Minimal-invasive anterior approach to the hip provides a better surgery-related and early postoperative functional outcome than conventional lateral approach after hip hemiarthroplasty following femoral neck fractures.

INTRODUCTION: Femoral neck fractures (FNF) are one of the most frequent fractures among elderly patients and commonly require surgical treatment. Bipolar hip hemiarthroplasty (BHHA) is mostly performed in these cases. MATERIAL AND METHODS: In the present retrospective study geriatric patients with FNF (n = 100) treated either by anterior minimal-invasive surgery (AMIS; n = 50) or lateral conventional surgery (LCS; n = 50) were characterized (age at the time of surgery, sex, health status/ASA score, walking distance and need for walking aids before the injury) and intraoperative parameters (duration of surgery, blood loss, complications), as well as postoperative functional performance early (duration of in-patient stay, radiological leg length discrepancy, ability to full weight-bearing, mobilization with walking aids) and 12 months (radiological signs of sintering, clinical parameters, complication rate) after surgery were analyzed. RESULTS: Patients in the AMIS group demonstrated a reduced blood loss intraoperatively, while the duration of surgery and complication rates did not differ between the two groups. Further, more patients in the AMIS group achieved full weight-bearing of the injured leg and were able to walk with a rollator or less support during their in-patient stay. Of interest, patients in the AMIS group achieved this level of mobility earlier than those of the LCS group, although their walking distance before the acute injury was reduced. Moreover, patients of the AMIS group showed equal leg lengths postoperatively more often than patients of the LCS group. No significant differences in functional and surgery-related performance could be observed between AMIS and LCS group at 12 months postoperatively. CONCLUSIONS: In conclusion, geriatric patients treated by AMIS experience less surgery-related strain and recover faster in the early postoperative phase compared to LCS after displaced FNF. Hence, AMIS should be recommended for BHHA in these vulnerable patients.

Locking Nail versus Plate Fixation in Calcaneal Fractures: Brief report on a Retrospective Analysis of Treatment Characteristics and Radiographic Correction Potential.

PURPOSE OF THE STUDY Minimal and limited access techniques are gaining increasing interest for the treatment of displaced intra-articular calcaneal fractures. The ideal treatment method is however still debated and largely based on individual case factors and surgeon experience. Aim of this study was thus to compare the treatment characteristics and radiographic correction potential of a locking nail system with a sinus tarsi approach to plate fixation via an extended lateral approach. MATERIAL AND METHODS We retrospectively reviewed 39 cases of patients with calcaneal fractures that received primary fracture treatment for displaced intra-articular calcaneal fractures between July 2017 and March 2020. Patient characteristics, time to surgery, time to discharge, OR time and the correction achieved were analyzed and comparative statistics performed. RESULTS In total 19 patients treated with the locking nail and 20 patients treated with plate fixation were analyzed. Patient age and fracture severity according to the Sanders classification were comparable between the groups. Overall surgical time, as well as the achieved reduction was equal between both groups. Time to surgery, as well as time from surgery to discharge was significantly shorter in the locking nail group. 2 additional soft tissue procedures were necessary in the extended lateral approach group. DISCUSSION AND CONCLUSIONS The results with the locking calcaneus nail and sinus tarsi approach suggest, that similar treatment results can be achieved as with plate osteosynthesis and an extended lateral approach. Soft tissue management, as well as pre- and postoperative timing and discharge management can be improved with the nail. Further controlled trials comparing the longterm outcome between the treatment options are needed. Key words: calcaneus fracture, sinus tarsi approach, calcaneal nail, C-Nail.

Weight-Bearing Restrictions after Acetabular Fracture, Necessity or False Hope? A Brief Observational Study.

PURPOSE OF THE STUDY Most common postoperative treatment recommendations after acetabulum fractures suggest at least 6 weeks of postoperative partial or non weight-bearing. To protect the osteosynthetic construct this surgically set weight-bearing limit is trained by physical therapy. Aim of our analysis was to determine the free field patient compliance to these weight-bearing restrictions and observe their influence on the early postoperative radiographic imaging. MATERIAL AND METHODS Patients after surgical treatment of an acetabulum fracture were included in our analysis. Every patient was instructed to maintain a 20 kg weight-bearing limit for 6 weeks. Postoperative weight-bearing was continuously monitored during this time with a pressure measuring insole. Maximum weight-bearing per day was recorded and maintenance of reduction assessed after this time. RESULTS In total 10 patients were included into the study. Only 1 patient stayed within the weight-bearing limit during the analysis. Maximum weight-bearing as high as 110 kg was recorded. All patients maintained postoperative reduction at the 6 week timepoint. DISCUSSION AND CONCLUSIONS Despite regular physical therapy training compliance to the generally accepted weight-bearing limits was low. Regardless of the non-compliance the radiographic outcome remained unchanged. Further analysis on the use of permissive weightbearing aftercare regimes are warranted. Key words: weight-bearing, acetabulum fracture, compliance.

