In-vitro study of species-specific coagulation differences in animals and humans using rotational thromboelastometry (ROTEM).

Animal tests are conducted in all fields of trauma research, but transferability of these data to humans is limited. For example, it is still unclear which animal species is most similar to humans in terms of physiology of blood coagulation. To improve transferability and raise awareness of the existing differences, we compared human coagulation to coagulation of different animals. Rotational thromboelastometry was used to analyse the blood of pigs, sheep, rabbits and dogs. Animal data were compared with human coagulation based on the number of significant differences of the test parameters and on a descriptive comparison of the extent of relative deviation of the single values. All animal species showed significant differences in coagulation properties when compared with humans. Coagulation parameters of dogs and sheep were on average most similar to humans. However, there is no animal which is most similar to humans concerning all aspects of coagulation. Differences in coagulation between humans and animals are significant. This must be taken into account when transferring animal test data to humans.

Clinical Relevance of Cement Leakage after Radiofrequency Kyphoplasty vs. Balloon Kyphoplasty: A Prospective Randomised Study.

BACKGROUND: Cement leakage is regarded as a typical complication of cement-based augmentation of vertebral fractures. The gold standard is balloon kyphoplasty (BK). Recent methods, such as radiofrequency kyphoplasty (RFK), must be compared with BK in terms of therapeutic success and complication rates. It is unclear whether the cement leakage rate in RFK is lower than with BK and whether this has any clinical relevance. Therefore, the aim of our prospective clinical study was to compare RFK with BK with respect to cement leakage rates and associated clinical complications. PATIENTS AND METHODS: After prospective randomisation, 100 patients (76 women and 24 men with an average age of 78.5 years) or 162 vertebral bodies were treated by BK (n = 79) or RFK (n = 83). We evaluated the parameters "localisation of cement leakage" (epidural, intradiscal, extracorporal, intravascular) and "clinical relevance". RESULTS: More cement is used in BK (5.2 ml) than in RFK (4.0 ml, p = 0.001). Cement leakage was found in 48/79 patients (60.8 %) with BK and 53/83 patients (63.9 %) with RFK (p = 0.420). Even subanalysis by location showed no significant difference between the two methods. Despite the high leakage rates, we experienced only two cases (1× BK, 1× RFK) with intravascular leakage in the inferior vena cava, with interventional endovascular salvage. CONCLUSION: The two examined kyphoplasty methods (BK vs. RFK) have the same high rates of cement leakage, but are rarely associated with clinically manifest complications. Clinically relevant differences between the two compared kyphoplasty methods could not be found.

[Influence of Peridural Infiltration Therapy on Postural Control in Chronic Pain of the Lower Lumbar Spine - A Prospective Clinical Study]. / Einfluss der periduralen Infiltrationstherapie auf die posturale Kontrolle bei chronischem Schmerz der unteren Lendenwirbelsäule ­ eine prospektive klinische Untersuchung.

Background: Postural control, balance stability, is reduced in patients with chronic low back pain, due to pain. Epidural injection therapy (EI) is an established treatment of low back pain. The objective of our study was to investigate whether EI-induced pain relief also leads to improvement in postural control, as detected by computerised dynamic posturography (CDP). Patients and Methods: In a prospective study, 32 patients underwent CDP during and after the EI series of three injections. The main objective was to measure changes in overall stability index (OSI) in a pre- and post-intervention comparison. Results: The pain, measured by the Visual Analog Scale (VAS), decreased by 62.8 %, from 4.3 ± 2.5 points to 1.6 ± 1.9 points (p < 0.001). Likewise, the OSI improved by 21.6 %, from 3.7 ± 1.7° to 2.9 ± 1.4° (day 5) (p = 0.019). Conclusion: Pain relief induced by EI results in improved postural control, which is of importance for supportive physiotherapy and rehabilitation.

[Effects of Surgically Treated Pelvic Ring and Acetabular Fractures on Postural Control]. / Einfluss von operativ versorgten Beckenring- und Azetabulumfrakturen auf die posturale Kontrolle.

BACKGROUND: The aim of surgical treatment of pelvic ring and acetabular fractures is to allow rapid mobilisation of patients in order to restore stance and gait stability (postural control), as this significantly correlates with a positive outcome. The regulation of postural stability is mainly controlled by transmission of proprioceptive stimuli. In addition, the pelvis serves as a connection between the legs and the spine and thus is also of great importance for mechanical stabilisation. It remains unclear whether surgical treatment of pelvic ring and acetabular fractures affects the regulation of postural control. Therefore, the aim of this study was to examine the impact of surgically treated pelvic ring and acetabular fractures on postural stability by means of computerised dynamic posturography (CDP) after a mean of 35 months and to compare the results with a healthy control group. PATIENTS AND METHODS: A retrospective case control study of 38 patients with surgically treated pelvic ring and acetabular fractures and 38 healthy volunteers was carried out using CDP. The average time of follow-up was 35 (12-78) months. The most important outcome parameter in this investigation was the overall stability index (OSI). Hip joint mobility, the health-related quality of life (SF-12) and pain were supplementary outcome parameters. RESULTS: It was found that surgically treated pelvic ring and acetabular fractures had no influence on postural stability. The OSI was 2.1 ° in the patient group and 1.9 ° in the control group. There was no significant difference between the groups in hip joint mobility. A total of 52 % of patients showed no or only mild pain. Mean health-related quality of life was the same as in the total population. CONCLUSION: Surgically treated pelvic ring and acetabular fractures do not lead to deterioration in postural control in the mid term. This is of high prognostic importance for rapid mobilisation of the patients. Therefore no increase in the risk of falling is expected after successfully treatment of fractures.

