Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study.

OBJECTIVES: The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy. MATERIALS AND METHODS: Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years). RESULTS: A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92). CONCLUSIONS: The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically.

E-vapor aerosols do not compromise bone integrity relative to cigarette smoke after 6-month inhalation in an ApoE-/- mouse model.

Cigarette smoke (CS) exposure is one of the leading risk factors for human health. Nicotine-containing inhalable products, such as e-cigarettes, can effectively support tobacco harm reduction approaches. However, there are limited comparative data on the effects of the aerosols generated from electronic vapor products (e-vapor) and CS on bone. Here, we report the effects of e-vapor aerosols and CS on bone morphology, structure, and strength in a 6-month inhalation study. Eight-week-old ApoE-/- mice were exposed to aerosols from three different e-vapor formulations-CARRIER (propylene glycol and vegetable glycerol), BASE (CARRIER and nicotine), TEST (BASE and flavor)-to CS from 3R4F reference cigarettes at matched nicotine concentrations (35 µg/L) or to fresh air (Sham) (N = 10 per group). Tibiae were analyzed for bone morphology by µCT imaging, biomechanics by three-point bending, and by histological analysis. CS inhalation caused a significant decrease in cortical and total bone volume fraction and bone density relative to e-vapor aerosols. Additionally, CS exposure caused a decrease in ultimate load and stiffness. In contrast, bone structural and biomechanical parameters were not significantly affected by e-vapor aerosol or Sham exposure. At the dissection time point, there was no significant difference in body weight or tibia bone weight or length among the groups. Histological findings revealed microcracks in cortical bone areas among all exposed groups compared to Sham control. In conclusion, because of the bone-preserving effect of e-vapor aerosols relative to CS exposure, e-vapor products could potentially constitute less harmful alternatives to cigarettes in situations in which bone health is of importance.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]. / Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsäule im Kindesalter : Empfehlungen der AG Wirbelsäulentrauma im Kindesalter.

BACKGROUND: Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist. OBJECTIVE: The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients. MATERIAL AND METHODS: Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process. RESULTS: Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients. CONCLUSION: Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.

Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients. / Empfehlungen zu Diagnostik und Behandlung von Frakturen des Dens axis bei geriatrischen Patienten.

BACKGROUND: Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature. METHODS: In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients. RESULTS: For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.

Recommendations for the Diagnostic Testing and Therapy of Atlas Fractures. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Atlasfrakturen.

In a consensus process with four sessions in 2017, the working group on "the upper cervical spine" of the German Society for Orthopaedic and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Fractures to the Upper Cervical Spine", incorporating their own experience and current literature. The following article describes the recommendations for the atlas vertebra. About 10% of all cervical spine injuries include the axis vertebra. The diagnostic process primarily aims to detect the injury and to determine joint incongruency and integrity of the atlas ring. For classification purposes, the Gehweiler classification and the Dickman classification are suitable. The Canadian c-spine rule is recommended for clinical screening for c-spine injuries. CT is the preferred imaging modality; MRI is needed to determine the integrity of the Lig. transversum atlantis in complete atlas ring fractures. Conservative treatment is appropriate in very many atlas fractures. Surgical treatment is recommended in existing or potential joint incongruity or instability, which are frequently seen in Gehweiler IIIB or Gehweiler IV fractures. Posterior atlanto-axial stabilisation and fusion using transarticular screws or an internal fixator are regarded as a gold standard in the majority of surgical cases. Especially in young patients, the possibility of isolated atlas osteosynthesis should be checked. A possible option for Gehweiler IV fractures is halo-fixation with mild distraction for ligamentotaxis. Secondary dislocation should be checked for frequently. Involvement of the occipito-atlantal joint complex requires stabilisation of the occiput as well.

Recommendations for Diagnosis and Treatment of Fractures of the Ring of Axis. / Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen: Axisringfrakturen.

