[Imaging of non-traumatic spinal diseases in children]. / Bildgebung nichttraumatischer erkrankungen der kindlichen wirbelsäule.

Pain is also the main symptom of spinal diseases in children. The younger the child, the more frequently organic causes are to be found, whereas in adolescents functional dorsalgia and lumbalgia are ubiquitous. Apart from the neonatal period, where ultrasound is used as the primary method for investigation of closed spinal dysraphia, radiography is still considered to be the first choice examination, which nevertheless should only be carried out after a thorough anamnesis and clinical examination. For targeted follow-up and especially exclusion of neoplasms, MRI is the method of choice in most cases. Computed tomography (CT) plays an important role preoperatively and postoperatively in corrective spine surgery and together with scintigraphy in the diagnostics of spondylolysis and some tumors such as osteoid osteoma. Important is the care of children with hereditary spinal malformations, especially dysraphias where the entire CNS may be affected as with the common association of myelomeningocele and Chiari II malformation with hydrocephalus and hydromyalia.

Minimally invasive retroperitoneal approach for lumbar corpectomy and anterior reconstruction. Technical note.

The anterior decompressive procedure in which spinal fusion is performed is considered an effective treatment for thoracolumbar fractures and tumors. However, it is also known to be associated with considerable surgery-related trauma. The purpose of this study was to show that lumbar corpectomy and anterior reconstruction can be performed via a minimally invasive retroperitoneal approach (MIRA) and therefore the surgical approach-related trauma can be reduced. The authors studied retrospectively the hospital records and radiological studies obtained in five patients (mean age 67.4 years, range 59-76 years) who underwent lumbar corpectomy and spinal fusion via an MIRA followed by posterior fixation. Four patients presented with osteoporotic compression fractures at L-2 and L-3, and one patient presented with metastatic disease in L-4 from prostate cancer. Neurological deficits due to cauda equina compression were demonstrated in all patients. The MIRA provided excellent exposure to facilitate complete decompression and anterior reconstruction in all patients, as verified on follow-up radiographic studies. All patients improved clinically. A 1-year follow-up record is available for four patients and a 6-month follow-up record for the fifth patient; continuing clinical improvement has been observed in all. Radiography demonstrated anatomically correct reconstruction in all patients, as well as a solid fusion or a stable compound union in the four patients for whom 1-year follow-up records were available. The MIRA allows the surgeon to perform anterior lumbar spine surgery via a less invasive approach. The efficacy and safety of this technique and its potential to reduce perioperative morbidity compared with conventional retroperitoneal lumbar spine surgery should be further investigated in a larger series.

Minimally invasive retroperitoneal approach for lumbar corpectomy and reconstruction. Technical note.

Anterior decompressive surgery with spinal fusion is considered an effective treatment for thoracolumbar fractures and tumors. However, it is also known to be associated with considerable surgical approach-related trauma. The purpose of this study was to show that lumbar corpectomy and spinal reconstruction can be performed via a minimally invasive retroperitoneal (MIR) approach and therefore, the surgical approach-related trauma can be reduced. The hospital records and radiological studies obtained in five patients (mean age 67.4 years, range 59-76 years) who underwent lumbar corpectomy and spinal fusion via an MIR approach were studied retrospectively. Four patients presented with osteoporotic compression fractures at L-2 and L-3 and one patient with metastatic disease at L-4 from prostate cancer. In all patients neurological deficits due to cauda equina compression were demonstrated. The MIR approach provided excellent exposure to facilitate complete spinal decompression and reconstruction in all patients, as verified on follow-up x-ray studies. All patients improved clinically. A 1-year follow-up record, available for four patients, showed evidence of continuing clinical improvement and, radiographically, a solid fusion or a stable compound union and anatomically correct reconstruction. The MIR approach allows anterior lumbar spine surgery to be performed less invasively. The efficacy and safety of this technique compared with the conventional retroperitoneal approach to lumbar spine surgery should be further investigated in a larger series.

