[Etiology and significance of growth disturbances of the spine]. / Ätiologie und Bedeutung von Wachstumsstörungen der Wirbelsäule.

BACKGROUND: The majority of growth disturbances of the spine are acquired and their etiology is still unknown. Both scolioses and sagittal profile disorders are most commonly of idiopathic origin. ETIOLOGY: The etiology is multifactorial and besides genetic, hormonal and mechanical factors also metabolic components seem to be involved. The risk of progression of an existing deformity is particularly high during the pubertal growth spurt. Accordingly, regular clinical and radiological controls should be carried out in this vulnerable period. Recently, spinal deformities have been classified according to the time of diagnosis rather than according to their etiology, considering the increasing knowledge about the correlation between spinal and thoracic growth and the associated maturation of the lungs. Therefore, the term "early onset scoliosis" considers all deformities of the spine diagnosed before the age of 10 years. TREATMENT: In the case of failure of conservative treatment options, which have to be applied for as long as possible, definitive spinal fusion surgery should be delayed by the use of growth-sparing surgical techniques, aiming to achieve as normal pulmonary function as possible.

Treatment of early onset spinal deformities with magnetically controlled growing rods: a single centre experience of 30 cases.

PURPOSE: The treatment of early onset scoliosis continues to be a major challenge, even when using motorized growth-sparing implants. We report on 30 cases operated on with magnetically controlled growing rods (MCGRs) at our institution, analyzing radiological parameters and complications, comparing our results with the literature and presenting a special implant fixation technique. A separate focus highlights the challenges of conversion from previous non-motorized implants. METHODS: Consecutive case series. The nature and effects of complications were recorded for all patients. Radiographic evaluations were performed for patients with a minimum follow-up of two years. Separate analyses were carried out for patients who were previously treated with non-motorized growth-sparing implants. RESULTS: There were 12 documented complications in 11/30 (37%) patients leading to 13 unplanned returns to the operating room. In all, 18/30 patients had a minimum follow-up of two years. Major curve and main kyphosis, as well as T1 to T12 and T1 to S1 distances significantly improved with MCGR implantation, however, less in patients converted from previous growth-sparing surgical treatment. While the achieved correction of the major curve was maintained, there was a loss of kyphosis correction with subsequent implant lengthening. Gain in implant length decreased with increasing number of extensions. CONCLUSION: Despite improved patient's comfort, MCGR show a considerable complication rate. Coronal plane deformities can be well controlled, but diminished implant lengthening is already apparent within two years after MCGR implantation. Central databases should help to clarify unresolved aspects and optimize the treatment of these young patients. LEVEL OF EVIDENCE: IV.

Treatment strategy and long-term functional outcome of traumatic elbow dislocation in childhood: a single centre study.

PURPOSE: Traumatic elbow dislocation (TED) is the most common injury of large joints in children. There is an ongoing debate on the optimal treatment for TED. We aimed to assess the functional outcome after operative and nonoperative treatment of TED. METHODS: We analysed the medical records of patients with TED treated at the University Children's Hospital, Basel, between March 2006 and June 2015. Functional outcome was assessed using the Mayo Elbow Performance Score (MEPS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) Sport and Music Module score. These scores were compared between nonoperatively and operatively treated patients. RESULTS: A total of 37 patients (mean age 10.2 years, 5.2 to 15.3) were included. Of these, 21 (56.8%) children had undergone nonoperative treatment, with 16 (43.2%) patients having had operative treatment. After a mean follow-up of 5.6 years (1.2 to 5.9), MEPS and QuickDASH Sport and Music Module scores in the nonoperative group and operative group were similar: MEPS: 97.1 points (SD 4.6) versus 97.2 points (SD 2.6); 95% confidence interval (CI)-2.56 to 2.03); p = 0.53; QuickDASH Sport and Music Module score: 3.9 points (SD 6.1) versus 3.1 points (SD 4.6); 95% CI 2.60 to 4.17; p = 0.94. We noted no significant differences regarding the long-term functional outcome between the subgroup of children treated operatively versus those treated nonoperatively for TED with accompanying fractures of the medial epicondyle and medial condyle. CONCLUSION: Functional outcome after TED was excellent, independent of the treatment strategy. If clear indications for surgery are absent, a nonoperative approach for TED should be considered. LEVEL OF EVIDENCE: Level III - therapeutic, retrospective, comparative study.