In a consensus process with four sessions in 2017, the working group "upper cervical spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) formulated "Therapeutic Recommendations for the Diagnosis and Treatment of Upper Cervical Fractures", taking their own experience and the current literature into consideration. The following article describes the recommendations for axis ring fractures (traumatic spondylolysis C2). About 19 to 49% of all cervical spine injuries include the axis vertebra. Traumatic spondylolysis of C2 may include potential discoligamentous instability C2/3. The primary aim of the diagnostic process is to detect the injury and to determine potential disco-ligamentous instability C2/3. For classification purposes, the Josten classification or the modified Effendi classification may be used. The Canadian C-spine rule is recommended for clinical screening for C-spine injuries. CT is the preferred imaging modality and an MRI is needed to determine the integrity of the discoligamentous complex C2/3. Conservative treatment is appropriate in case of stable fractures with intact C2/3 motion segment (Josten type 2 and 2). Patients should be closely monitored, in order to detect secondary dislocation as early as possible. Surgical treatment is recommended in cases of primary severe fracture dislocation or discoligamentous instability C2/3 (Josten 3 and 4) and/or secondary fracture dislocation. Anterior cervical decompression and fusion (ACDF) C2/3 is the treatment of choice. However, in case of facet joint luxation C2/3 with looked facet (Josten 4), a primary posterior approach may be necessary.

[Subaxial Cervical Spine Injuries: Treatment Recommendations of the German Orthopedic and Trauma Society]. / Therapieempfehlungen zur Versorgung von Verletzungen der subaxialen Halswirbelsäule.

In a consensus process during four sessions in 2016, the working group "lower cervical spine" of the German Society for Orthopedic and Trauma Surgery (DGOU), formulated "Therapeutic Recommendations for the Lower Cervical Spine", taking into consideration the current literature. Therapeutic goals are a permanently stable, painless cervical spine and the protection against secondary neurologic damage while retaining the greatest possible amount of motion and spinal profile. Due to its ease of use and its proven good reliability, the AOSpine classification for subaxial cervical injuries should be used. The Canadian C-Spine Rule is recommended as a clinical decision rule whether to perform imaging or not. If a structural or unstable injury is suspected by patient history or clinical findings, a spiral CT scan of the cervical spine is the favoured diagnostic modality. Conventional X-ray is reserved for patients in whom there is no "dangerous mechanism of injury". MR imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and open posterior surgery and to exclude disco-ligamentous injuries. Urgency of MR imaging depends on the specific findings. CT angiography is recommended in higher-grade facet joint injuries or in the presence of vertebra-basilar symptoms. Flexion-extension imaging is recommended only as a physician-guided dynamic fluoroscopy, when an unstable lesion is still suspected. The therapeutic strategy is mainly dependent on morphologic criteria, which are described using the AOSpine classification. A0-injuries are treated conservatively. A1- and A2-injuries are treated conservatively in the majority of cases, and in single cases a gross kyphotic deformity might indicate surgical stabilisation. A3-injuries do indicate a surgical therapy in the majority of cases, but certain cases might be treated conservatively. A4-fractures as well as B- and C-type injuries are to be treated surgically. Most injuries can be treated by anterior plate stabilisation with interbody support; when a complete burst fracture is present, corpectomy and vertebral body replacement is necessary. In certain cases, an additive posterior or pure posterior instrumentation might be possible or even mandatory. In most of these cases, lateral mass screws are sufficient; when pedicle screws are applied in C3 to C6, a 3D-navigation system is recommended. Injuries in an ankylosing spine (M3-modifier) should be treated preferably from posterior with long-segment instrumentation.

Postoperative functional rehabilitation after repair of quadriceps tendon ruptures: a comparison of two different protocols.

PURPOSE: Early functional rehabilitation after surgical tendon repair facilitates the healing process and leads to improved joint function. There is a paucity of studies commenting on rehabilitation after surgical repair of ruptured quadriceps tendons, and most surgeons prefer a prolonged period of immobilization and protected weight bearing. The purpose of the present study is to compare the clinical outcome after a more functional and after a rather restrictive postoperative rehabilitation protocol. METHODS: All consecutive patients were included who had a surgical repair of a primary unilateral quadriceps tendon rupture in one of the two participating hospitals and a minimum follow-up of 24 months. Patients of site A were only allowed limited flexion and weight bearing while patients from site B were allowed early functional rehabilitation with full weight bearing. Clinical outcome was measured with the subjective IKDC form. Fisher's exact test and Mann-Whitney U test were used for statistical analysis. RESULTS: Sixty-six patients were included in the study. Twenty-eight patients (Group A) were treated with restrictive and 38 patients (Group B) with early functional postoperative rehabilitation. The two groups did not differ in terms of demographic characteristics. Clinical follow-up was available for 95% of patients after an average of 4.5 years. No clinical difference was identified with the use of IKDC form. Patients of group A returned to work an average of 10 days later than patients from group B, but this difference was not significant. Two re-ruptures were observed in each group. There was no significant difference in terms of complication quality or quantity. CONCLUSION: Early functional postoperative mobilization with full weight bearing after primary repair of a quadriceps tendon rupture is safe and will not lead to inferior clinical outcome or an increased complication rate. LEVEL OF EVIDENCE: Therapeutic, III.