Midterm experience with the cementless Zweymueller system. Results of a minimum five-year follow-up study.

Eighty-five patients with 96 cementless press-fit hip implants were followed over a period of at least 5 years postoperatively. The average Harris score was 87.5 points. One socket had to be exchanged 4 years postoperatively because of aseptic loosening. Additionally, 5 sockets developed radiolucent lines, one of them totally around the socket, but without signs of subsidence progression. In no case was a change of the stem necessary; one stem subsided 4 mm within the first postoperative year but was stable at the last follow-up investigation. One patient was personally dissatisfied with the outcome of the operation. No implant-specific complications such as breakage of the implant, breakage or crack of the stem, or blasting of the pelvic girdle by socket-screwing were observed.

[Clinical results following the transgluteal and anterolateral (Watson-Jones) approach to hip prosthesis implantation]. / Klinische Ergebnisse nach transglutäalem und anterolateralem (Watson-Jones) Zugang zur Hüftprothesen-implantation.

80 total hip endoprostheses with antero-lateral (Watson-Johnes) approach are compared with 77 total hip endoprostheses with transgluteal approach (Bauer) after a period of at least one year after the operation. In all cases a cementless implanted model has been used. After transgluteal approach we found less bleeding and hematoma, but slight increased periarticular ossifications. The clinical results (pain, range of motion, distance walked, walking aid, manner of walking) were only a little different. For the technic of implantation of the cementless endoprosthesis the transgluteal approach seems to be more useful.

[Periarticular ossifications following implantation of cement-free total hip endoprostheses of the Zweymüller-Endler type]. / Periartikuläre Ossifikationen nach Implantation zementfreier Hüfttotalendoprothesen vom Typ Zweymüller-Endler.

Ectopic ossifications after 158 cementless implanted Total hip endoprostheses Type Zweymüller-Endler have been examined postoperatively within 12 months at the earliest. The rate of ossification was 39.9%. This range is higher than the mean range of cemented hip endoprostheses reported in the literature. The higher range of ossification is found in low grade ossification grade CA I. Severe ossification of grade CA III occurred only in a low percentage. The influence of various factors (as prophylaxis for thrombosis approach, duration of operation, sex, age, other diseases, complications) on the frequency of occurrence is examined. There was no significant result concerning these parameters. The main causes for ectopic ossification seem therefore to be dispositional and constitutional factors. Male patients under the age of fifty show ectopic ossification in the highest degree.

The transtrochanteric anterior rotational osteotomy of Sugioka. Early and late results in idiopathic aseptic femoral head necrosis.

The early and late results of 39 transtrochanteric anterior rotational osteotomies of Sugioka, performed since 1975 in idiopathic aseptic necroses of the femoral head, are presented; 23 results are excellent and good. The rates of postoperative complications and reoperations are high, more than 40% each. Reoperations in smaller necrotic areas are far less frequent. There is no deterioration of the result when the hip joint is replaced by an endoprosthesis after Sugioka osteotomy. Insufficiency of the gluteus muscles is more frequent, but, on the other hand, range of motion of the hip joint increases after total hip replacement. Based on the results, we feel that there are fewer indications for this operation. The procedure is indicated for young patients with good function of the hip joint and sectors of necrosis up to 90 degrees, especially when there is not other way to remove the area of necrosis from the weight-bearing zone of the femoral head.

[Sugioka's trans-trochanteric osteotomy. Results of interventions 1975-1983]. / Die transtrochantäre Osteotomie nach Sugioka. Ergebnisse der Operationen 1975-1983.

