Articulating spacers compared to fixed spacers for the treatment of infected knee arthroplasty: A follow-up of 37 cases.

BACKGROUND: The standard treatment of a periprosthetic infection after TKA involves a two-stage reimplantation with the intermittent implantation of spacers. Different designs of spacers have been described; currently articulating spacers and fixed spacers are used. The aim of the present study is to compare the advantages/disadvantages of the different spacers. PATIENTS AND METHODS: In this retrospective study we analyzed 37 cases after revision surgery of infected TKA. All patients that received spacers as part of the two-stage reimplantation were included. Exclusion criteria were massive bone loss prior to revision, because the implantation of a mobile spacer would not have been possible. RESULTS: The average ROM was 98.0 (± 14.9) degrees in the articulating spacer group (group 1) and 79.3 (± 22.5) in the group that received the fixed spacers (group 2) before revision surgery started. At a late follow up the average ROM for group 1 was 102.0 (± 8.4) and 79.0 (± 26) for group 2. CONCLUSION: The use of articulating spacers in the two-stage revision for infected total knee arthroplasty is a safe alternative to fixed spacers, that equally preserves ligament balancing and has equal infection eradication rates. A long term improvement of the range of motion following reimplantation of the new joint was, however, not observed.

[Post disc surgery syndrome: indications for surgery and conservative and operative treatment possibilities]. / Postnukleotomiesyndrom: Operationsindikation, konservative und operative Behandlungsmöglichkeiten.

Post disc surgery syndrome is characterised by the presence of persistent disabling pain in the hip, thigh, or lower back. Persistent or recurrent pain may be related to neurologic compression, incomplete discectomy with retained disc fragments, recurrent disc herniation, or altered biomechanics of the operated segments. Early failure is usually due to poor patient selection, incorrect diagnosis, incorrect procedure, or infection. A new onset of pain following a good surgical result may be due to recurrent disc herniation, instability of the operated segment, or disease at a different disc level. It can also be the result of a chronic pain syndrome. Therapy depends on exact diagnostics and can include conservative as well as surgical treatment.

Long-term results of ventro-dorsal versus ventral instrumentation fusion in the treatment of spondylitis.

This study examines prospectively the randomised, long-term, clinical and radiological results of the treatment of spondylitis patients by ventro-dorsal or ventral spine fusion. Group 1 consisted of 12 patients who (after ventral removal of the focus of infection and autologous bone grafting) were treated by dorsal instrumentation. Group 2 consisted of ten patients who, after similar ventral removal and bone interposition, were stabilised by ventral instrumentation. The patients prospectively underwent clinical and radiological studies. In addition, they were asked to fill in self-assessment questionnaires such as the short-form (SF)-36 health survey, the Oswestry questionnaire, and the visual analog scales (VAS). The postoperative follow-ups were at 6 months, 2 years and 5.4 years. It proved possible to demonstrate clinically that patients with an isolated ventral spondylodesis feel significantly better and experience significantly less pain in the area of spinal fusion than patients with ventro-dorsal fusion 2 and 5.4 years after the operation. Over a number of years a stable fusion can be achieved through either operation. Ventral stabilisation yields more advantages than dorsal instrumentation in the long term. These advantages result in a clinically smoother course after the operation. If, in the individual case, ventral instrumentation is feasible, this method should be used.

[Material removal after anterio-posterior spondylodesis -- necessity of posterior instrumentation removal after osseous fusion]. / Implantatentfernung bei ventro-dorsalen Spondylodesen. Ist eine Entfernung des dorsalen Implantats nach knöcherner Durchbauung sinnvoll?

BACKGROUND: The present study on spondylitis patients with anterio-posterior spondylodesis was carried out to get a recommendation whether material removal is necessary after osseous fusion. METHODS: A total of 12 patients with spondylitis were operated on at the Orthopaedic Department of Ludwig-Maximilians-University Munich with posterior instrumentation after debridement and fusion with autologous bone transplant. In a prospective clinical investigation we examined our patients regarding clinical and radiological outcome preoperatively, 2 weeks, 12 months and 4.9 years after operation. We paid special attention on complications and loss of correction in leaving posterior instrumentation. RESULTS: Compared with the advanced clinical signs of spondylitis, minor intra- and postoperative complications were seen. Two patients showed superficial wound infections with fistulization because of the posterior implants 3 years postoperatively. Both cases closed after revision and material removal without complications. 12 months and 4.9 years postoperatively the average loss of correction was constant 2 degrees . CONCLUSION: Generally material removal of posterior spinal instruments results in a significant loss of correction in the spondylodesis segment. Our study shows, that persisting posterior instrumentation could prevent loss of correction. On the other hand we recommend material removal in case of spondylodesis after osseous fusion to prevent wound healing complications.

