Neuromuscular performance of balance and posture control in childhood and adolescence.

This study examined a potential age-dependency of both posture and stability (balance) control in children and adolescents in a healthy population. Body posture with open and closed eyes was examined for a total of 456 test persons (age 6.7-17.6 years. Posture parameters (posture index, upper body tilt, trunk tilt) were assessed in the sagittal plane. Additionally, the oscillation of the center of pressure with open and closed eyes was additionally analyzed in a sub-sample of 318 subjects. Absolute values of stability control parameters changed significantly during childhood and adolescence for both boys (p = 0.005) and girls (p = 0.01). Relative changes of stability and posture parameters when closing the eyes did not change (p > 0.05) and were independent of age, gender or sports activity in healthy children and adolescents. The shifting of the body segments towards each other, as a result of the loss of visual information, does not seem to be primarily responsible for the increase in COP fluctuation. This is a further indication that stability control and posture control are complex interdependent mechanisms whose interaction is not yet fully understood.

Targeted Athletic Training Improves the Neuromuscular Performance in Terms of Body Posture From Adolescence to Adulthood - Long-Term Study Over 6 Years.

Poor posture in childhood and adolescence is held responsible for the occurrence of associated disorders in adult age. This study aimed to verify whether body posture in adolescence can be enhanced through the improvement of neuromuscular performance, attained by means of targeted strength, stretch, and body perception training, and whether any such improvement might also transition into adulthood. From a total of 84 volunteers, the posture development of 67 adolescents was checked annually between the age of 14 and 20 based on index values in three posture situations. 28 adolescents exercised twice a week for about 2 h up to the age of 18, 24 adolescents exercised continually up to the age of 20. Both groups practiced other additional sports for about 1.8 h/week. Fifteen persons served as a non-exercising control group, practicing optional sports of about 1.8 h/week until the age of 18, after that for 0.9 h/week. Group allocation was not random, but depended on the participants' choice. A linear mixed model was used to analyze the development of posture indexes among the groups and over time and the possible influence of anthropometric parameters (weight, size), of optional athletic activity and of sedentary behavior. The post hoc pairwise comparison was performed applying the Scheffé test. The significance level was set at 0.05. The group that exercised continually (TR20) exhibited a significant posture parameter improvement in all posture situations from the 2nd year of exercising on. The group that terminated their training when reaching adulthood (TR18) retained some improvements, such as conscious straightening of the body posture. In other posture situations (habitual, closed eyes), their posture results declined again from age 18. The effect sizes determined were between η2 = 0.12 and η2 = 0.19 and represent moderate to strong effects. The control group did not exhibit any differences. Anthropometric parameters, additional athletic activities and sedentary behavior did not influence the posture parameters significantly. An additional athletic training of 2 h per week including elements for improved body perception seems to have the potential to improve body posture in symptom free male adolescents and young adults.

Assessment of the posture of adolescents in everyday clinical practice: Intra-rater and inter-rater reliability and validity of a posture index.

OBJECTIVES: The assessment of the posture of children and adolescents using photometric methods has a long tradition in paediatrics, manual therapy and physiotherapy. It can be well integrated into the clinical routine and enables objective documentation. One-dimensional parameters such as angle sizes are mostly used in the diagnosis of postural defects in children and adolescents by means of photogrammetry. This study examined the posture index, a complex parameter, which evaluates the alignment of several trunk segments in the sagittal plane and is suitable for use as a screening parameter in everyday clinical practice. METHODS: For this postural photographs were taken in the sagittal plane of the habitual posture in a subgroup of 105 adolescents (12.9 ± 2.6 years) for analysing validity, and in a subgroup of 25 adolescents (12.1 ± 2.8 years) for analysing reliability and objectivity. Marker spheres (12 mm) were placed on five anatomical landmarks. The posture was also evaluated clinically by experienced investigators (PT, MD, DSc). The distances of the marker points to the plumb line through the malleolus lateralis were calculated and the posture index calculated from these. In order to determine the objectivity, reliability and validity of the posture index, statistical parameters were calculated. RESULTS: The posture index demonstrated very good objectivity (intraclass correlation coefficient ICC = 0.865), good reliability (Cronbach's alpha = 0.842) and good validity compared to the posture assessment done by the medical experts (Spearman's rho = 0.712). CONCLUSIONS: The posture index reflects a doctor's assessment of the posture of children and adolescents and is suitable as a clinical parameter for the assessment of postural defects.