The long-term results of 46 Sugioka osteotomies are presented: In 22 patients no joint replacement had yet been necessary, and 17 hip joints had already been replaced by total hip prostheses. Of the 22 preserved joints, 12 were graded as clinically excellent and good, 10 as fair or poor. The radiological course showed worsening osteoarthritic changes in almost all cases. In the "survival curve" for the Sugioka osteotomy in the group with 17 total hip prostheses the most significant slope can be seen during the first 3 years postoperatively; between 5 and 10 years there are no failures; and then the curve descends again. Fair and poor results are noted most frequently between 6 and 10 years after the operation in the group of 22 patients with no joint replacement. The preoperative extent of necrosis and the radiological stage are the main factors determining the result. Over the years it has been possible to define a narrow spectrum of indications: the greatest benefit is obtained in young, cooperative patients with necrotic sectors of about 90 degrees and good function of the hip joint.

The effect of prophylaxis for thrombosis on heterotopic ossification following total hip joint replacement.

The effect of prophylaxis for thrombosis on heterotopic ossification was investigated using 216 total hip joint endoprostheses implanted between 1976 and 1978. During this period a random comparative study of low dose heparin and oxyphenbutazone/acetylsalycilic acid was carried out. The rate of ossification in the 216 hip joints was 17.6%, and was about average for the values specified in literature on this subject. Heterotopic ossification occurred in 30.1% of the 103 hip joints treated with heparin, whilst the rate of ossification in the 113 hip joints treated with oxyphenbutazone/acetylsalycilic acid was only 6.2%. This represents a statistically significant difference in disfavour of prophylaxis with heparin.

Bone reaction to uncemented threaded polyethylene acetabular components.

One hundred and eighty-one cementless total hip arthroplasties with threaded polyethylene acetabular components, carried out between 1980 and 1981, have been reviewed retrospectively. Discrepancy between the complaints of the patients with loose components and destruction of acetabular bone led to the development of a four stage radiological grading system which would enable loosening to be anticipated in routine cases. There was a high percentage of loosening (33%) in our series and direct bone-polyethylene contact gave rise to severe granulomatous reactions around the implants. Strict radiological follow up and early revision surgery is indicated in this type of arthroplasty.

[The lateral profile of the lumbar vertebrae following lumbosacral spondylodesis--comparison between Harrington rods and a transpedicular fixation system (Zielke's USIS method)]. / Das laterale Profil der Lendenwirbelsäule nach lumbosacraler Spondylodese--Vergleich zwischen Harringtonstäben und einem transpedikulären Fixationssystem (USIS nach Zielke).

We compared the lateral profile of the lumbar spine after lumbosacral dorsal fusion in two groups of each 32 patients with comparable age, sex distribution and indication; one group had been fused with the use of two short Harrington rods, the other with the Universal Spinal Instrumentation System (USIS) according to Zielke/Harms. The sparing of motion segments using a transpedicular system is demonstrated by the average number of 1.7 fused motion segments compared to 2.2 with the Harrington rods. The average increase of cyphosis of the fused area could be reduced with USIS from 7.3 to 3.0 degrees in spite distraction. The greatest difference could be seen in cases of spondylolisthesis (2.0 degrees compared to 8.2) and in fusions including three segments (2.0 versus 7.0). No significant difference in total lordosis of the lumbar spine could be evaluated and there was no influence of preoperative mobility on the grade of postoperative cyphosis. The early results of lumbar fusion using USIS are clinically satisfying in spite of a relative high rate of rod fracture. measures to achieve a higher stability and diminish the rate of implant failure are discussed.

A special technique of compound osteosynthesis of the distal humerus. A case report about extramedullary blast crisis in chronic myelogenous leukemia.

In a rare case of chronic myelogenous leukemia, extramedullary myeloblast crisis occurred in the distal humerus after 27 years. The pathological fracture was stabilized with double-plate compound osteosynthesis. The small distal fragment was stabilized without restriction of the range of movement of the elbow joint. The osteosynthesis remained stable until the patient died.

Indomethacin for prevention of ectopic ossification in cementless hip arthroplasties. A prospective 1-year study of 100 cases.

