Vertebroplasty and kyphoplasty - inefficient treatments for degenerative spine disease.

Osteoporotic vertebral fractures and pathological vertebral lesions are frequent clinical situations causing severe back pain. The pharmacological treatment of the underlying disease and the analgetic treatment of the associated back pain usually do not rid the patient's back pain completely and are insufficient to prevent the fracture-weakened vertebral body from further fracturing with long term consequences for the biomechanical competence of the entire spine. In the last 10 years the minimal invasive treatment options vertebroplasty (VP) and balloon kyphoplasty (BK) have spread quickly because these procedures appeared to be promising treatments to stop the fracture and vertebral lesion associated back pain and to internally stabilize a fractured vertebral body. Numerous published reports on VP and BK appeared to support the notion of an immediate and lasting pain reduction after VP and BK in additon to a prevention of further fracturing of the treated vertebrae. The first three randomized controlled and partly blinded trials have been published this year. Two of these trials demonstrate that VP does not result in a better pain control than a sham operation whereas BK was shown to reduce back pain due to verterbal fractures for at least 12 months. Considering that more than 1.5 million people world-wide have been treated with VP and BK until now this work discusses the recent trials and suggests clinical and academic consequences on the basis of the most recent evidence.

[Filling of metaphyseal defects with nanocrystalline hydroxyapatite (Ostim) for fractures of the radius]. / Verwendung von nanokristallinem Hydroxyapatit (Ostim) bei der Versorgung von Radiusfrakturen.

AIM OF THE STUDY: In this study, innovative bone replacement material was tested after complicated metaphyseal radius fractures with the affected joints. MATERIAL AND METHODS: In all, 11 C 2, 11 C 3 and 3 A 3 radius fractures were treated by surgery combining an angularly stable palmar plate osteosynthesis with defect filling using nanocrystalline hydroxyapatite. Examinations were conducted preoperatively and postoperatively after 4 weeks, 12 weeks and 9-12 months. RESULTS: After 10.5+/-1.4 months, inclination angles of 8.7+/-1.8 degrees (dorsopalmar) and 18.8+/-2.9 degrees (radioulnar) were measured at the treated fractures, the ulnar drift was 0.6+/-1.8 mm. According to the Gartland/Werley scale, 10 therapeutic results were considered "excellent", 12 "good" and 3 "fair". CONCLUSION: An angularly stable plate osteosynthesis with metaphyseal defect filling using nanocrystalline hydroxyapatite for the treatment of A 3, C 2 and C 3 radius fractures showed satisfactory radiological and clinical results.

[Kyphoplasty : method for minimally invasive treatment of painful vertebral fractures]. / Kyphoplastie : Minimal-invasives Verfahren zur Versorgung schmerzhafter Wirbelkörperfrakturen.

Painful osteoporotic and malignant vertebral fractures are frequent causes of chronic back pain with negative consequences regarding immobility, quality of life, morbidity, mortality, and fracture incidence. The best currently available evidence-based treatment reduces vertebral fracture risk but does not totally prevent follow-up fractures. Kyphoplasty is a causal treatment of pain by internal stabilization that prevents the ongoing pain of constant vertebral (micro-)fracture. The indication for this minimally invasive procedure requires interdisciplinary discussion of the individual case to guarantee technical feasibility, increase the likelihood that kyphoplasty will indeed reduce pain, and embed this procedure in the individual patient's long-term therapeutic concept or treatment of painful vertebral metastases. In addition to internal stabilization of painful vertebral fractures, kyphoplasty seeks to restore lost vertebral height, which appears promising in acute and painful vertebral fractures. Available controlled prospective studies demonstrate long-term patient benefits in terms of pain reduction, mobility, and improved quality of life.

[In vitro studies on various PMMA bone cements: a first comparison of new materials for arthroplasty]. / In-vitro-Untersuchung unterschiedlicher PMMA-Knochenzemente--ein erster Vergleich neuer Materialien für die Endoprothetik.