[A new continuous gait analysis system for ankle fracture aftercare]. / Ein neues, kontinuierliches Ganganalysesystem zur Nachbehandlung von Sprunggelenkfrakturen.

BACKGROUND: Correct aftercare following lower extremity fractures remains a controversial issue. Reliable, clinically applicable weight-bearing recommendations have not yet been defined. The aim of the current study was to establish a new gait analysis insole during physical therapy aftercare of ankle fractures to test patients' continuous, long-term compliance to partial weight-bearing restrictions and investigate whether patients can estimate their weight-bearing compliance. MATERIALS AND METHODS: The postoperative gait of 14 patients after operative treatment of Weber B-type ankle fractures was monitored continuously for six weeks (OpenGO, Moticon GmbH, Munich). All patients were instructed and trained by physical therapists on how to maintain partial weight-bearing for this time. Discontinuous (three, six and twelve weeks) clinical (patient questionnaire, visual analogue pain score [VAS]) and radiographic controls were performed. RESULTS: Despite the set weight-bearing limits, individual ranges for overall weight-bearing (range 5-107% of the contralateral side) and patient activity (range 0-366 min/day) could be shown. A good correlation between weight-bearing and pain was seen (rs = -0.68; p = <0.0001). Patients significantly underestimated their weight-bearing time over the set limit (2.3 ± 1.4 min/day vs. real: 12.6 ± 5.9 min/day; p < 0.01). CONCLUSIONS: Standardized aftercare protocols and repeated training alone cannot ensure compliance to postoperative partial weight-bearing. Patients unconsciously increased weight-bearing based on their pain level. This study shows that new, individual and possibly technology-assisted weight-bearing regimes are needed. The introduced measuring device is feasible to monitor and steer patient weight-bearing during future studies.

BMP-2-coated mineral coated microparticles improve bone repair in atrophic non-unions.

Atrophic non-unions are a major clinical problem. Mineral coated microparticles (MCM) are electrolyte-coated hydroxyapatite particles that have been shown in vitro to bind growth factors electrostatically and enable a tuneable sustained release. Herein, we studied whether MCM can be used in vivo to apply Bone Morphogenetic Protein-2 (BMP-2) to improve bone repair of atrophic non-unions. For this purpose, atrophic non-unions were induced in femurs of CD-1 mice (n = 48). Animals either received BMP-2-coated MCM (MCM + BMP; n = 16), uncoated MCM (MCM; n = 16) or no MCM (NONE; n = 16). Bone healing was evaluated 2 and 10 weeks postoperatively by micro-computed tomographic (µCT), biomechanical, histomorphometric and immunohistochemical analyses. µCT revealed more bone volume with more highly mineralised bone in MCM + BMP femurs. Femurs of MCM + BMP animals showed a significantly higher bending stiffness compared to other groups. Histomorphometry further demonstrated that the callus of MCM + BMP femurs was larger and contained more bone and less fibrous tissue. After 10 weeks, 7 of 8 MCM + BMP femurs presented with complete osseous bridging, whereas NONE femurs exhibited a non-union rate of 100 %. Of interest, immunohistochemistry could not detect macrophages within the callus, indicating a good biocompatibility of MCM. In conclusion, the local application of BMP-2-coated MCM improved bone healing in a challenging murine non-union model and, thus, should be of clinical interest in the treatment of non-unions.

Neuropsychological and neuroimaging underpinnings of schizoaffective disorder: a systematic review.

