole organism. Manual medicine focuses on the (peri)articular and myofascial levels as well as on the nervous control level of the motion segment and may interact with therapeutic methods. For therapeutic purposes, the joint may be manipulated with impulse as well as without therapeutic impulse for soft techniques. Different muscle relaxation techniques are used on the myofascial system to achieve improved function of reflectory or structurally altered musculature and of the myofascial system.

[Stabilization of the osteoporotic spine from a biomechanical viewpoint]. / Stabilisierung der osteoporotischen Wirbelsäule unter biomechanischen Gesichtspunkten.

The altered trabecular structure of the osteoporotic spine leads to an increased vulnerability of its biomechanical characteristics and reduction of load resistance. Therefore, any surgical procedure must account for these circumstances. In cement-augmented vertebrae, both the overall stability and load transfer to the adjacent structures are influenced by a variety of factors. This has been demonstrated by different findings regarding volume, special characteristics, choice of approach and application, as well as distribution of the cement within the vertebral body. Independent of the well-known good clinical results, these features leave the discussion regarding the most appropriate form of cement-augmenting technique open. In cases where implants are required, there are increasing data to allow for an appropriate choice of stabilizing devices to fit the biomechanical demands in poor bone quality. Thereby, multilevel instrumentation, additive stabilization techniques, cement-augmented pedicle screws and adapted implant designs ensure and increase patient safety. However, regardless of the procedure chosen to stabilize the osteoporotic spine, reconstruction of the column profile appears to be of pre-eminent importance.

[Fatal complex fracture of the cervical spine in a patient with ankylosing spondylitis after a fall from a racing bicycle]. / Fatale komplexe HWS-Verletzung bei M. Bechterew nach Sturz mit dem Rennrad.

Patients with ankylosing spondylitis are endangered suffering from cervical spine fractures following falls caused by kyphosis, stiffness and osteoporotic bone quality of the spine. Risk sustaining neurological deficits is higher than average. We present a patient with ankylosing spondylitis, who was admitted to our hospital with a complex fracture pattern of the cervical spine after a fall from a racing cycle. In spite of early operative treatment the patient died in the follow up because of severe hypoxic brain damage. We discuss the area of conflict between the recommendation for sport activities in patients with ankylosing spondylitis and the resulting risks for the diseased spine.

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.

An fMRI study of emotional face encoding in youth at risk for bipolar disorder.

Face memory deficits may be a bipolar disorder (BD) endophenotype. BD (n=27) and unaffected youth at risk (n=13) exhibited middle frontal gyrus hypoactivation during successful vs. unsuccessful encoding. Parahippocampal gyrus dysfunction was found in BD and at-risk youth (vs. low-risk, n=37). Middle occipital gyrus hypoactivation was only present in BD.

[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.

Comparative investigations on COD-removal in sequencing batch reactors and continuous flow plants.

Investigations on enhanced COD removal from municipal wastewater were performed over a period of 2.5 years, comparing three different types of reactor. The main idea was to determine the influence of the mixing characteristics of the reactor on the treatment processes and the effluent quality. Therefore three pilot plants (a completely mixed reactor, a cascade of three reactors and a SBR) were operated under equal conditions (wastewater, hydraulic load, temperature, sludge age) in parallel to each other. Investigations were carried out at different sludge ages. It could be shown that within one sludge age the CODf removal efficiency increased, when mixing characteristics came closer to the plug flow and it also increased with higher temperatures. A significant correlation was observed between the COD removal efficiency and the sludge load. The higher the sludge load was the greater the CODf concentration in the effluent. Especially the SBR reactor showed an excellent performance under the given operating conditions. Dynamic simulation calculations were carried out, to investigate whether the influence of the type of reactor on the COD-elimination could be described theoretically by combining growth kinetics and the mixing characteristics of the individual reactors. The results showed that performance was better when mixing characteristics came closer to plug flow.