AIM: Two clinically established PMMA bone cements (Refobacin Palacos R and Palacos R + G) and two newer cements not yet in widespread clinical use (Refobacin Bone Cement R and SmartSet GHV) were tested in vitro for practically relevant differences. METHODS: The tests included chemical analyses, handling properties and testing according to the ISO standard for PMMA bone cements. RESULTS: The results obtained indicate clearly that the copolymers used in Refobacin Bone Cement R and SmartSet GHV differ from those used in the Palacos cements. There were also significant differences in viscosity behaviour and waiting time (p < 0.01 for Palacos cements versus Refobacin Bone Cement R) as an expression of different handling properties. The hardening times under ISO 5833 conditions also differed significantly (p < 0.01 and p < 0.05 for Palacos cements compared with Refobacin Bone Cement R and p < 0.01 for Refobacin Bone Cement R compared with SmartSet GHV). CONCLUSION: In view of these differences in material properties, the clinical data from long-term use of the bone cements Refobacin Palacos R and Palacos R + G cannot be extrapolated to the newly developed PMMA cements Refobacin Bone Cement R and Smart GHV. Before broad clinical use of these cements, prospective clinical studies using RSA or DEXA and, as a second step, statistically powerful prospective comparative studies should be performed. Until these data are available, patients in whom Refobacin Bone Cement R and SmartSet GHV are used should be informed that the material employed deviates from the standard procedures for cemented joint replacement in the Scandinavian arthroplasty registers and that the long-term consequences cannot, in the final instance, be foreseen. This is essential in order to avoid later malpractice claims on the grounds of inadequate information.

Problems and costs associated with alcohol and drug abuse in emergency medicine.

Preclinical care refers to patients with life-threatening conditions. It remains unclear how alcohol and drug abuse contribute to the frequency and severity of emergency cases. This study evaluated the influence of these psychotropic substances on preclinical emergencies and the social security costs arising from this. The records of 400 emergency patients were analyzed prospectively regarding type and severity of emergency, intake of psychotropic substances before the emergency, and their influence on patients' outcome. Psychotropics were detected in 19% of patients; 84% of these patients (vs. 55% overall) were scored below 4 (not life threatening) on the National Advisory Committee for Aeronautics scale and therefore did not require a physician on-site. Alcohol or drug intake frequently causes emergencies with physicians on-site; retrospectively 84% of these interventions were thus found to be unnecessary, caused by difficulties in recognizing the severity of the disorder, especially in mental or respiratory disorders. Extrapolated to Germany overall this means 675,000 drug-related emergencies yearly, costing euro 310,000,000.

Open reduction and palmar plate-osteosynthesis in combination with a nanocrystalline hydroxyapatite spacer in the treatment of comminuted fractures of the distal radius.

In a prospective study, we used the nanocrystalline hydroxyapatite paste Ostim (Osartis, Obernburg, Germany) in combination with a palmar plate to treat comminuted radius fractures with a metaphyseal and articular component in order to examine the clinical use of Ostim as a bone substitute. Twenty-one patients with 22 radius fractures of AO types C2 and C3 were included in the study. The measurements, taken 10.2+/-1.3 months after the initial treatment, revealed a dorsopalmar tilt of 8.8+/-3.7 degrees , a radioulnar inclination of 18.8+/-2.8 degrees and an ulnar variance of 0.8+/-1.8mm. According to the Gartland and Werley evaluation, eight of the treated fractures attained an excellent, 11 a good and the remaining three a fair result. The study demonstrates that Ostim, in combination with angularly stable osteosynthesis, can be used as an acceptable bone substitute for the treatment of type C2 and C3 radial fractures.

Detection of high-energy phosphates in cortical bone as an indicator of bone healing and remodelling: use of a rabbit model.

UNLABELLED: PURPOSE; To study high-energy phosphates in cortical bone through experiments on inbred white New Zealand rabbits. METHODS: Tibial fractures were induced in 80 rabbits and then stabilised by screw osteosynthesis. After 3 (group A; n=40) or 7 days (groups B; n=40), the defective tissue was covered by local muscle flaps. At increasing intervals (from 1 to 16 weeks), the screws were removed and the animals were euthanised (n=8 per group). The bone was removed and analysed histomorphologically; adenosine triphosphate (ATP) levels were determined by high-performance liquid chromatography. RESULTS: The mean ATP concentration in healthy cortical bone at 16 weeks was 0.092 (standard error, 0.009) nmol/mg dry mass, which was significantly higher than that in the group with delayed healing: 0.081 (0.011) nmol/mg in group A and 0.005 (0.001) nmol/mg in group B (paired t test, p<0.05). Earlier healing led to lower rates of necrosis (0 vs 38; groups A vs B) and osteomyelitis. CONCLUSION: Early muscle-flap coverage can revascularise the cortical bone, which is reflected in the higher ATP content in the cortical bone measured by high-performance liquid chromatography. Measuring changes of ATP levels can help investigate the metabolism of the pathological bone.