OBJECTIVES: The neurobiological basis and nosological status of schizoaffective disorder remains elusive and controversial. This study provides a systematic review of neurocognitive and neuroimaging findings in the disorder. METHODS: A comprehensive literature search was conducted via PubMed, ScienceDirect, Scopus and Web of Knowledge (from 1949 to 31st March 2015) using the keyword 'schizoaffective disorder' and any of the following terms: 'neuropsychology', 'cognition', 'structural neuroimaging', 'functional neuroimaging', 'multimodal', 'DTI' and 'VBM'. Only studies that explicitly examined a well defined sample, or subsample, of patients with schizoaffective disorder were included. RESULTS: Twenty-two of 43 neuropsychological and 19 of 51 neuroimaging articles fulfilled inclusion criteria. We found a general trend towards schizophrenia and schizoaffective disorder being related to worse cognitive performance than bipolar disorder. Grey matter volume loss in schizoaffective disorder is also more comparable to schizophrenia than to bipolar disorder which seems consistent across further neuroimaging techniques. CONCLUSIONS: Neurocognitive and neuroimaging abnormalities in schizoaffective disorder resemble more schizophrenia than bipolar disorder. This is suggestive for schizoaffective disorder being a subtype of schizophrenia or being part of the continuum spectrum model of psychosis, with schizoaffective disorder being more skewed towards schizophrenia than bipolar disorder.

Housing conditions alter properties of the tibia and humerus during the laying phase in Lohmann white Leghorn hens.

Osteoporosis in caged hens is one driving factor for the United States egg industry to explore options regarding alternative housing systems for laying hens. The aim of our research was to study the influence of housing systems on tibiae and humeri of 77-week-old Lohmann White hens. Pullets raised in an aviary system were either continued in aviary hen systems (AV) or conventional cages (AC) whereas pullets reared in conventional cages continued in conventional hen cages (CC) or enriched colony cages (EN) at 19 weeks. From each group, 120 hens were randomly euthanized and right and left tibae and humeri were excised for structural and mechanical analysis. Volumetric density of the cortical bone was measured using quantitative computed tomography (QCT). Aviary (AV) hens had greater cortical thickness and density but similar outer dimensions to AC hens (P < 0.05). Hens in EN system had humeri with similar cortical thickness and density but wider outer dimensions than the humeri of CC hens (P < 0.05). Cortical geometry of the tibiae was the same for the EN and CC hens, whereas EN hens had denser tibial cortex than CC hens (P < 0.05). Geometrical changes in the humeri suggest that hens in the AV system were better able to protect their structure from endosteal resorption during the laying phase. Humeri of AV and EN hens had increased second moment of area compared to the AC and CC hens; however, the changes were not observed in tibiae. Mechanical property differences were observed, with bones of AV hens having greater failure moment and stiffness than AC hens and the same difference was observed between the EN and CC hens, (P < 0.05). These findings indicate that movement limitation causes loss of bone mass and density whereas provision of moderate movement increases certain bone quality parameters during adulthood in laying hens.

Effect of rearing environment on bone growth of pullets.

Alternative housing systems for laying hens provide mechanical loading and help reduce bone loss. Moreover, achieving greater peak bone mass during pullet phase can be crucial to prevent fractures in the production period. The aim of this study was to determine the housing system effects on bone quality of pullets. Tibiae and humeri of White Leghorn pullets reared in conventional cages (CCs) and a cage-free aviary (AV) system were studied. At 16 wk, 120 birds at random from each housing system were euthanized. Right and left tibiae and humeri were collected and further analyzed. Cortical bone density and thickness were measured using computed tomography. Periosteal and endosteal dimensions were measured at the fracture site during mechanical testing. At 4, 8, 12, and 16 wk, serum concentrations of osteocalcin and hydroxylysyl pyridinoline were analyzed as markers of bone formation and resorption. Cortical bone density was higher (P<0.05) in humeri of AV pullets, and tibiae were denser (P<0.05) for AV pullets in the distal section of the bone compared to CC pullets. Ash content was higher (P<0.05) in AV humeri with no difference in tibiae ash content. Tibiae and humeri of AV pullets had a thicker cortex than the CC pullets (P<0.05). Additionally, the tibiae and humeri of AV pullets had greater (P<0.05) second moment of areas than the CC pullets. While some bone material properties between groups were different (P<0.05), the differences were so small (<7%) that they likely have no clinical significance. Serum osteocalcin concentrations were not different between the treatments, but hydroxylsyl pyridinoline concentrations were higher in CC pullets at 12 wk compared to the AV pullets and the effect reversed at 16 wk (P<0.05). These findings indicate that tibiae and humeri respond differently to load bearing activities during growth. The improved load bearing capability and stiffness in bones of AV pullets were related to increased cross-sectional geometry.

Abnormal resting-state connectivity of motor and cognitive networks in early manifest Huntington's disease.