In a prospective series of 100 patients we investigated the effect of indomethacin for 6 weeks in the prophylaxis of ectopic bone formation in hip replacements with cementless fixation. Indomethacin prophylaxis reduced (P < 0.0001) ectopic bone formation compared to a retrospective control group of equal size. Side-effects occurred in one-fifth of the patients, but most of these could continue the medication for at least 4 weeks.

[Paget's coxarthrosis. Implantation of a modular tumor reconstruction system. Case report]. / Paget-Coxarthrose. Implantation eines modularen Tumor-Rekonstruktionssystems. Fallbericht.

A male patient aged 69 years suffering from Paget-coxarthrosis with a large distension of the proximal femur was implanted a cementless tumor reconstruction system. The surgical procedure consisted of opening of the femoral shaft with a special drill, insertion of the prosthesis and its anchorage within the healthy distal bone. By this method we were able to save the femoral muscle insertion planes. Twenty-eight months postoperatively the patient is pain-free and very satisfied with the outcome. The X-rays show a good fit of the prosthesis. The Harris Hip Score is now 90.1 points as compared to 46.4 points preoperatively.

[Radiologic measurement of the behavior of lumbar intervertebral disks in idiopathic scoliosis based on so-called "bending" images]. / Radiologische Messungen des Verhaltens lumbaler Bandscheiben bei idiopathischer Skoliose anhand der sogenannten "Bending"-Aufnahmen.

Total disc mobility, segmental mobility, both depending upon location of the disc and upon its position within the scoliotic curve as well as the opening angle of the disc in the ap x-ray were measured in the so-called "bending-test" x-rays of the lumbar curve of 40 patients with idiopathic scoliosis. The measurements showed a maximum of mobility in the segments L2/3, L3/4 and L4/5. In no direct dependence an increased mobility of the most proximal motion segment against the next lower one of the lumbar curve was found. No direct relation between lateral flexion and degree of scoliosis was measurable. Mobility towards the convexity increases directly with the opening angle of the disc concerned while mobility towards the concavity decreases; lateral flexion remains constant altogether. The results achieved might become quite relevant in connection with the possible therapeutic progress in the treatment of lumbar scoliosis with enzymatic dissolution of nucleus pulposus.

Cemented titanium stems show high migration: transprosthetic drainage system has no advantage over third-generation cementation technique.

INTRODUCTION: A newly developed cemented titanium stem with excellent laboratory results using a transprosthetic drainage system (TDS) was clinically tried for the first time. Prognostic radiographic methods including migration measurement and clinical investigation were performed for up to 7 years. MATERIALS AND METHODS: Twenty-two patients prospectively and consecutively received total hip replacement using a cemented titanium stem and a threaded Zweymüller cup. Ten stems (CPS) were cemented conventionally with a third-generation cementation technique. In 12 stems (TRIOS) a TDS was used to enhance cement mantle quality. Design of cup and stem was similar in all cases. RESULTS: More than 50% of all stems showed considerable subsidence (>1 mm at 2 years and >2.5 mm at 5 years) and progressive radiolucent lines ( >1 mm at 2 years). Two patients of the TRIOS group had to be revised at 7 years postoperatively. No significant differences were found in radiological parameters (migration, stem subsidence, tilting, occurrence of radiolucent lines) and clinical outcome between the two cementation techniques. All parameters indicate an unfavourable long-term survival. Use of a TDS did not show any significant advantages over the conventional cementation technique. CONCLUSION: It can be concluded that cementing titanium stems of this design cannot be recommended.

Noncontiguous spinal metastases and plasmocytomas should be operated on through a single posterior midline approach, and circumferential decompression should be performed with individualized reconstruction.