Laser doppler flow imaging of open lower leg fractures in an animal experimental model.

PURPOSE: Open lower leg fractures are frequently associated with severe soft tissue damage, followed by osteomyelitis. Using an animal experimental model, we investigated the effect of timing of coverage of a tibial fracture with a local muscle flap. METHODS: 80 rabbits had a tibial fracture induced in a standardised fashion, which was stabilised by screw osteosynthesis. After 3 (group A; n=40) and 7 days (group B; n=40), respectively, the tissue defect was covered by a local gastrocnemius flap. In increasing intervals from 1 to 2, 4, 8, and 16 weeks, the rabbits from each group were killed and the bone fracture was analysed histomorphologically. Cortical microcirculation was measured by 2-channel laser doppler flowmetry. RESULTS: Muscle flaps after 3 days improved perfusion significantly as compared with 7 days (24 Flux [standard error, 5 Flux] versus 10 Flux [3 Flux]; baseline, 1.4 Flux). Group A animals also displayed a lower rate of necrosis (0 versus 38). The incidence of osteomyelitis was higher in group B than in group A (24% versus 0%). CONCLUSION: Laser doppler flowmetry was proven to be a reliable, minimally invasive means for identifying avital tissue, leading to reduction in the loss of vital bone tissue in experimental settings.

[Psychotropic substances in the area of preclinical intensive care medicine]. / Psychotrope Substanzen im Bereich der präklinischen Intensivmedizin.

The aim of preclinical intensive care is to prevent severe consequences by providing immediate therapeutic aid to emergency patients in a life-threatening condition. We investigated how the abuse of drugs and alcohol influences the frequency and the category of emergency cases as well as the patient outcome. 250 emergency cases were analysed in a prospective study in the area of Heidelberg, Germany, from the summer of 1995 to the spring of 1999. The analysis is based on patient data obtained from the German standardised Emergency Record and on the clinical outcome and influence of drugs and alcohol. A serious level of drugs or alcohol was detected in 17% of the patients (the average level of alcohol was 1.97 promille). 81% of these intoxicated patients were given a NACA (National Advisory Committee for Aeronautics) score of less than 4 (not life-threatening) and therefore were not in need of the a presence of a physician.

["High pouch output" syndrome. Role of mineralocorticoid diagnosis after restorative proctocolectomy]. / "High-Pouch-Output"-Syndrom. Stellenwert der Mineralocorticoiddiagnostik nach restaurativer Proktocolektomie.

UNLABELLED: The two-phase restorative proctocolectomy is the treatment of choice for surgical therapy of the familial adenomatous polyposis (FAP) and also for the ulcerative colitis (UC). Besides the well-known complications the entire removal of the colorectum leads to an impairment of fluid and electrolyte resorption. PATIENTS AND METHODS: Over a time period of two years we observed 320 proctocolectomized patients with ileal pouch-anal anastomosis (IPAA). All patients with high pouch output but without organic malfunction were identified. The organic reasons were excluded with the help of pouchoscopy, radiography or MR imaging. We evaluated routine parameters, the kidney function, the electrolyte changes, the acid-base balance and the urine pH, as well as the hormonal changes of the suprarenal glands. We identified seven patients with 'high pouch output' out of 320 patients observed. The control group consisted of 14 proctocolectomized patients without hints of complications in the endoscopic, radiographic and routine laboratory diagnostics. RESULTS: Neither group showed any significant differences in the analysis of the routine parameters. A significant drop of the urine sodium concentration of 40.5 +/- 18.7 mmol/l (control group 98 +/- 43.4 mmol/l) was observed in the group with 'high pouch output'. In this group the plasma aldosterone values were strongly increased with an average of 42.6 +/- 28.9 ng/dl (control group 13.2 +/- 6.8 ng/dl) as well as the plasma 18-hydroxycorticosterone with an average of 153.7 +/- 121.1 ng/dl (control group 153.7 +/- 121.1 ng/dl). Neither group of patients showed increased activity of free corticosterone and free cortisol. Only free 11-desoxycorticosterone was elevated in the group with 'high pouch output'. CONCLUSION: Our results prove that the mineralocorticoid adrenal activity plays a central role in order to preserve the volume and electrolyte homeostasis. The low frequency of 'high-pouch-output'-complications in realms of the restorative proctocolectomy proves the excellent compensation of the removal of the colon mucosa. Plasma aldosterone seems to be a diagnostic marker encapsulating the reabsorption problems of intestinal salt and volume losses after proctocolectomy.