BACKGROUND: Functional magnetic resonance imaging (fMRI) of multiple neural networks during the brain's 'resting state' could facilitate biomarker development in patients with Huntington's disease (HD) and may provide new insights into the relationship between neural dysfunction and clinical symptoms. To date, however, very few studies have examined the functional integrity of multiple resting state networks (RSNs) in manifest HD, and even less is known about whether concomitant brain atrophy affects neural activity in patients. METHOD: Using MRI, we investigated brain structure and RSN function in patients with early HD (n = 20) and healthy controls (n = 20). For resting-state fMRI data a group-independent component analysis identified spatiotemporally distinct patterns of motor and prefrontal RSNs of interest. We used voxel-based morphometry to assess regional brain atrophy, and 'biological parametric mapping' analyses to investigate the impact of atrophy on neural activity. RESULTS: Compared with controls, patients showed connectivity changes within distinct neural systems including lateral prefrontal, supplementary motor, thalamic, cingulate, temporal and parietal regions. In patients, supplementary motor area and cingulate cortex connectivity indices were associated with measures of motor function, whereas lateral prefrontal connectivity was associated with cognition. CONCLUSIONS: This study provides evidence for aberrant connectivity of RSNs associated with motor function and cognition in early manifest HD when controlling for brain atrophy. This suggests clinically relevant changes of RSN activity in the presence of HD-associated cortical and subcortical structural abnormalities.

The neuroanatomy of subthreshold depressive symptoms in Huntington's disease: a combined diffusion tensor imaging (DTI) and voxel-based morphometry (VBM) study.

BACKGROUND: Depressive symptoms are prominent psychopathological features of Huntington's disease (HD), making a negative impact on social functioning and well-being. METHOD: We compared the frequencies of a history of depression, previous suicide attempts and current subthreshold depression between 61 early-stage HD participants and 40 matched controls. The HD group was then split based on the overall HD group's median Hospital Anxiety and Depression Scale-depression score into a group of 30 non-depressed participants (mean 0.8, s.d. = 0.7) and a group of 31 participants with subthreshold depressive symptoms (mean 7.3, s.d. = 3.5) to explore the neuroanatomy underlying subthreshold depressive symptoms in HD using voxel-based morphometry (VBM) and diffusion tensor imaging (DTI). RESULTS: Frequencies of history of depression, previous suicide attempts or current subthreshold depressive symptoms were higher in HD than in controls. The severity of current depressive symptoms was also higher in HD, but not associated with the severity of HD motor signs or disease burden. Compared with the non-depressed HD group DTI revealed lower fractional anisotropy (FA) values in the frontal cortex, anterior cingulate cortex, insula and cerebellum of the HD group with subthreshold depressive symptoms. In contrast, VBM measures were similar in both HD groups. A history of depression, the severity of HD motor signs or disease burden did not correlate with FA values of these regions. CONCLUSIONS: Current subthreshold depressive symptoms in early HD are associated with microstructural changes - without concomitant brain volume loss - in brain regions known to be involved in major depressive disorder, but not those typically associated with HD pathology.

Bone characteristics and femoral strength in commercial toms: the effect of protein and energy restriction.

Selection for rapid growth in turkeys has resulted in skeletal problems such as femoral fractures. Slowing growth rate has improved bone structure, but the effect on mechanical properties of the bone is unclear. The current study's hypothesis was that slowing the growth of turkeys by reducing energy and CP in the diet would result in increased femur integrity. Commercial turkeys were fed 1 of 3 diets: control with 100% of NRC energy and CP levels, as well as a diet feeding 80 or 60% of NRC energy and CP levels. All other nutrients met or exceeded NRC requirements. Control birds were grown to 20 wk of age, whereas the 80 and 60% NRC birds were sampled when BW matched that of control birds at wk 4, 8, 12, 16, and 20. Both femurs were extracted, with one being measured and ashed and the other twisted to failure to evaluate mechanical properties. Total bone length, diameter, cortical thickness, and cortical density were measured. The total femur length was longer in the 60% NRC birds at 5 and 10 kg of BW compared with control (P < 0.05); this significance was lost by the time birds reached 16 kg of BW. At 5 and 10 kg of BW, ash content was higher in the control birds than in the 60% NRC birds (P < 0.05). At 16 kg of BW, the 60% NRC birds had the highest femur ash (P < 0.05). The mechanical testing parameters were failure torque, shear strength, and shear modulus of the bones. The 60% diet produced the highest failure torque (P < 0.05), at 16 kg of BW and onward. The shear strength was greater (P = 0.01) once the birds reached 5 kg of BW for the 60% diet than other diets. In conclusion, reducing the energy and protein in the diet to 60% of NRC recommendations, thus slowing growth, improved bone strength, as measured by failure torque, and bone quality, as measured by shear strength, without altering bone length or ash content by the time birds reached market weight.