[Treatment of early onset scoliosis : How far can we go?]. / Behandlung von frühkindlichen Skoliosen : Wo liegen die Grenzen?

BACKGROUND: Recently, inconsistent definitions of early onset scoliosis (EOS) and a wide variety of treatment options have been observed. OBJECTIVES: To clearly define the term EOS, to depict non-operative and operative treatment options, and to present the limitations of the boundaries of these techniques. METHODS: Review of the literature, including conference presentations and expert opinions, in addition to personal experiences. RESULTS: Early onset scoliosis (EOS) refers to spine deformity that is present before 10 years of age, regardless of etiology. All existing operative treatment options share a high risk of complications. Therefore, non-operative treatment should act as a time-buying approach to postpone surgery. DISCUSSION: Awareness of treatment options and their specific indications, in addition to respecting each patient's individual needs and feasibilities, are crucial for the optimal outcome.

Selective fusion in adolescent idiopathic scoliosis: a radiographic evaluation of risk factors for imbalance.

STUDY DESIGN: Retrospective database, chart and medical imaging review. OBJECTIVES: To report on the outcome and evaluate possible risk factors for postoperative complications following selective spinal fusion in patients with adolescent idiopathic scoliosis (AIS). MATERIALS AND METHODS: All patients with AIS who underwent either a selective thoracic or selective thoracolumbar/lumbar spinal fusion at our institution from January 2001 to December 2011 inclusive were included in this study. The minimum postoperative follow-up period of all patients was 2 years. RESULTS: During the 11-year study period, 157 patients with AIS underwent surgery for their progressive spinal deformity. Thirty patients (19 %) had a selective spinal fusion, with 16 patients (group A) having a selective thoracic, and 14 patients (group B) having a selective thoracolumbar/lumbar spinal arthrodesis. In both groups the main postoperative complications were adding-on (25 % group A, 36 % group B) and coronal decompensation (25 % group A, 29 % group B). In group A, no statistically significant risk factors for postoperative complications were identified. In group B, global coronal balance was identified as a significant risk factor for adding-on. Patients with adding-on had significantly higher coronal balance scores (mean 3.6) than those who did not experience adding-on (mean 1.9) (p = 0.03). In addition, those with adding-on had a significantly smaller bending lumbar Cobb angle (mean 15) than those without adding-on (mean 31.6) (p = 0.015). None of the patients who underwent selective spinal fusion required revision surgery. CONCLUSION: Although the complication rate after performing a selective spinal fusion is high, the revision rate remains low and the debate whether or not to perform a selective spinal fusion will continue.

[Process optimization by central control of acute pain therapy: implementation of standardized treatment concepts and central pain management in hospitals]. / Prozessoptimierung durch zentrale Steuerung der Akutschmerztherapie : Implementierung von standardisierten Behandlungskonzepten und zentralem Schmerzmanagement im Krankenhaus.

BACKGROUND: The aim of this investigation was to describe the effects of standardization and central control of the processes involved in postoperative pain management from patient and employee perspectives. MATERIALS AND METHODS: Patients (n = 282/307) and respective hospital staff (n = 149/119) evaluated the processes, the quality of postoperative pain management and result parameters 3 months before and 12 months after the introduction of standardization of the postoperative pain therapy process using a set of standardized questionnaires. RESULTS: Pain level and the waiting period for an analgesic partially decreased and a higher subjective effectiveness of medication was achieved in patients after the standardization. Patients felt that the pain was taken more seriously and contacted the staff for additional medication more frequently. From an employee viewpoint the quality of care and individual competence and ability to treat pain increased after the introduction of standardization. Pain assessment was improved and employees rated their knowledge and education level as higher than before the intervention. Patients with pre-existing chronic pain and patients with special regional therapy benefited only partially after the introduction and an increase in pain intensity was even observed. CONCLUSIONS: The quality of care was improved by standardization of the postoperative pain management. The legal and practical ability of the nursing stuff to administer pain medication within well-defined margins reduced the dependence on the ward doctor and at the same time patient pain levels. Patients received analgesics more quickly and experienced increased effectiveness. These results should be an incentive to reconsider the importance of the organization of postoperative pain management, because the quality of care with all potential medical and economic advantages, can be easily optimized by such simple mechanisms. They also show that the quality assessment of acute pain and the selection of appropriate indicators need further development.

Pseudovacuoles--immobilized by high-pressure freezing--are associated with blebbing in walker carcinosarcoma cells.