[Differences between anteroposterior and posterior spondylodesis in clinical scores]. / Vergleich ventrodorsaler und ventraler Spondylodese bei Patienten mit Spondylitis anhand klinischer Scores.

The present study on spondylitis patients was carried out to compare prospectively results of clinical scores of patients treated with anteroposterior or anterior spondylodesis. A total of 22 patients with spondylitis were enrolled in the randomized trial to undergo an operation with anteroposterior or posterior spondylodesis. For quality of life adjustment, the SF-36 health survey was applied. Pain and disability were measured using the Oswestry low-back pain disability questionnaire and visual analogue scales (VAS). Twelve patients were assigned to undergo anteroposterior spondylodesis and ten patients anterior spondylodesis. Postoperative improvement of spinal function, general health, well being, back pain, and mobility could be observed in both groups of patients. Better results of patients treated with anterior spondylodesis compared with anteroposterior spondylodesis were seen. No statistical difference was found between the two groups at any time. The less invasive nature of anterior spondylodesis could be responsible for that result.Anterior spondylodesis should used if possible and deemed adequate because it causes less discomfort.

[First results of anterior versus posterior instrumentation-fusion in the treatment of spondylodiscitis]. / Erste Ergebnisse ventraler versus dorsaler Instrumentation nach Ausräumung und intervertebraler Fusion bei Spondylodiszitis.

AIM: The present study on spondylodiscitis patients was carried out to compare prospectively and randomized the results of clinical and radiological outcomes of anterior versus posterior instrumentation after debridement and grafting. We aimed to make a recommendation concerning the optimum treatment of spondylodiscitis. METHOD: A total of 22 patients with spondylodiscitis were enrolled in the randomized trial to undergo an operation with anterior or posterior instrumentation after debridement and fusion with autologous bone transplant. 12 patients (group 1) were assigned to posterior Universal Spine System stabilization. 10 patients (group 2) were treated with anterior VentroFix instrumentation. In a prospective clinical investigation we have examined both operative therapies with regard to clinical and radiological outcome. The follow-up was one year. RESULTS: In patients with ventral Spondylodesis (group 2), prior recreation of patients was achieved in clinical examination and blood tests. Radiological results are even equivalent in both groups. Therefore we recommend ventral instrumentation as the superior surgical procedure. But the individual local situation has to enable ventral stabilization. CONCLUSION: We found advantages with anterior instrumentation in comparison to posterior stabilization in patients with spondylodiscitis. Advantages of ventral stabilization cause early mobilization postoperatively without any increase in complication rates. Except for operation time and intraoperative blood loss, no statistical difference were was seen. Important is the individual indication for each method depending on anatomical and clinical signs. Ventral instrumentation should be restricted to cases with sufficient bone stock.

Harman and norharman plasma levels in weaned alcoholics: correlations with depression and tobacco smoking.

Based on the hypothesis that ß-carbolines are involved in the pathogenesis of alcohol-related mood disturbance, harman and norharman levels were assayed in the blood plasma of alcoholics and correlated to the Hamilton Depression (HAM-D) scores after 3 and 5 weeks post-admission. Tobacco smoking was co-evaluated since it is known to influence ß-carboline levels. After a 3-week period, plasma harman but not norharman was increased in depressed alcoholics and positively related to the HAM-D sum-score (r = 0.47; p < 0.04) and to tobacco smoking (r = 0.56; p < 0.02). Since no correlation between depression and smoking was found, these data could account for the higher incidence of depressive symptoms in withdrawn alcoholics with increased harman levels. The partial correlations support this hypothesis.

Anterior debridement, fusion, and extrafocal stabilization in the treatment of osteomyelitis of the spine.