[Management of complications of acetabular fractures]. / Management der Komplikationen von Acetabulumfrakturen.

Surgical treatment of acetabular fractures represents a special challenge in the field of trauma surgery. Complications are mostly due to the trauma itself or are iatrogenic. The handling and strategy to overcome complications in acetabular surgery are oriented towards the type of complication and the time of occurrence. Generally, a differentiation is made between early perioperative complications and late complications. The present article describes the most frequent complications during the surgical treatment of acetabular fractures, discusses the various treatment options based on individual case examples and gives differentiated recommendations to overcome the complications. The treatment concept should initially comprise a comprehensive primary prophylaxis to prevent complications. In cases of early perioperative complications, e.g. postoperative wound infections, hemorrhage or incorrect implant positioning, rapid and systematic surgical revision should be performed. In contrast, the treatment of late complications (e.g. implant associated failures, secondary osteoarthrosis of the hip, periarticular heterotopic ossification, non-unions and late infections) depends on the clinical and functional condition of the patient. In symptomatic elderly patients secondary total hip replacement is usually a valid option, whereas younger patients with late complications can be candidates for joint-preserving procedures. The management of complications in acetabular surgery regularly requires intense patient guidance as well as thorough clarification and should be performed in specialized centers.

[Clavicle fractures: practical approach in clinical routine]. / Klavikulafrakturen ­ praktisches Vorgehen im klinischen Alltag.

Fractures of the clavicle are among the most common fractures. They typically result from a fall onto the lateral shoulder or the extended arm and are often related to sports and bicycle accidents. Obtaining the exact trauma mechanism, proper clinical findings and adequate X­rays usually lead to the correct diagnosis. Non-displacement fractures can be treated conservatively with good results. Unstable and displaced fractures should be treated operatively. Open fractures or looming penetration are emergencies und should be treated immediately. In addition to fracture classification and morphology, other factors such as additional injuries and patient-related factors need to be considered in order to make an individualized therapy decision. In operative treatment, angular stable plating is the therapy of choice, and in most cases early functional aftercare is possible.

The morphological, material-level, and ash properties of turkey femurs from 3 different genetic strains during production.

Femoral fractures are observed in selective-bred commercial turkeys; however, the etiology of such fractures is unknown. The current study investigated the whole bone morphological, material-level mechanical, and bone ash properties to determine the effect of selective breeding on bone strength. Femora from 3 divergent strains of turkeys, a commercial line, a different selectively bred heavy line (F-line), and a lighter age or weight matched random-bred line (RBC2/R-EQ, respectively), were compared. Bone geometric properties were measured with micro-CT and bone mechanical properties were measured using 3-point bending tests. Whole bone ash quantities were also recorded. Statistics were run using a general linear model multivariate ANOVA (GLM ANOVA). Results showed that at similar ages, the faster growing birds (commercial and F-line) had femurs twice the size of the RBC2 line as measured by cross-sectional area as early as 8 wk into the study. The femurs of the commercial and F-lines also exhibited as much as 20% greater mechanical strength than femurs from the RBC2 line at 16 and 20 wk of age as measured by properties such as elastic modulus and ultimate tensile strength. However, at similar BW, the slower growing R-EQ line had higher mechanical properties than the other lines, with the elastic modulus being 40% greater and the ultimate tensile strength being 37% greater at weights equivalent to those of the commercial and F-lines at 12 wk of age. Moreover, it was observed that the morphological properties (i.e., cross-sectional area, moments of inertia) are largely governed by BW, as there is little difference in the amount gained per week of age across the different lines. Conversely, the mechanical properties, as well as the related ash content, appear to be governed at least in part by time. Therefore, whereas modulation of bone geometry is the key responder for changes in BW, sufficient time for matrix mineralization or maturation or both to occur is also essential for mechanical competence of bone.

[Health-related consequences of obstructive sleep apnea: daytime sleepiness, accident risk and legal aspects]. / Gesundheitliche Auswirkungen der obstruktiven Schlafapnoe: Schläfrigkeit, Unfallgefahr und Begutachtung.