Age-dependency of posture parameters in children and adolescents.

[Purpose] Poor posture in children and adolescents is a well-known problem. Therefore, early detection of incorrect posture is important. Photometric posture analysis is a cost-efficient and easy method, but needs reliable reference values. As children's posture changes as they grow, the assessment needs to be age-specific. This study aimed to investigate the development of both one-dimensional posture parameter (body inclination angle) and complex parameter (posture index) in different age groups (childhood to adolescence). [Subjects and Methods] The participants were 372 symptom-free children and adolescents (140 girls and 232 boys aged 6-17). Images of their habitual posture were obtained in the sagittal plane. High-contrast marker points and marker spheres were placed on anatomical landmarks. Based on the marker points, the body inclination angle (INC) and posture index (PI) were calculated using the Corpus concepts software. [Results] The INC angle significantly increased with age. The PI did not change significantly among the age groups. No significant differences between the corresponding age groups were found for PI and INC for both sexes. [Conclusion] When evaluating posture using the body inclination angle, the age of the subject needs to be considered. Posture assessment with an age-independent parameter may be more suitable.

Changes in Habitual and Active Sagittal Posture in Children and Adolescents with and without Visual Input - Implications for Diagnostic Analysis of Posture.

INTRODUCTION: Poor posture in children and adolescents has a prevalence of 22-65% and is suggested to be responsible for back pain. To assess posture, photometric imaging of sagittal posture is widely used, but usually only habitual posture positions (resting position with minimal muscle activity) are analysed. AIM: The objective of this study was 1) to investigate possible changes in posture-describing parameters in the sagittal plane, when the subjects changed from a habitual passive posture to an actively corrected posture, and 2) to investigate the changes in posture parameters when an actively corrected posture was to be maintained with closed eyes. MATERIALS AND METHODS: In a group of 216 male children and adolescents (average 12.4 ± 2.5 years, range 7.0 - 17.6 years), six sagittal posture parameters (body tilt BT, trunk incline TI, posture index PI, horizontal distances between ear, shoulder and hip and the perpendicular to the ankle joint) were determined by means of photometric imaging in an habitual passive posture position, in an actively erect posture with eyes open, and in active stance with eyes closed. The change in these parameters during the transition between the posture positions was analysed statistically (dependent t-Test or Wilcoxon-Test) after Bonferroni correction (p<0.004). RESULTS: When moving from a habitual passive to an active posture BT, TI, PI, dEar, dShoulder, and dHip decreased significantly(p< 0.004). When the eyes were closed, only the perpendicular distances (dEar, dShoulder, and dHip) increased significantly. The parameters that describe the alignment of the trunk sections in relation to each other (BT, TI, PI), remained unchanged in both actively regulated posture positions. CONCLUSION: Changes in sagittal posture parameters that occur when a habitual passive posture switches into an active posture or when an active posture is to be maintained while the eyes are closed can be used for diagnostic purposes regarding poor posture and posture regulation.

A rare case of acetabulum osteomyelitis mimicking bone sarcoma.

A 57-year-old man presented to the authors' department with pain over the right hip joint over a 3-month period. External magnetic resonance imaging showed a structure in the right acetabulum that was highly suspicious for a bone sarcoma. External 3-phase bone scintigraphy substantiated the suspected diagnosis. A computer tomography-guided biopsy was performed. Microbiologic examination showed a Staphylococcus aureus strain. Histopathologic findings showed chronic fibrous osteomyelitis. Because of doubts about these findings made by radiologists, open biopsy with retrieval of bony samples from the acetabulum and hip joint puncture was repeated. At that time, the serum C-reactive protein level was 48.8 mg/dL and the white blood cell count was 5600 × 106/L. Microbiologic examination showed a S aureus and a Staphylococcus epidermidis strain in both regions. Results of blood cultures were negative. Based on these findings, the decision was made to perform a septic femoral head and neck resection. After meticulous debridement, necrosectomy, and pulsatile lavage, a gentamicin and vancomycin-impregnated cement spacer was implanted. Postoperatively, systemic antibiotic treatment with cefuroxime and rifampicin was administered for 4 weeks, followed by 2 weeks of oral antibiotics. Mobilization was allowed under toe-touch bearing of the operated extremity. The further postoperative course was uneventful. Prosthesis implantation was performed after 3 months. White blood cell count and C-reactive protein values were normal at the time of surgery. Histologic and microbiologic examination of tissue samples taken intraoperatively showed no evidence of persistent infection. At follow-up after 1 year, the patient had no complaints and has no local or systemic signs of infection.