Regeneration of cartilage and bone by defined subsets of mesenchymal stromal cells--potential and pitfalls.

Mesenchymal stromal cells, also referred to as mesenchymal stem cells, can be obtained from various tissues. Today the main source for isolation of mesenchymal stromal cells in mammals is the bone marrow. Mesenchymal stromal cells play an important role in tissue formation and organogenesis during embryonic development. Moreover, they provide the cellular and humoral basis for many processes of tissue regeneration and wound healing in infancy, adolescence and adulthood as well. There is increasing evidence that mesenchymal stromal cells from bone marrow and other sources including term placenta or adipose tissue are not a homogenous cell population. Only a restricted number of appropriate stem cells markers have been explored so far. But routine preparations of mesenchymal stromal cells contain phenotypically and functionally distinct subsets of stromal cells. Knowledge on the phenotypical characteristics and the functional consequences of such subsets will not only extend our understanding of stem cell biology, but might allow to develop improved regimen for regenerative medicine and wound healing and novel protocols for tissue engineering as well. In this review we will discuss novel strategies for regenerative medicine by specific selection or separation of subsets of mesenchymal stromal cells in the context of osteogenesis and bone regeneration. Mesenchymal stromal cells, which express the specific cell adhesion molecule CD146, also known as MCAM or MUC18, are prone for bone repair. Other cell surface proteins may allow the selection of chondrogenic, myogenic, adipogenic or other pre-determined subsets of mesenchymal stromal cells for improved regenerative applications as well.

Computer-assisted periacetabular screw placement: Comparison of different fluoroscopy-based navigation procedures with conventional technique.

The current gold standard for operatively treated acetabular fractures is open reduction and internal fixation. Fractures with minimal displacement may be stabilised by minimally invasive methods such as percutaneous periacetabular screws. However, their placement is a demanding procedure due to the complex pelvic anatomy. The aim of this study was to evaluate the accuracy of periacetabular screw placement assessing pre-defined placement corridors and comparing different fluoroscopy-based navigation procedures and the conventional technique. For each screw an individual periacetabular placement corridor was preoperatively planned using the planning software iPlan CMF(©) 3.0 (BrainLAB). 210 screws (retrograde anterior column screws, retrograde posterior column screws, supraacetabular ilium screws) were placed in an artificial Synbone pelvis model (30 hemipelves) and in human cadaver specimen (30 hemipelves). 2D- and 3D-fluoroscopy-based navigation procedures were compared to the conventional technique. Insertion time and radiation exposure to specimen were also recorded. The achieved screw position was postoperatively assessed by an Iso-C(3D) scan. Perforations of bony cortices or articular surfaces were analysed and the screw deviation severity (difference of the operatively achieved screw position and the preoperatively planned screw position in reference to the pre-defined corridors) was determined using image fusion. Using 3D-fluoroscopy-based navigation, the screw perforation rate (7%) was significantly lower compared to 2D-fluoroscopy-based navigation (20%). For all screws, the deviation severity was significantly lower using a 3D- compared to a 2D-fluoroscopy-based navigation and the conventional technique. Analysing the posterior column screws, the screw deviation severity was significantly lower using 3D- compared to 2D-fluoroscopy-based navigation. However, for the anterior column screw, the screw deviation severity was similar regardless of the imaging method. Despite the advantages of the 3D-fluoroscopy-based navigation, this method led to significantly longer total procedure and fluoroscopic times, and the applied radiation dose was significantly higher. Percutaneous periacetabular screw placement is demanding. Especially for posterior column screws, due to a lower perforation rate and a higher accuracy in periacetabular screw placement, 3D-fluoroscopy-based navigation procedure appears to be the method of choice for image guidance in acetabular surgery.

Inter- and intra-observer reliability of the Cobb angle in the measurement of vertebral, local and segmental kyphosis of traumatic lumbar spine fractures in the lateral X-ray.