Changes in glucocorticoid and mineralocorticoid hormone levels due to compensation for ileostomy losses.

BACKGROUND: The Ileo-Pouch-Anal-Anastomosis (IPAA) is the standard restorative procedure for Ulcerative Colitis and Familial Adenomatous Polyposis (FAP). IPAA may lead to considerable losses of fluids, especially in association with a protective loop ileostomy. AIM: The aim of this study was to investigate adrenal mechanisms in the regulation of volume homeostasis immediately after IPAA and protective ileostomy. METHODS: For that purpose, 20 patients out of our patient population with elective IPAA with ileostomy participated in this study between 1993 and 1997. In all patients, routine laboratory tests and gluco- and minealocorticoid hormone measurements were performed preoperatively and 10 days after operation. RESULTS: These blood analyses indicated functional hyperaldosteronism immediately after IPAA. Significantly elevated levels of Aldosterone (36.4 +/- 25.1 ng/dl) and 18-OH-Corticosterone ( 173 +/- 11.3 ng/dl) were found. Among hormones with glucocorticoid effects, blood levels of Cortisol (10.4 +/- 4.8 microg/dl) were significantly elevated, while 11-Desoxycortiosterone (13.9 +/- 8.4 ng/dl) and Corticosterone (0.8 +/- 0.6 microg/dl) were not significantly elevated. Serum electrolytes remained unchanged. CONCLUSIONS: Our results indicate that hormones with mineralocorticoid effects play a predominant role in the compensation of ileostomy losses after IPAA.

Effects of restorative proctocolectomy on renal and adrenal function.

PURPOSE: Restorative proctocolectomy is a standard procedure in the surgical treatment of ulcerative colitis and familial adenomatous polyposis. The radical removal of the colorectum with construction of an ileostomy often results in high stoma losses. These may lead to changes in the electrolyte and acid-base balance and to alterations in renal and suprarenal gland function. METHODS: In this study 33 patients who received an ileoanal pouch before and after proctocolectomy were investigated at different time intervals for electrolyte changes, alteration of the acid-base balance, kidney function, and hormonal changes of the suprarenal glands. Measurements were performed before proctocolectomy, ten days after proctocolectomy with ileal pouch-anal anastomosis under protective loop ileostomy, before ileostomy closure, and 6 to 12 months after ileostomy closure. Neither acute renal failure nor other vital complications were observed. RESULTS: Statistical analysis showed a significant decrease of urine pH to 5.4 +/- 0.22 (before ileostomy closure) and metabolic acidosis (pH 7.32 +/- 0.04; base excess -1.3 +/- 5.6 (before ileostomy closure)). Likewise, we found a decrease in renal clearance to 86 ml/minute (before ileostomy closure) without signs of tubular damage. The most important change during the phase with ileostomy was a functional secondary hyperaldosteronism with aldosterone levels of 63.2 +/- 70.8 ng/dl (before ileostomy closure). In comparison with preoperative levels, there was a ten-fold increase in mineralocorticoid adrenal activity. Additionally, during the period with protective ileostomy, the hepatic synthesis of aldosterone-18-glucuronide was only slightly increased, and the cortisol/cortisone ratio was extremely decreased. CONCLUSIONS: These results show that restorative proctocolectomy with ileal pouch-anal anastomosis and protective loop ileostomy significantly influences fluid, electrolyte, and acid-base balance. Functional secondary hyperaldosteronism is of central importance for subsequent renal recompensation. Approximately one-half year after ileostomy closure, the endogenous hormones with mineralocorticoid effects returned to normal levels.