BACKGROUND: In noncontiguous spinal metastatic disease, anterior or combined anterior-posterior surgery is an effective treatment. The objective of this study is to investigate whether circumferential decompression through a single-stage posterior midline approach with individualized spinal reconstruction can still achieve comparable results for functional improvement and for maintenance of spinal alignment in the absence of the risks associated with the more invasive transcavitary or combined approaches. METHOD: Seventeen patients with noncontiguous spinal metastases and plasmocytomas at one or two adjacent levels were included in this series. Circumferential decompression was obtained with anterior reconstruction and posterior fixation in ten patients, and with posterior instrumentation alone in seven patients. Postoperatively the patients were prospectively followed, and their functional status and spinal alignment were periodically evaluated. FINDINGS: Fourteen patients died from progression of their underlying cancer. Their mean survival time was 8 months (range: 1 to 21 months). Three survivors were evaluated at 10, 4 and 3 months respectively. At one month after surgery, 14 patients (82%) showed neurological improvement. Of 10 preoperative nonambulators, seven regained walking capacity. Five patients who were ambulatory with assistance improved to full functional independence. Local tumour recurrence was recorded in one patient after subtotal vertebrectomy for a plasmocytoma at L5. No other tumour recurrences were noted. In one patient a partial loss of correction occurred at T6 - without functional deterioration, however. Spinal alignment was maintained in all other patients who became or remained ambulatory. No major intra-operative complications or peri-operative deaths occurred. CSF leakage was recorded as the most common complication in four patients. INTERPRETATION: Circumferential decompression and spinal reconstruction through a single-stage posterior midline approach is feasible and effective. The extent of surgery can be individualized by means of this technique to the patient's specific problem. In patients with limited life expectancy from metastatic neoplastic disease, the results compare favourably with the more invasive anterior or combined antero-posterior procedures.

Duration of first remission as an indicator of long-term survival in chronic myelogenous leukaemia.

Approximately 31 patients with chronic myelogenous leukaemia (CML) are documented in the literature who survived more than 10 years after diagnosis. We present a CML-patient whose survival of 27 years is probably the longest reported so far. The analysis of the course of disease in these patients revealed that the duration of unmaintained first remission after chemotherapy is of high prognostic significance. In 17 of 24 evaluable patients the remission lasted more than 1 year and in another five at least 6 months (mean 73.8 months, range 0-240 months). In most patients busulfan was used as initial therapy. There was no correlation between the amount of drug given and the duration of remission or survival. Other parameters such as sex, age, initial leucocyte counts, differential count, haemoglobin, platelet count or spleen size seemed to have no prognostic relevance. While approximately 25% of CML patients with typical duration of survival exhibit a Ph1 chromosome mosaicism only, this finding was present in nearly half of the long-term survivers.

Heterotopic ossification with total hip endoprostheses in various models of thrombosis prophylaxis.

The influence of thrombosis prophylaxis on the occurrence of heterotopic ossification after implantation of total hip endoprostheses was analyzed in a series of randomized studies. When low-dose heparin or dextran 40 was administered, the rate of ossification was comparatively high (30.1% and 65.1%). When a combination of acetylsalicylic acid and an antirheumatic (oxyphenbutazone) or low-dose heparin with an antirheumatic (indomethacin) was administered, the ossification rate became significantly lower (6.2% and 16.7%). No severe ossification (Arcq degree III) was observed in the groups given an antirheumatic in addition to thrombosis prophylaxis.

[Treatment strategy of malignant bone tumors of the spine]. / Behandlungsstrategie maligner Knochentumoren der Wirbelsäule.

In patients with big, tumorous changes in the vertebral bodies, conservative measures like radiotherapy, medical therapy, and external support measures are often no longer applicable. As a result of the instability of the spinal column, most of the patients are bedridden and in great pain. Signs of root compression occur frequently, as do incipient or incomplete transverse lesions. On the one hand, these signs result from tumor growth and on the other from collapse of the vertebral bodies with kyphosis and fragment dislocation in the spinal canal. In these patients the procedure of choice is "ventral" tumor removal, decompression of the spinal cord and roots, followed by stabilization. By the "dorsal" operative method, it is not possible to overcome the major cause of the instability and pain. On the basis of the results obtained in 100 "ventral" resections of the vertebral bodies, the treatment strategy is presented, ranging from the preliminary examination to the postoperative period.