Treatment of Fractures of the Thoracolumbar Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU).

STUDY DESIGN: consensus paper with systematic literature review. OBJECTIVE: The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts. METHODS: The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences. RESULTS: As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers. CONCLUSION: Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.

[Refresher Orthogeriatrics]. / Orthogeriatrie.

Fragility fractures are associated with a substantial mortality and morbidity. Because of the high prevalence of comorbidities and a high risk of complications the application of geriatric principles in the complex treatment of these patients is vital. The last years have seen a paradigm shift in the treatment of fragility fractures from an orthopedic disorder towards an orthogeriatric syndrome. This article reviews the orthogeriatric principles of treating fragility fractures.

MIGS: therapeutic success of combined Xen Gel Stent implantation with cataract surgery.

PURPOSE: Glaucoma, a common disease in the elderly population, is frequently coexistent with cataract. While the combination of filtration surgery and cataract surgery is a challenging topic with limited success, minimal invasive glaucoma surgery (MIGS), such as Xen Gel Stents, seems to provide promising results. The aim of this study was to investigate the complete and qualified therapeutic success of Xen Gel Stent implantation with (XenPhaco) and without cataract surgery. METHODS: One hundred and eleven open-angle glaucoma eyes underwent implantation of Xen45 Gel Stent (AqueSys, Inc.) with or without cataract operation. Complete therapeutic success was defined as target intraocular pressure (IOP) < 18 mmHg at any time point within 6 months of follow-up without local antiglaucomatous therapy or further surgical interventions. Qualified success was defined as target IOP <18 mmHg with additional 1-2 local antiglaucomatous eye drops. Failure included all cases with the necessity of at least three local antiglaucomatous eye drops or additional glaucoma surgery. RESULTS: Combined implantation of Xen Gel Stent with cataract surgery was performed in 30 eyes and stand-alone Xen Gel Stent implantation was performed in 81 eyes. A complete therapeutic success was achieved in 46.9% of single Xen Gel Stent implantation, whereas 53.3% was reached with combined XenPhaco. Qualified success was seen in 2.5% in the eyes of the single Xen Gel Stent implantation group and in 3.3% of the combined surgery group. Therapeutic failure rate was 49.4% in the stand-alone group vs 46.7% in the combined group. Data were not significantly different for group and subgroup analyses. CONCLUSIONS: Complete and qualified therapeutic success is similar for the combination of Xen Gel Stent implantation with and without cataract surgery in open-angle glaucoma patients. MIGS using Xen Gel Stent can be recommended in situations if glaucoma surgery is indicated besides coexisting cataract.

ICE-Syndrome: A Case Report of Implantation of a Microbypass Xen Gel Stent After DMEK Transplantation.

PURPOSE: Treatment of glaucoma eyes with iridocorneal endothelial syndrome is complex. Minimally invasive glaucoma surgery, such as one that implements a novel, microinvasive device, known as Xen gel stents, has shown promise in surgical glaucoma treatment and offers a new therapeutic option. METHODS: This is a case report. RESULTS: A successful implantation of Xen45 gel stent in a woman with secondary glaucoma due to unilateral iridocorneal endothelial syndrome after descement membrane endothelial keratoplasty operation, and the follow-up are presented. CONCLUSIONS: Implantation of Xen gel stents may be a promising option for minimally invasive glaucoma surgery in difficult situations, as low adverse effects, good postsurgery visual acuity and sufficient regulation of intraocular pressure can be seen.

Preventive effects of omega-3 and omega-6 Fatty acids on peroxide mediated oxidative stress responses in primary human trabecular meshwork cells.