[Stoma physiology]. / Stomaphysiologie.

In addition to psychological stress, stomas may lead to metabolic consequences. Colostomies normally cause only minor physiological problems; however, patients with ileostomies are at risk for severe metabolic disturbances. The small intestine essentially manages the balance of water and electrolytes and the absorption of nutrition. In special circumstances such as "high output" or short-bowel syndrome, dangerous consequences like kidney disorders may arise. Basic therapeutic strategies such as enteral or parenteral substitution are discussed.

[GSG (Structured Health Regulation)-conforming documentation of surgical interventions in a university clinic--3 years clinical experiences 1994-1996]. / GSG-konforme Dokumentation operativer Eingriffe an einer Universitätsklinik--3 Jahre klinische Erfahrung 1994-1996.

The cost increase in the public health sector is steadily mounting and hence politicians are forced to redefine the economic conditions for regulations. As a new quality in the area of inpatient hospital care the new German law of structural health care (GSG), valid as of January 1, 1993 replaces the principle of covering full costs. The GSG law required in our hospital an adjustment of existing EDP structures with integrated automatic remuneration estimate and the installation of a medical structure of the organisation for complete and correct documentation. Weakpoints of the prescribed obligatory ICPM codes and inadequate legal regulations result in a lack of separation or wrong integration of the lump sum payment in individual cases (FP) and special compensation (SE). The summary analysis of the compensation system with a subsequent medical control system showed a primarily inaccurate classification by 12%. There is as yet no proof for the usefulness of a lump sum payment system resulting in a selection of risks.

[Bilateral tibial compartment syndrome with crush symptoms after cannabis abuse]. / Beidseitiges Unterschenkel-Compartmentsyndrom mit Crush-Symptomatik nach Cannabisabusus.

Acute compartmental syndrome (CS) is a surgical emergency. Different conditions in which high non-physiological pressure appears within a closed fascial space reduce the necessary blood perfusion. CS is caused by trauma, burns, bleeding in patients with coagulopathies arterial injuries, nephrotic syndrome or unusual physical exercise with secondary compartmental swelling. When decompression occurs too late, permanent loss of function and limb contracture may result. In the following paper we report on a case of four-compartmental syndrome in the lower legs of a patient with drug intoxication. After cannabis consumption, the patient fell asleep sitting cross-legged. During our first examination several hours later, the signs of compartmental syndrome with spontaneous pain, turgid swelling and paresis were present. Bilateral skin incision technique was used to gain entrance into the four compartments in both lower legs. Immediately after the operation, the patient showed crush syndrome with high serum creatine kinase activity 140.501 U/l and acute renal failure caused by rhabdomyolysis. Within 2 weeks of haemofiltration and dialysis, a full recovery to a normal serum creatinine level of 0.7 mg/dl was achieved. After emergency treatment and rehabilitation, the patient showed neither vascular nor neural defects.

[ICPM-independent documentation of new reimbursement forms--method and 1995 results]. / ICPM-unabhängige Dokumentation der neuen Entgeltformen--Methode und Ergebnisse 1995.

The structural health care law (known as the Gesundheitsstrukturgesetz or GSG) of the Federal Republic of Germany has been enacted to replace the covering cost prices by various forms of payment. On the basis of the Godesberg Diagnosis and Therapy Catalogue, a new system has been developed that assesses all new implications of the care benefit law. With the help of intelligent plausibility tests, a particular case (PC) or a special rate (SR) is suggested. The documentation system works without ICPM numbers. The conversion of diagnosis and therapies to ICD-10/ICPM numbers is possible. The results of the first half of 1995 and the second half of 1995 show that only two-fifths of operations can be assessed with PC or SR. Neither emphasis on certain operations nor the more differentiated illnesses are recognised as extra costs by the GSG regulations. Complete and correct documentation is achieved by a strict and stratified control system.