Daytime sleepiness for any reason leads to impairment of daytime performance and an increased accident rate. The consequences are an increase of illness- and accident-related costs for the health system. Obstructive sleep apnea (OSA) is one of the major reasons for increased daytime sleepiness, especially in professional drivers. The accident frequency in OSA can be significantly reduced by adequate continuous positive airway pressure (CPAP) therapy. Up till now there are no uniform legal regulations about the handling of OSAS patients or patients with daytime sleepiness due to other diseases as far as driving ability is concerned.

A novel N440K sodium channel mutation causes myotonia with exercise-induced weakness--exclusion of CLCN1 exon deletion/duplication by MLPA.

We report a 4-generation Turkish family with 10 affected members presenting with myotonia and potassium- and exercise-induced paralytic attacks. The clinical presentation was neither typical for the chloride channel myotonias Thomsen and Becker nor for the separate sodium channel myotonia entities potassium-aggravated myotonia, paramyotonia congenita, and hyperkalemic periodic paralysis. It is best described by a combination of potassium-aggravated myotonia and hyperkalemic periodic paralysis. We excluded exonic chloride channel mutations including CLCN1 exon deletion/duplication by MLPA. Instead we identified a novel p.N440K sodium channel mutation that is located at the inner end of segment S6 of repeat I. We discuss the genotype phenotype relation.

Local Application of Mineral-Coated Microparticles Loaded With VEGF and BMP-2 Induces the Healing of Murine Atrophic Non-Unions.

Deficient angiogenesis and disturbed osteogenesis are key factors for the development of nonunions. Mineral-coated microparticles (MCM) represent a sophisticated carrier system for the delivery of vascular endothelial growth factor (VEGF) and bone morphogenetic protein (BMP)-2. In this study, we investigated whether a combination of VEGF- and BMP-2-loaded MCM (MCM + VB) with a ratio of 1:2 improves bone repair in non-unions. For this purpose, we applied MCM + VB or unloaded MCM in a murine non-union model and studied the process of bone healing by means of radiological, biomechanical, histomorphometric, immunohistochemical and Western blot techniques after 14 and 70 days. MCM-free non-unions served as controls. Bone defects treated with MCM + VB exhibited osseous bridging, an improved biomechanical stiffness, an increased bone volume within the callus including ongoing mineralization, increased vascularization, and a histologically larger total periosteal callus area consisting predominantly of osseous tissue when compared to defects of the other groups. Western blot analyses on day 14 revealed a higher expression of osteoprotegerin (OPG) and vice versa reduced expression of receptor activator of NF-κB ligand (RANKL) in bone defects treated with MCM + VB. On day 70, these defects exhibited an increased expression of erythropoietin (EPO), EPO-receptor and BMP-4. These findings indicate that the use of MCM for spatiotemporal controlled delivery of VEGF and BMP-2 shows great potential to improve bone healing in atrophic non-unions by promoting angiogenesis and osteogenesis as well as reducing early osteoclast activity.

Motor cortex excitability and comorbidity in Gilles de la Tourette syndrome.

BACKGROUND: Gilles de la Tourette syndrome (GTS) is often complicated by comorbid attention-deficit/hyperactivity disorder (ADHD) or obsessive-compulsive disorder (OCD). This study examines whether motor cortex excitability differs between uncomplicated GTS patients and those complicated by ADHD or OCD. METHODS: Motor thresholds, short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF), and short latency afferent inhibition (SAI) were measured using transcranial magnetic stimulation (TMS) in 29 untreated GTS patients (18 uncomplicated, six with comorbid ADHD, five with comorbid OCD) and 24 healthy subjects. Tic severity was rated with standard clinical scales. RESULTS: Patients had slightly higher resting (RMT) and active motor thresholds (AMT). The threshold of SICI and ICF expressed as a percentage of each individual's AMT was similar in controls and GTS patients. Above threshold, GTS patients had less SICI and more ICF. SICI was similar in all subgroups, but ICF differed significantly between them. Patients with GTS+ADHD had more ICF than controls, uncomplicated GTS patients or GTS+OCD patients; ICF was similar in these other groups. GTS patients as a whole had reduced SAI. Uncomplicated GTS patients or GTS+ADHD patients had less SAI than controls or GTS+OCD patients. CONCLUSIONS: GTS with ADHD comorbidity is associated with more extensive changes in the excitability of motor cortex circuits than uncomplicated GTS or GTS+OCD. The extent to which various different neuronal circuits are affected may be relevant for the phenotype of Tourette spectrum disorders.