Pathologic processes in glaucoma include increased apoptosis, accumulation of extracellular material in the trabecular meshwork and optic nerve, condensations of the cytoskeleton and precocious cellular senescence. Oxidative stress was shown to generate these alterations in primary ocular cells. Fatty acids omega-3 and -6 are alleged to constitute a prophylaxis against these deleterious effects. Here, we tested actual preventive effects omega-3 and -6 against peroxide induced stress responses in primary human trabecular meshwork cells. Changes of mitochondrial activity, proliferation, heat shock proteins, extracellular matrix components, and inflammatory markers were evaluated. Alterations of the cytoskeleton were evaluated by phalloidin labeling. Here we report a repressive effect of omega-6 on metabolic activity and proliferation, which was not detected for omega-3. Both agents were able to prevent the anti-proliferative effect of H2O2, but only omega-3 prevented metabolic repression. Expression of heat shock protein 27 was unaltered by both fatty acids, whereas heat shock protein 90 was significantly induced by both. Omega-6 increased fibronectin and connective tissue growth factor synthesis, as well as the amount of secreted fibronectin. Omega-3, instead, induced plasminogen activator inhibitor 1 synthesis. H2O2 further increased fibronectin production in omega-6 supplemented cells, which was not the case in omega-3 treated cells. H2O2 stimulation of plasminogen activator inhibitor 1 and connective tissue growth factor was repressed by both fatty acids. Both fatty acids appeared to abolish H2O2 mediated stimulation of nuclear factor κB and IL-6, but not IL-1α and IL-8. H2O2 induced formation of cross-linked actin networks and stress fibers, which was reduced by preemptive application of omega-3. Omega-6, in contrast, had no protective effect on that, and even seemed to promote condensation. Based on the observed side effects of omega-6, omega-3 appears to be the more beneficial fatty acid in respect of prophylactic intake for prevention of a glaucomatous disease.

Surgical therapy of vertebral metastases. Are there predictive parameters for intraoperative excessive blood loss despite preoperative embolization?

AIMS AND BACKGROUND: Preoperative embolization of vertebral metastases has been shown to lower intraoperative blood loss. Nevertheless, excessive up to life-threatening blood loss can occur despite embolization. We therefore decided to evaluate possible parameters for predicting significant blood loss in a surgically homogeneous group of patients with vertebral metastases. METHODS: Patients with vertebral metastases of the thoracic and thoracolumbar spine who underwent preoperative embolization were included. All patients had existing or impending neurological deficit as the main indication for direct metastasis reduction. The parameters evaluated were the technical feasibility of embolization, vascularization grade of metastasis, success of embolization, tumor type in relation to blood loss, and interval between embolization and surgery. RESULTS: Twenty-seven patients fullfilled the inclusion criteria. Technically complete embolization was feasible in 14 patients (52%) and fully successful embolization was obtained in 10 patients (37%). Eighty-three percent of the renal cell carcinomas were hypervascularized, but also 67% of the breast carcinoma patients had hypervascularized tumors. No permanent complications occurred during embolization, but two patients had pain and another two experienced a transient burning sensation. A significant difference in intraoperative blood loss was only found between patients achieving partially or fully successful embolization in the subgroup of hypervascularized grade III metastases. CONCLUSIONS: The success of embolization in the group of hypervascularized grade III metastases was the only predictor for the extent of blood loss in our study. Due to the inaccuracy of predicting high blood loss in general all possible precautions for excessive blood loss should be taken despite preoperative embolization. Further randomized studies to determine the indications and results of embolization seem desirable.

Osteopontin and 'melanoma inhibitory activity': comparison of two serological tumor markers in metastatic uveal melanoma patients.

BACKGROUND: Evaluation of the protein osteopontin (OPN) as a potential new marker in comparison to melanoma inhibitory activity (MIA) for screening and detection of metastatic uveal melanoma. METHODS: Plasma levels of 32 patients with uveal melanoma were analyzed for OPN and MIA by enzyme-linked immunosorbent assay (ELISA). Fourteen of these patients had clinically detectable liver metastases. RESULTS: Median plasma concentration of OPN in patients with metastatic disease was 152.01 ng/ml compared to 47.39 ng/ml in patients without clinically detectable metastases (p < 0.001). The difference between the median MIA plasma levels in patients with (13.11 ng/ml) and patients without (5.64 ng/ml) metastatic disease was also statistically significant (p < 0.001). No correlation could be found between MIA or OPN levels and tumor height in patients without clinically detectable metastases. CONCLUSION: The proteins MIA and OPN seem to be promising tumor markers for the metastasis screening in patients with uveal melanoma.

Osteopontin as a serologic marker for metastatic uveal melanoma: results of a pilot study.

PURPOSE: To evaluate the protein osteopontin (OPN) as a potential new marker for screening and detection of metastatic uveal melanoma. DESIGN: Prospective, clinical study. METHODS: Twenty-eight plasma samples of 27 patients with uveal melanoma were analyzed, and the OPN plasma levels were quantified. Eight of these patients showed liver metastasis. As a control, we measured OPN levels in eight healthy, age-matched individuals. RESULTS: The median plasma concentration of OPN in patients with melanoma without metastasis was 46.78 ng/ml (range, 14.5 to 118.67 ng/ml). In contrast, increased median levels of OPN of 170.72 ng/ml (range, 87.37 to 375.54 ng/ml, P <.001) were seen in eight patients with proven metastatic disease. Healthy patients without uveal melanoma showed a median plasma concentration of OPN of 54.6 ng/ml (range, 38.23 to 71.21 ng/ml). CONCLUSION: The protein OPN seems to be a promising tumor marker for detecting metastatic disease in patients with uveal melanoma.