By applying high pressure freezing and freeze-substitution, we observed large inclusions of homogeneous appearance in the front of locomoting Walker carcinosarcoma cells that have not been described earlier. Live cell imaging revealed that these inclusions were poor in lipids and nucleic acids but had a high lysine (and hence protein) content. Usually one such structure 2-5 mum in size was present at the front of motile Walker cells, predominantly in the immediate vicinity of newly forming blebs. By correlating the lysine-rich areas in fixed and embedded cells with electron microscopic pictures, inclusions could be assigned to confined, faintly stained cytoplasmic areas that lacked a surrounding membrane; they were therefore called pseudovacuoles. After high-pressure freezing and freeze substitution, pseudovacuoles appeared to be filled with 20 nm large electron-transparent patches surrounded by 12 and 15 nm large particles. The heat shock protein Hsp90 was identified by peptide sequencing as a major fluorescent band on SDS-PAGE of lysine-labelled Walker cell extracts. By immunofluorescence, Hsp90 was found to be enriched in pseudovacuoles. Colocalization of the lysine with a potassium-specific dye in living cells revealed that pseudovacuoles act as K+ stores in the vicinity of forming blebs. We propose that pseudovacuoles might support blebbing by locally regulating the intracellular hydrostatic pressure.

A rapid microbiopsy system to improve the preservation of biological samples prior to high-pressure freezing.

A microbiopsy system for fast excision and transfer of biological specimens from donor to high-pressure freezer was developed. With a modified, commercially available, Promag 1.2 biopsy gun, tissue samples can be excised with a size small enough (0.6 mm x 1.2 mm x 0.3 mm) to be easily transferred into a newly designed specimen platelet. A self-made transfer unit allows fast transfer of the specimen from the needle into the specimen platelet. The platelet is then fixed in a commercially available specimen holder of a high-pressure freezing machine (EM PACT, Leica Microsystems, Vienna, Austria) and frozen therein. The time required by a well-instructed (but not experienced) person to execute all steps is in the range of half a minute. This period is considered short enough to maintain the excised tissue pieces close to their native state. We show that a range of animal tissues (liver, brain, kidney and muscle) are well preserved. To prove the quality of freezing achieved with the system, we show vitrified ivy leaves high-pressure frozen in the new specimen platelet.

Improved preservation of the subepidermal extracellular matrix in axolotl embryos using electron microscopical techniques based on cryoimmobilization.

The purpose of this metholdological survey was to find optimal methods for the fixation and demonstration of glycosaminoglycans, mainly hyaluronan, and proteoglycans, in subepidermal extracellular matrix (ECM) regions of axolotl embryos. We compared living ECM in the laser-scanning microscope (LSM) with chemically fixed or cryoimmobilized extracellular matrix in the transmission (TEM) and scanning electron microscope (SEM). The gel-like structure of living extracellular matrix in the LSM undoubtedly provides the most natural state, whereas shrinkage of the extracellular matrix occurs during conventional fixation and dehydration for TEM or SEM. Among the methods used for fixation and processing of subepidermal extracellular matrices for SEM, plunge-freezing/freeze-drying is to be preferred. Still more satisfying, however, are results obtained with high-pressure frozen/freeze-substituted ECM material in the TEM, for which 10% polyvinyl pyrrolidon +7% methanol was used as a cryoprotectant before high-pressure freezing. In these specimens, no freeze-damage could be observed and they could be regarded as adequately frozen. Conversely, the yield in adequately frozen specimens without cryoprotection was insufficient. In these specimens, the ECM contained honeycomb-like structures which, in the current literature, are regarded as hyaluronan.

Cloning, sequencing and expression analysis of mouse cartilage matrix protein cDNA.

A cDNA encoding the mouse cartilage matrix protein (CMP) was cloned following the reverse-transcription polymerase chain reaction and rapid amplification of cDNA ends procedures using mRNA isolated from trachea. The open reading frame encodes a product of 500 amino acids. Large parts of the protein have been completely conserved when compared to chicken and human sequences, including all 12 cysteine residues of the mature CMP. In situ hybridization reveals an even distribution of the CMP mRNA in the developing skeleton, which is followed by a zonal distribution paralleling hypertrophy and calcification. From early cartilage differentiation and onwards, CMP transcript is absent in the forming articular surfaces and intervertebral discs. Extraskeletal expression of CMP mRNA was detected in the adult eye.