Fungal periprosthetic hip and knee joint infections clinical experience with a 2-stage treatment protocol.

Fungal periprosthetic joint infections are a rare entity in orthopedic surgery, and there exist no guidelines according to which these infections can be successfully managed. Between 2004 and 2009, 7 patients with fungal periprosthetic joint infections (4 total hip arthroplasties and 3 total knee arthroplasties) have been treated with a 2-stage protocol and implantation of antibiotic-loaded cement spacers. Most of the infection was caused by Candida species. Systemic antifungal agents were administered for 6 weeks in 6 cases and 6 months in 1 case. The mean spacer implantation time was 12 weeks. At a mean follow-up of 28 months (5-70 months), no persistence of infection or reinfection could be observed. A 2-stage treatment protocol with implantation of an antibiotic-loaded cement spacer is an efficient option in the treatment of fungal periprosthetic infections.

Relationship between the McPherson classification and complications after hip spacer implantation.

The implantation of antibiotic-loaded cement spacers is established in the treatment of late hip joint infections, and the McPherson staging system has been widely used in this context. The aim of our study was to evaluate the relationship between the McPherson classification and complications at the site of hip spacer implantation. 60 patients were retrospectively identified who fulfilled our inclusion criteria. Using the McPherson classification, 12 patients were categorised as IIIA1, 4 as IIIA2, 19 as IIIB1, 7 as IIIB2, 12 as IIIC1, and 6 as IIIC2. Complications recorded were infection-associated, mechanical, systemic, general, and mortality. Statistical analysis was performed by means of the Mantel-Haenszel and the exact Fisher tests. In relation to complications with respect to the systemic host grade, the Mantel-Haenszel test revealed significant differences regarding only the emergence of a draining sinus. In relation to complications with respect to the local extremity grade, the exact Fisher test revealed significant differences regarding only the emergence of wound healing complications. All other complications showed no significant differences. The McPherson classification, in association with an increasing number of comorbidities, indicates a higher risk of occurrence of a postoperative draining sinus, whereas the grade of compromised local tissues is associated with wound healing complications. Improvement of the general medical condition of patients between stages as well as an anatomical dissection and closure of the wound may lead to a decreased incidence of these complications.

Two-stage treatment protocol for isolated septic acetabular cup loosening.

The aim of this study was to evaluate the treatment of isolated septic acetabular cup loosening without involvement of the prosthesis stem by insertion of an antibiotic-loaded spacer head and stem retention. Between 1999 and 2008, 13 patients (5 men, 8 women, mean age 69 years) were treated according to this regimen. S. epidermidis and S. aureus were the two most commonly identified pathogens. In 12 cases the polymethylmethacrylate spacers were impregnated with 0.5 g gentamicin + 2 g vancomycin per 40 g bone cement, except in one patient with vancomycin allergy, in whom 0.5 g gentamicin + 0.4 g teicoplanin were used. The spacers acted as hemiarthroplasties. The mean spacer head implantation time was 88 (35-270) days. At a mean follow-up of 55 (12-83) months, infection eradication was achieved in 11 out of 12 cases (91.6%). Complications included a draining sinus, and one spacer and one definitive prosthesis dislocation. One patient died after reimplantation due to cardiopulmonary decompensation.

Vacuum-assisted closure in the treatment of early hip joint infections.

The aim of the present study was to evaluate the efficacy of the vacuum-assisted closure (V.A.C.) system in the treatment of early hip joint infections. 28 patients (11 m/17 f; mean age 71 y. [43-84]) with early hip joint infections have been treated by means of the V.A.C.-therapy. At least one surgical revision [1-7] has been unsuccessfully performed for infection treatment prior to V.A.C.-application. Pathogen organisms could have been isolated in 22/28 wounds. During revision, cup inlay and prosthesis head have been exchanged and 1-3 polyvinylalcohol sponges inserted into the wound cavity/ periprosthetically at an initial continuous pressure of 200 mm Hg. Postoperatively, a systemic antibiosis was given according to antibiogram. 48-72 h after surgery an alteration from haemorrhagic to serous fluid was observed in the V.A.C.-canister. Afterwards, the pressure was decreased to 150 mm Hg and remained at this level till sponge removal. After a mean period of 9 [3-16] days the inflammation parameters have been retrogressive and the sponges were removed. An infection eradication could be achieved in 26/28 cases. In the two remaining cases the infected prosthesis had to be explanted and a gentamicin-vancomycin-loaded spacer has been implanted, respectively. At a total mean follow-up of 36 [12-87] months no reinfection or infection persistence was observed. The V.A.C.-system can be a valuable contribution in the treatment of early joint infections when properly used. Indications should be early infections with well-maintained soft-tissues for retention of the negative atmospheric pressure.