INTRODUCTION: Measurement of the vertebral, local and segmental kyphosis according to Cobb is a standard procedure in the assessment of traumatic, idiopathic and degenerative spinal deformities. The purpose of this study was to evaluate the inter- and intra-observer reliability of these three radiological angles on the basis of lateral X-rays in lumbar spine fractures with spinal kyphosis. PATIENTS AND METHODS: A consecutive series of 88 patients with traumatic lumbar spine fractures with kyphotic deformities were included in the study. All patients were younger that 50 years of age and had an adequate trauma leading to the fracture. Three independent observers with different levels of clinical training measured the vertebral, segmental and local kyphosis of these patients on the basis of lateral X-rays. The readings were repeated 4 weeks later to assess intra-observer reliability. RESULTS: The most common injury mechanism was a fall from a height of more than 3 m. The first lumbar vertebra was the most commonly affected. Mean inter- and intra-observer reliabilities were good for the vertebral (mean ICC: 0.6607; mean ICC: 0.6979) and local (mean ICC: 0.7778; mean ICC: 0.7642) kyphosis and excellent (mean ICC: 0.8129; mean ICC: 0.8103) for the segmental kyphosis. CONCLUSION: In this study, the segmental-, vertebral-, and local kyphosis angle according to Cobb showed sufficient inter- and intra-observer reliability for the use in daily practice and scientific studies.

Long-term results after non-plate head-preserving fixation of proximal humeral fractures.

A retrospective study was conducted to evaluate displaced proximal humeral fractures treated with a non-plate head-preserving fixation and to detect factors predicting functional outcome. After a median follow-up period of 79.7 months, 105 patients with nine A-fractures, 36 B-fractures and 60 C-fractures (nine two-part-fractures, 41 three-part fractures and 55 four-part fractures) were assessed. Functional outcome was measured based on the Constant and UCLA scores. Of all patients, 70-75% had excellent or good Constant and UCLA scores. In 74% a good or satisfactory quality of initial reduction fracture was achieved. About one-fifth (21%) of the fractures showed a secondary displacement. Twenty-seven percent of the patients had signs of humeral head necrosis and 22% had implant related problems. There were significant correlations between a high final score and young age, low AO fracture severity, good quality of fracture reduction and residual osseous deformity, absence of secondary fracture displacement, implant-related complications, shoulder arthrosis and humeral head necrosis at the time of follow-up. In conclusion, the non-plate head-preserving fixation of proximal humeral fractures is an alternative treatment for displaced proximal humeral fractures. Especially in severely displaced C-fractures in older patients, non-anatomical reduction leads to a high rate of secondary displacement, residual osseous deformity and only a fair shoulder function. For these cases alternative methods such as prosthetic replacement should be chosen.

Preoperative marking of musculoskeletal tumors guided by magnetic resonance imaging.

BACKGROUND: The purpose of this study was to evaluate a new stereotactic method for preoperative coil-marking of musculoskeletal tumors with use of interventional magnetic resonance imaging. METHODS: Nine patients with a soft-tissue or bone-marrow tumor were referred to our department for preoperative marking of the extent of the lesion. In one patient, two lesions were marked. Guidance for the punctures and the delivery of the coils was provided by an open low-field magnetic resonance imaging system with horizontal access. After imaging of the extent of the lesion, magnetic resonance imaging-compatible titanium coils were placed with use of nearly real-time or step-by-step magnetic resonance imaging control. The coils were placed up to seventy-two hours before the surgery. The inclusion of the tumor borders within the area of the excision was examined with cross-sectional histological analysis of surgical specimens. RESULTS: The tumor-marking intervention was successfully performed with the guidance of magnetic resonance imaging only in all patients. Preoperatively, nineteen coils were used to mark the ten lesions in the nine patients. All of the coils were easily located with intraoperative fluoroscopy. No coil migrated between the time of the percutaneous marking and the surgery. Histological examination of the resection borders revealed no residual tumor cells. No complications were observed, and, after a mean of twenty-three months of follow-up, no tumor had recurred. CONCLUSIONS: Preoperative coil-marking guided by magnetic resonance imaging for exact delineation of a musculoskeletal tumor is technically feasible and can readily demonstrate the full extent of the tumor. Use of magnetic resonance fluoroscopy reduces the time needed for the intervention. We recommend the coil-marking technique.