Intramedullary k-wire fixation of metacarpal fractures.

INTRODUCTION: The majority of metacarpal fractures can be treated conservatively. Nevertheless, surgical treatment is justified in certain cases. Palmar dislocation of >30 degrees and shortening of >5 mm will significantly affect extension and flexion of the hand. Consequently, surgical treatment is indicated. The aim of our study was to evaluate the clinical results of intramedullary Kirschner-wire fixation of metacarpal fractures. MATERIAL AND METHODS: In a retrospective study we analyzed the clinical results of 35 patients with metacarpal fractures that had been treated by closed reduction and elastic fixation with at least two intramedullary k-wires. RESULTS: Most of the patients were young, with good bone quality and low anesthetic risk, and they had suffered the fractures as a result of a direct trauma. Predominantly uncomplicated, the fractures were metaphyseal, subcapital and of the fifth metacarpal bone (750.3-B1 fractures). Surgical treatment was indicated for a palmar axis dislocation of >20 degrees or if a rotatory deficiency was present. Metacarpal joint function and correction of rotatory displacement could be assessed on median after a period of 1.1 year. In 34 patients flexion and extension was normal on both sides. In one patient we found an extension deficiency of 15 degrees and a rotatory deficiency of 10 degrees . In 34 out 35 patients with metacarpal fractures, minimally invasive intramedullary k-wire osteosynthesis resulted in complete restoration. CONCLUSIONS: Intramedullary k-wire fixation is a minimally invasive method for stabilizing metacarpal fractures. The excellent long-term clinical results are due to the fact that the gliding tissue around the fracture will not be affected at all by the surgical procedure.

Unreamed tibia nail (UTN) bending: case report and problem solution.

BACKGROUND: An unreamed tibia nail (UTN), implanted for operative stabilization of the tibia after a distal shaft fracture of the lower leg, was bent by excessive load prematurely applied during the healing process, whereby the cross-section-dependent maximum torque permitted in the edge fiber of the UTN during bending load was exceeded. Straightening of the bent, not broken UTN by hand was impossible. Therefore, the bent UTN could only be removed by causing additional damage to the tibia, which is why bending of the nail must be avoided. CONCLUSION: Our analysis shows that modification of the arrangement of the locking holes by 45 degrees increases bending load capacity of the UTN, which can minimize the probability of the occurrence of a bent nail.

Expression pattern and regulation of heme oxygenase-1/heat shock protein 32 in human liver cells.

Heme oxygenase-1 (HO-1) is a stress response protein that is highly inducible under various conditions, such as oxidative or heat stress. The present study investigated expression pattern and regulation of HO-1 in human liver. Expression pattern of HO-1 immunoreactive protein was studied in liver biopsies by immunohistochemistry, revealing constitutive expression in Kupffer cells but not in hepatocytes. HO-1 was, however, inducible in hepatocytes and vascular tissue under pathological conditions, e.g. associated with fatty degeneration or liver malignancies. Regulation of HO-1 gene expression was further studied by Northern blot analysis in HepG2 cells and freshly isolated peripheral blood mononuclear cells as model systems of parenchymal and nonparenchymal liver cell populations, respectively. HO-1 mRNA was inducible in HepG2 cells and mononuclear cells by various agents inducing oxidative stress. However, HO-1 gene expression was not inducible by heat shock. Pyrrolidine dithiocarbamate, an inhibitor of nuclear factor kappaB-dependent gene expression, dose dependently decreased HO-1 mRNA transcripts in human mononuclear cells subjected to oxidative stress while slightly increasing HO-1 gene expression in HepG2 cells. In contrast, HO-1 induction upon oxidative stress was attenuated in HepG2 cells by cycloheximide and dexamethasone. Although activator protein-1 has been reported as the predominant redox-sensitive transcription factor inducing HO-1 expression in murine macrophages, nuclear factor kappaB seems to play a significant role in human mononuclear cells. Our data are consistent with a role for activator protein-1 in HO-1 induction in human HepG2 hepatoma cells. These data suggest a differential regulation of HO-1 gene expression in parenchymal and non-parenchymal human liver cells and may provide a topographic basis for the understanding of the role of the heme oxygenase/carbon monoxide pathway in human liver disease.