Complications after spacer implantation in the treatment of hip joint infections.

The aim of this retrospective study was to identify and evaluate complications after hip spacer implantation other than reinfection and/or infection persistence. Between 1999 and 2008, 88 hip spacer implantations in 82 patients have been performed. There were 43 male and 39 female patients at a mean age of 70 [43-89] years. The mean spacer implantation time was 90 [14-1460] days. The mean follow-up was 54 [7-96] months. The most common identified organisms were S. aureus and S. epidermidis. In most cases, the spacers were impregnated with 1 g gentamicin and 4 g vancomycin/80 g bone cement. The overall complication rate was 58.5% (48/82 cases). A spacer dislocation occurred in 15 cases (17%). Spacer fractures could be noticed in 9 cases (10.2%). Femoral fractures occurred in 12 cases (13.6%). After prosthesis reimplantation, 16 patients suffered from a prosthesis dislocation (23%). 2 patients (2.4%) showed allergic reactions against the intravenous antibiotic therapy. An acute renal failure occurred in 5 cases (6%). No cases of hepatic failure or ototoxicity could be observed in our collective. General complications (consisting mostly of draining sinus, pneumonia, cardiopulmonary decompensation, lower urinary tract infections) occurred in 38 patients (46.3%). Despite the retrospective study design and the limited possibility of interpreting these findings and their causes, this rate indicates that patients suffering from late hip joint infections and being treated with a two-stage protocol are prone to having complications. Orthopaedic surgeons should be aware of these complications and their treatment options and focus on the early diagnosis for prevention of further complications. Between stages, an interdisciplinary cooperation with other facilities (internal medicine, microbiologists) should be aimed for patients with several comorbidities for optimizing their general medical condition.

Mechanical complications and reconstruction strategies at the site of hip spacer implantation.

Over the past two decades antibiotic-impregnated hip spacers have become a popular procedure in the treatment of hip joint infections. Besides infection persistence and/or reinfection, major complications after hip spacer implantation include spacer fracture, -dislocation, and bone fracture. Moreover, in cases with extensive loss of femoral and/or acetabular bone alternative reconstructive techniques should be used for a stable spacer fixation and prevention of fractures or dislocations. The present article reviews the different types of spacer fractures and dislocations and offers some suggestions about reconstructive techniques for management of extensive loss of femoral and/or acetabular bone at the site of hip spacer implantation.

Elution of gentamicin and vancomycin from polymethylmethacrylate beads and hip spacers in vivo.

BACKGROUND AND PURPOSE: Late infections after total hip arthroplasty are still a problem. Treatment procedures include resection arthroplasty with implantation of antibiotic-loaded beads or implantation of an antibiotic-impreganted spacer. However, little is known about antibiotic elution from bone cement beyond the first 2-3 postoperative days in humans. METHODS: 17 hip spacers (80 g PMMA, 1g gentamicin, and 4 g vancomycin) and 11 chains (40 g PMMA, 0.5 g gentamicin, and 2 g vancomycin) in 28 patients were studied. The release of both agents was measured in the drainage fluid on a daily basis. The drains were left in situ until less than 50 mL was produced per day. The elution of both antibiotics was determined by fluorescence polarization immunoassay. Systemic antibiotics were given postoperatively according to antibiogram. If possible, no gentamicin or vancomycin was given. RESULTS: Peak mean concentrations from beads and spacers were reached for gentamicin (1,160 (12-371) microg/mL and 21 (0.7-39) microg/mL, respectively) and for vancomycin (80 (21-198) microg/mL and 37 (3.3-72) microg/mL) on day 1. The last concentrations to be determined were 3.7 microg/mL gentamicin and 23 microg/mL vancomycin in the beads group after 13 days, and 1.9 microg/mL gentamicin and 6.6 microg/mL vancomycin in the spacer group after 7 days. Between the fifth and seventh day, an intermittent increase in elution of vancomycin from both beads and spacers and of gentamicin from spacers was noticed. No renal or hepatic dysfunction was observed. INTERPRETATION: Beads showed higher elution characteristics in vivo than the spacers due to their larger surface area; however, a great amount of inter-subject variability was seen for both beads and spacers. The inferior elution properties of spacers emphasize the importance of additional systemic antibiotics for this treatment procedure during the postoperative period. Future studies should clarify whether the dose of antibiotics or length of antibiotic therapy may be reduced in the case of bead implantation, without jeopardizing the control of infection.