To simplify and shorten the rehabilitation after anterior debridement and fusion in pyogenic and tuberculous osteomyelitis of the spine, the role of additional extrafocal dorsal transpedicular instrumentation was studied. Thirty-three (10 female, 23 male) patients were followed up in a prospective study and controlled with an average follow-up period of 22.1 months after the operation with clinical and neurologic check-up, blood test, and serial radiographs. Solid bony fusion and healing of the infection was achieved in all patients. Preoperative deformities could be corrected, and there were no life-threatening complications. Dorsal extrafocal stabilization offered the advantage of braceless rehabilitation without adding unpredictable risks.

Fibromatosis of the plantar fascia: diagnosis and indications for surgical treatment.

Plantar fibromatosis is a rare, benign lesion involving the plantar aponeurosis. Eleven patients (13 feet) underwent 24 operations, including local excision, wide excision, or complete plantar fasciectomy. Clinical results were evaluated retrospectively. There were no differences among the subgroups in postoperative complications. Two primary fasciectomies did not recur. Three of six revised fasciectomies, seven of nine wide excisions, and six of seven local excisions recurred. Our results indicate that recurrence of plantar fibromatosis after surgical resection can be reduced by aggressive initial surgical resection.

Rapidly progredient scoliosis associated with multicore disease.

Multicore disease is a rare congenital myopathy that normally stops or makes slow progress. It starts with delayed motor development and frequent falls. Especially the proximal muscles are involved. Other symptoms include contractures of joints, clubfoot, high arched palate, chest deformities, involvement of eye-muscle, cardiac abnormalities, hyperlordosis and scoliosis that normally does not require surgery. We report a rare case of advanced scoliosis in multicore disease requiring operative treatment in a 15-year-old girl. In this case the scoliosis took a rapidly progredient course in puberty close to the end of skeletal growth. A dorsal spondylodesis with USS instrumentation from T9 to L3 was performed. A significant reduction of the scoliosis was obtained. Scoliosis in multicore disease may take a rapidly progredient course. Frequent checks will lead to the initiation of surgical treatment in time.

Diffusion-weighted MR imaging of bone marrow: differentiation of benign versus pathologic compression fractures.

PURPOSE: To evaluate the usefulness of diffusion-weighted magnetic resonance (MR) imaging of bone marrow for differentiating between benign and pathologic vertebral compression fractures. MATERIALS AND METHODS: Thirty patients with 39 vertebral compression fractures were examined with MR imaging. Diffusion-weighted MR imaging was performed with a steady-state free precession sequence in 22 acute benign osteoporotic and/or traumatic fractures and 17 pathologic compression fractures. Biplanar radiographs, T1-weighted spin-echo (SE) MR images, and short inversion time inversion-recovery (STIR) MR images were available for all patients. The signal intensity characteristics were analyzed qualitatively and quantitatively (bone marrow contrast ratios and signal-to-noise ratios) for all sequences. RESULTS: At diffusion-weighted MR imaging, all benign vertebral compression fractures were hypo- to isointense to adjacent normal vertebral bodies. Pathologic compression fractures were hyperintense to normal vertebral bodies. Benign vertebral fractures had negative bone marrow contrast ratios at diffusion-weighted imaging, whereas pathologic vertebral fractures had positive values (P < .001). The difference in bone marrow contrast ratios for benign and pathologic compression fractures at T1-weighted SE and STIR imaging was not significant (P > .01). CONCLUSION: Diffusion-weighted MR imaging provided excellent distinction between pathologic and benign vertebral compression fractures.

[Spatial orientation and postural regulation in patients with idiopathic scoliosis]. / Untersuchung zur Raumwahrnehmung und Haltungsregulation bei Patienten mit idiopathischer Skoliose.

QUESTION: Etiology of idiopathic scoliosis is unknown. In literature a primarily neurogenic disturbance of postural regulation is discussed with subsequent changes of the spine. In the present paper, individual functions of postural regulation in patients with idiopathic scoliosis were examined by neurophysiologic investigations and compared to a normal population. METHOD: The body sway of 28 patients was investigated in upright position under various testing conditions by means of a force measuring platform, allowing examination of the efferent part of postural regulation as well as the sensory systems involved. Registration of the eye movements (ENG) made it possible to investigate the function of the vestibulo-cerebellar system. Furthermore the optokinetic capability of scoliotic patients was tested by determination of the subjective visual vertical (SVV). RESULTS: It turned out that none of the neurophysiologic test procedures showed clearly pathological findings in scoliotic patients as compared to a normal population. CONCLUSION: It has not to be considered as probable that idiopathic scoliosis is caused by a disturbance of postural regulation.