[Freiburg intervention program for ambulatory therapy of obesity in childhood (FITOC)]. / Freiburger Interventionsprogramm zur ambulanten Therapie der Adipositas im Kindesalter (FITOC).

In this study we first try to answer the question, whether it is possible to make a successful treatment for obese children in an interdisciplinary program. Second it is asked whether a transfer of this program to further regions in Germany leads to comparable results. In FITOC children from the age of 8-11 years and over the 97. BMI-percentile are integrated in this program. The goals weight management, increased physical fitness and improvement of the cardiac risk profile are checked by weight, height, fasting blood serum, a standardized cycle ergometry and a medical measurement at the beginning, after treatment and at all check-ups. The recorded medical data show clearly that the intervention leads to a significant improvement in almost all checked parts. The successful treatment can be recorded after 8 months, likewise after 2.5 years as a long-term result. The further cornerstones of FITOC nutrition and psychology are not subject of this publication. In future the psychological part in FITOC will be evaluated by standardized inventories. The group from Düren has a success in therapy according to the definition of the program. Thereby it is shown that FITOC is extendable, if teams are trained intensively and the conditions are comparable. FITOC is able to treat obese children successfully over a long period of time. In consideration of the rising prevalence of obesity in childhood and the limited financial resources in health care this outpatient interdisciplinary program is an effective choice of treatment.

Osseofix® system for percutaneous stabilization of osteoporotic and tumorous vertebral compression fractures - clinical and radiological results after 12 months.

PURPOSE: Determining whether implantation of an expandable titanium mesh cage (Osseofix® system) is a successful and safe minimally invasive therapy for osteoporotic and tumorous vertebral compression fractures (VCFs). MATERIALS AND METHODS: 32 patients (25 women, 7 men, mean age 71) with 46 osteoporotic or tumorous VCFs (T6 to L4) from June 2010 to January 2012 were included. All of them were stabilized with the Osseofix® system. Preinterventionally we performed X-ray, MRI, and bone density measurements (DXA). The clinical and radiological results were evaluated preop, postop and 12 months postop based on the visual analog scale (VAS) and the Oswestry Disability Index (ODI), X-ray (Beck Index, Cobb angle) and CT. RESULTS: There was a significant improvement in pain intensity (VAS) (7.8 to 1.6) as well as a significant reduction in the mean ODI (71.36 % to 30.4 %) after 12 months. The mean kyphotic angle according to Cobb showed significant improvements (12.3° to 10.8°) after 12 months. Postinterventional imaging showed one case of loss of height in a stabilized lumbar vertebral body (2.2 %) in osteoporosis and one case with adjacent fracture (2.2 %) in osteoporosis. We saw no changes in the posterior vertebral wall. Except for one pronounced postoperative hematoma, we saw no surgical complications including no cement leakage. CONCLUSION: The clinical mid-term results are good at a low complication rate. The stabilization of symptomatic osteoporotic and tumorous VCFs with the Osseofix® system is a safe and effective procedure, even in fractures with posterior wall involvement. The Osseofix® system is an interesting alternative to the established procedures of cement augmentation. KEY POINTS: • The Osseofix® system is well suited for stabilizing osteoporotic and tumorous VCFs.• It is a safe and effective procedure without cement leakage and with a low complication rate.• The procedure is an interesting alternative to established cement augmentation procedures.

[Manual-medical differential diagnosis of low back pain including osteopathic procedures]. / Differenzialdiagnostik manualmedizinischer Syndrome bei unteren Rückenschmerzen unter Einbeziehung osteopathischer Verfahren.

The differential diagnostic evaluation of painful functional disorders of the lumbosacral and lumbopelvic region, i. e. the so-called "low back pain" is very extensive, but is often reduced to the question of chronicity. The manual medical diagnosis can make a valuable contribution in such cases for determination of structural and functional pathology. Early application of manual medical therapies seems to be effective for peracute complaints. The mobilization of restrictions of the pelvic visceral attachments should be included. In the following review manual medical syndromes are presented that summarize the findings from the musculoskeletal and visceral system. This is intended to facilitate the primary differential diagnostic evaluation, as well as treatment planning. The combination with osteopathic methods is very profitable. A necessary specialist differential diagnosis remains essential.