Antimicrobial properties and elution kinetics of linezolid-loaded hip spacers in vitro.

Bacterial adhesion to and -persistence on antibiotic-loaded bone cement is an increasing problem. New antibiotics with good antimicrobial and pharmacokinetic properties (e.g. linezolid) may be the solution to this problem; however, few data concerning linezolid-loaded acrylic cement are currently available. Ten gentamicin-linezolid-loaded hip spacers (1 g gentamicin/2.4 g linezolid/80 g PMMA; five spacers including a metallic endoskeleton, five with no metallic components) were tested in vitro against a strain of methicillin-resistant Staphylococcus aureus with regard to antibiotic release and bacteria growth inhibition. Daily, the antibiotic elution was determined by high liquid performance chromatography (linezolid) and fluorescence polarization immunoassay (gentamicin), the bacteria growth inhibition photometrically at 546 nm. All spacers demonstrated growth inhibition for 8 days. Peak average concentrations were reached for both agents on day 1 (gentamicin-35.10 mug/mL [24.10-52.52], linezolid-36.28 mug/mL [22.87-71.76]). After 8 days, 0.97% [0.93-1.05%] of the initial amount of linezolid and 3.13% [2.85-3.31%] of gentamicin were meanly released from spacers containing a metallic endoskeleton. In those containing of simple cement these values were 1.22% [0.91-1.59%] and 2.67% [2.12-2.73%], respectively. Linezolid demonstrated acceptable elution kinetics from bone cement; however, further experimental research and animal studies should clarify any possible side effect of linezolid-loaded cement media before definitive use in the clinical practice.

In vivo and in vitro studies of antibiotic release from and bacterial growth inhibition by antibiotic-impregnated polymethylmethacrylate hip spacers.

The antimicrobial properties and the elution characteristics of gentamicin-vancomycin-loaded hip spacers were studied in vivo and in vitro. Vancomycin elution was greater than gentamicin elution. The antibiotic concentrations in vivo were less than those in vitro. Not dependent on implantation duration, growth inhibition by spacers in vitro was observed for 2 weeks. The reason for protracted wound healing cannot be insufficient antibiotic release.

In vitro evaluation of antibiotic release from and bacteria growth inhibition by antibiotic-loaded acrylic bone cement spacers.

The antibiotic release from and the bacteria growth inhibition by antibiotic-loaded acrylic bone cement hip spacers were studied. The cement used was Palacos R, and it was loaded with either one antibiotic powder (gentamicin, vancomycin, teicoplanin, or synercid) [monoantibiotic case] or two antibiotic powders (gentamicin + vancomycin or gentamicin + teicoplanin) [biantibiotic case] and then tested against Staphylococcus epidermidis, Staphylococcus aureus, Enterococcus faecalis, and methicillin-resistant Staphylococcus aureus (MRSA). Antibiotic elution and bacteria growth were measured every 24 h simultaneously by fluorescence polarization immunoassay and photometrically, respectively. The gentamicin + vancomycin combination achieved the longest growth inhibition on S. epidermidis and MRSA (mean of 20 and 14 days, respectively). Gentamicin + teicoplanin-loaded spacers were capable of inhibiting growth on E. faecalis and S. aureus for the longest period (11 and 16 days, respectively). The highest concentrations of gentamicin and vancomycin could be assayed during the first 4 days. Teicoplanin concentrations could be detected only during the first 72 h, synercid was not detected at all, possibly because of the limitation of the detection technique used. A greater percentage of the gentamicin was released than of the vancomycin. The aminoglycosid-glycopeptid combination showed a synergistic effect on the release of gentamicin, but not on vancomycin or teicoplanin. Biantibiotic-impregnated hip spacers proved to be superior to monoantibiotic ones. Because of important differences between the conditions used for the present tests and the in vivo environment, any recommendation with regard to the use of monoantibiotic- and biantibiotic-loaded acrylic bone cement spacers must await the results of further investigations.