Spinal cord compression caused by the rod of a Harrington instrumentation device: a late complication in scoliosis surgery.

We report a unique complication caused by the rod of a Harrington instrumentation device, which resulted in spinal stenosis and myelopathy. A literature review revealed no previous causes of direct spinal cord impingement caused by the rod of a Harrington device. In this case, years after the initial operation, the rod penetrated the lamina at the junction between a thoracic and a lumbar curve, causing spinal stenosis and myelopathy. We conclude that regular control of the position of the device and awareness of possible late neurological complications are necessary to identify such complications as early as possible.

[Praying for the hunchback man. On the cultural history of scoliosis and kyphosis]. / Beten fürs bucklicht Männlein. Zur Kulturgeschichte der Skoliose und Kyphose.

Numerous ancient burial sites contain spines with scoliotic deformities. However, very little is known about the lives of these people, the "hunchbacks". Their everyday life, how they saw themselves and were seen by others, their social status and perspectives can usually only be deduced indirectly from a variety of sources. These include fairy-tales and myths, beliefs and superstitions, classical and light literature, and accounts by theological and philosophical writers. The present paper proves that severely deformed scoliosis patients were generally burdened with a pitful fate in ancient times and during the Middle Ages. There was no effective treatment, healthy citizens showed little compassion, hunchbacks were said to have a vile and base character, and they were usually stigmatised outsiders. The sociopsychological situation for these patients did not improve until modern times, beginning with increased public awareness during the last century, in parallel with the slow development of orthopaedic treatment methods for scoliosis.

[Avoidance of homologous blood transfusion despite extreme blood loss]. / Vermeidbarkeit von Fremdblut trotz extremen Blutverlustes.

We report the case of a 22-year-old woman who underwent two-step scoliosis surgery without allogeneic transfusion, although the intraoperative blood loss (3500 ml) during the first procedure was higher than the calculated blood volume (3250 ml). Preoperatively the patient had donated four units of autologous blood. Intraoperatively blood-saving methods were combined. During the first operation acute normovolemic hemodilution (target hemoglobin 9.0 g/dl) was applied and during the second operation controlled hypotension (systolic blood pressure 80 mmHg). Intraoperative auto-transfusion was used in both procedures. During the first operation severe normovolemic anemia (minimal hemoglobin 3.5 g/dl) was accepted while the patient was ventilated with FiO2 1.0. The hemoglobin concentration was 8.6 g/dl after the first procedure and had increased to 11.6 g/dl 4 weeks after the second procedure. No severe complications occurred during the postoperative phase. This case report shows that also in surgical procedures with extreme blood loss any allogenic transfusion can be avoided by the combination of blood-saving methods, acceptance of low intraoperative transfusion trigger and ventilation with 100% oxygen.

Mechanical principles of compressive interbody fusion.

STUDY DESIGN: A biomechanical study on cadaveric lumbar spines was performed measuring interfragmentary forces and contact areas between intercorporal bone blocks and vertebral endplates. OBJECTIVES: To show the correct application of internal fixators to achieve interfragmentary compression between bone blocks and adjacent endplates. SUMMARY OF BACKGROUND DATA: Several researchers have previously tried to compress interbody bone blocks by internal fixator systems. Knowledge of the correct way to use the internal fixator systems for this purpose has been lacking. METHODS: Ten cadaveric lumbar spines were analyzed by instrumenting each motion unit with an intercorporal bone block and a dorsal transpedicular arbeitsgemeinschaft osteosynthesefragen internal fixator. Interfragmentary load and compression surface and their distribution were measured with a capacitive measuring mat. The internal fixator was loaded in compression in two different ways to determine the optimum mode of application. RESULTS: Simple compression of an internal fixator did not achieve sufficient interfragmentary forces and compression surfaces. Usually lordotic contouring of the instrumented spinal motion unit with a decrease in interfragmentary forces and width of compression surfaces developed. Preloading the fixator in slight kyphosis and compressing it in a second step achieved significantly improved interfragmentary forces and sufficient compression surfaces. CONCLUSIONS: Preloading an internal fixator in kyphosis and secondary compression is mandatory to get sufficient interfragmentary forces and compression surfaces between interbody bone blocks and adjacent vertebral endplates. The technique described provides a compressive interbody fusion and can be performed preserving the physiological shape of the spine.