[Sledge versus bicondylar surface treatment in the endoprosthetic therapy for unicompartmental knee arthrtitis--a comparative cost analysis]. / Kostenvergleichskalkulation der Schlitten- vs. bikondylären Oberflächenversorgung am Kniegelenk.

BACKGROUND: The G-DRG system reimburses sledge endoprosthetic implantations (UKA) at a much lower rate than surface replacements (TKA), at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, the complete endoprosthesis implantation produces higher gains. An orientation on these revenues alone, however, does not provide the basis for an economically sound decision-making process. The aim of this study is to present a comparison of the variable costs of the two procedures. MATERIAL AND METHODS: The mean cost and performance data of 28 Endo-Model UKA implantations and of 85 NexGen CR TKA replacements were compared with each other in 2007. RESULTS: From the perspective of the hospital, when the correct medical indication is present, UKA treatment is of greater economic advantage. In this way the total unit contribution margin can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of the TKA. CONCLUSION: For the desired maximisation of the unit contribution margin, assuming that it is the proper medical indication, the recommendation for the hospital would be implantation of the UKA. Considered from the economic perspective of gains and costs, the assumption that a TKA would be advantageous could not be confirmed in the present study.

[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.

[Treatment options for problematic thoracic and lumbar osteoporotic fractures]. / Behandlungsmöglichkeiten bei thorakalen und lumbalen osteoporotischen Problemfrakturen.

Most osteoporotic sintering fractures are treated conservatively. However, persistent pain and consecutive spinal deformity may require certain cement-augmenting interventions. These procedures have proven their intermediate-term efficacy in pain reduction, prevention of progressive sintering and improvement of the overall quality of life in the majority of patients. In fractures with relevant spinal stenosis, persisting instability, gross deformity and trauma-associated osteoporotic fractures with or without neurological deficits, the therapeutic options may call for more extensive surgical procedures. In this regard, poor bone quality, age and respective comorbidities of the individual patient must be considered during preoperative planning and management. This article provides an overview of the diverse problem-solving strategies discussed in today's literature. It is generally acknowledged that any decision to perform surgery on an osteoporotic fracture is strongly case-dependent. Treating physicians must therefore master the complete therapeutic spectrum in order to meet this complex orthopedic challenge appropriately.

Brown-Séquard syndrome caused by a high velocity gunshot injury: a case report.

STUDY DESIGN: Case report. OBJECTIVE: To present an unusual traumatic neurologic pathology caused by gunshot injury. SETTING: Spine unit of Department of Trauma and Orthopaedic Surgery, University Medical School, Charité - Campus Benjamin Franklin, Berlin, Germany. METHOD AND RESULT: A 35-year-old male sustained a gunshot injury from a machine gun. The projectile caused a fracture of the left pedicle of Th10. The spinal cord was indirectly damaged by cavitation that caused a Brown-Séquard syndrome (BSS). After a microscopically assisted posterior revision at T9/10 with removal of bullet and bone fragments from the spinal canal and debridement of the bullet cavity via extended fenestrectomy the patient gained his motor function back. The sensory deficit remained unchanged. CONCLUSION: BSS can be caused by bullet-related injury of the spinal canal with no direct damage of neural structures. The initial treatment is always based on the total injury pattern. Possible spinal cord injuries are only clarified after restitution of vital functions. Decompression of neural structures in shotgun injury is indicated in incomplete paraplegia, injury of intra-abdominal hollow organs or high velocity bullet wounds. Through debridement and decompression of neural structures and chronic damage caused by foreign body granulomas can be prevented. Secondary destabilization of the spine should be avoided.