Degenerative disk vascularization on MRI: correlation with clinical and histopathologic findings.

OBJECTIVE: This prospective study was designed to determine the MRI features, clinical significance, and correlation to histopathologic findings of secondary vascularized degenerative intervertebral disks. MATERIALS AND METHODS: Fifty-three patients with localized painful spine syndrome were investigated prospectively by contrast-enhanced MRI. Pain was not predominantly radiating and there was no clinical evidence of spinal infection. In all patients sagittal SE T1-weighted, fast SE T2-weighted or turbo-STIR, and T1-weighted frequency-selective fat-suppressed images were obtained. RESULTS: We identified 37 vascularized disks in 26 patients. In 18 patients the changes had occurred spontaneously, in 6, the affected disk had been operated on previously, and 2 patients had spondylolisthesis. In 15 patients, vascularization was accompanied by medullary edema adjacent to the vertebral endplates. In one of the vascularized disks, herniation was also found. In seven patients, ventral diskectomy was performed. Histopathologic findings confirmed disk vascularization in six of seven cases. CONCLUSIONS: Degenerative, band-like disk vascularization is a feature which is associated with local pain. It was demonstrated by contrast-enhanced MRI. Degenerative disk vascularization is an important differential diagnosis to bacterial spondylodiskitis. It can be a cause of pain in patients with postdiskectomy syndrome.

Role of internal and external fixation in ankle fusion.

Between August 1980 and September 1993, 35 tibiotalar arthrodeses in 34 patients with primary and secondary osteoarthritis of the ankle were performed. Two different surgical techniques were employed. Internal screw fixation according to Wagner and Pock [20] and an external fixation method according to the resection compression arthrodesis by Charnley and Muller [14]. Twenty patients with 21 fusions could be investigated retrospectively. For evaluation we used self-assessment, clinical examination and radiographic analysis in combination with the score described by McGuire et al. [12]. In 80% the results were good and satisfactory with a median improvement of 23 score points on a scale of 100% 95 points, respectively. The most important advantages were pain relief and increase of walking distance. The fusion rate was 95%. We found osteoarthritis in the neighbouring joints did not have any influence on the surgical result. With respect to the two surgical techniques, the internal screw fixation method achieved fusion earlier with fewer complications and better improvement according to the McGuire score. Tibiotalar fusion is a safe therapy with reproducible good results involving pain relief, full weight-bearing and increase of walking distance.

[Surgical therapy of polytopic vertebral metastasis in malignant pheochromocytoma]. / Die operative Therapie einer polytopen Wirbelsäulenmetastasierung bei malignem Phäochromocytom.

Malignant pheochromocytoma has a low incidence. Metastatic disease with skeletal spread is a known entity while osseous involvement of the spine is uncommon. Therefore the case of a 27 year of female with successive, polytopic spinal metastases is reported who underwent surgical resection and stabilisation. 6 years after onset of spinal metastases and operative treatment the patient is free of complaints according to the spinal column.

Surgical treatment of acromioclavicular dislocation.

Sixty-five patients were operated on for acromioclavicular dislocation between 1980 and 1991. Seventeen type II and 48 type III dislocations according to the criteria of Tossy et al. were treated. Three different surgical techniques were employed. (1) tension band wiring, (2) a modification of the Bosworth repair, (3) reconstruction of the ligaments with augmentation by a PDS (polydioxanon) cord. Forty-four patients could be investigated retrospectively, and an additional 12 were recorded by questionnaire. The Taft score was used, representing self-assessment, clinical statements and radiological findings. Of all investigated patients 87.5% had a normal range of motion without any loss of strength, and 32% suffered an osteoarthritis of the acromioclavicular joint. The average Taft score was 9.8. With respect to the three surgical techniques, reconstruction of the ligaments augmented by a PDS cord produced the best result, an average Taft score of 10.8.