[Influence of anterior cruciate reconstruction on postural stability: A pre- and postoperative comparison]. / Der Einfluss einer VKB-Plastik auf die stabile Standfähigkeit: Ein prä- und postoperativer Vergleich.

BACKGROUND: Ruptures of the anterior cruciate ligament (ACL) lead to an anteromedial rotational instability in the knee joint and, thus, to a deterioration of the patient's ability to stand (postural control). It still remains unclear whether postural control can be restored by ACL reconstruction. The aim of this study was to investigate the effect of a unilateral ACL graft on the ability to stably stand on the injured leg using computer-aided dynamic posturography (CDP); the stability indices on standing on one leg were compared pre- and postoperatively. PATIENTS AND METHODS: A total of 25 patients were studied after unilateral ACL injury and subsequent ACL reconstruction using CDP. The average time of follow-up was 608 days (range 357-821 days). The ability to stably stand on the healthy and injured leg was compared and evaluated for significant differences. RESULTS: There was a significant improvement of postural control after ACL reconstruction. The Overall Stability Index (OSI) for the leg with ACL rupture was 3.7° ± 1.6° preoperatively and 3.0° ± 1.1° postoperatively (p < 0.05). In the postoperative comparison with the healthy leg, the value in the operated leg was 3.0° ± 1.1° and the healthy leg was 3.0° ± 1.4° (p = 0.99). CONCLUSIONS: ACL replacement can be improve stability compared to the preoperative value by about 21% and even the stability level of the contralateral healthy knee can be achieved.

[Anterior cruciate ligament ruptures and postural control: correlation of functional knee scores with computerized dynamic posturography]. / Verletzungen des vorderen Kreuzbandes und posturale Kontrolle: Korrelation von Kniescores und Klinik mit der computergestützten dynamischen Posturographie.

BACKGROUND: Quantification of postural stability deficits after anterior cruciate ligament (ACL) rupture requires a complex measurement process, the so-called computerized dynamic posturography (CDP). It would be desirable if the decrease in postural stability caused by ACL rupture could be estimated by simpler functional scores. The aim of this study was therefore to review the currently available standard knee scores for the suitability to assess postural stability. PATIENTS AND METHODS: In this study 58 patients with isolated unilateral ACL rupture were examined using CDP. The questionnaires used were Tegner, WOMAC, ADL-KOS, KOS-Sport, KSS and Lysholm scores. The values obtained were compared and correlated with the results of the CDP. In addition, a subgroup analysis of copers and non-copers was performed. RESULTS: There was no significant correlation with the postural stability deficit for any of the scores examined in this study. Only the subjectively perceived instability correlated appreciably with the CDP with r=0.423. CONCLUSIONS: All currently used scores for the investigation of patients with ACL rupture cannot give any information about the ability of postural balance. If patients complain about an increased subjective feeling of instability a close observation of postural stability using CDP is inevitable.

[Necrotizing fasciitis. 2011 update]. / Nekrotisierende Fasziitis. Update 2011.

Necrotizing fasciitis belongs to a group of complicated soft tissue infections that can be even life threatening. Despite growing knowledge about its etiology, predictors, and the clinical progression, the mortality remains at a high level with 20%. A relevant reduction can be achieved only by an early diagnosis followed by consistent therapy. The clinical findings in about 75% of the cases are pain out of proportion, edema and tenderness, blisters, and erythema. It is elementary to differentiate a necrotizing or a non-necrotizing soft tissue infection early. In uncertain cases it can be necessary to perform a surgical exploration to confirm the diagnosis. The histopathologic characteristics are the fascial necrosis, vasculitis, thrombosis of perforating veins, the presence of the disease-causing bacteria as well as inflammatory cells like macrophages and polymorphonuclear granulocytes. Secondly, both the cutis and the muscle can be affected. In many cases there is a disproportion of the degree of local and systemic symptoms. Depending on the infectious agents there are two main types: type I is a polymicrobial infection and type II is a more invasive, serious, and fulminant monomicrobial infection mostly caused by group A Streptococcus pyogenes.Invasive, severe forms of streptococcal infections seem to occur more often in recent years. Multimodal and interdisciplinary therapy should be based on radical surgical débridement, systemic antibiotic therapy as well as enhanced intensive care therapy, which is sometimes combined with immunoglobulins (in streptococcal or staphylococcal infections) or hyperbaric oxygen therapy (HBOT, in clostridial infections). For wound care of extensive soft tissue defects vacuum-assisted closure has shown its benefit.

Anterior column reconstruction in thoracolumbar injuries utilizing a computer-assisted navigation system.

BACKGROUND: Discectomy, corpectomy, and resection of isolated posterior wall fragments are technically demanding steps requiring maximum surgical precision during anterior reconstruction of the unstable thoracolumbar spine. PURPOSE: This study investigates the feasibility of computer-aided guidance for these steps. It also analyzes the precision, advantages, and disadvantages of the procedure. STUDY DESIGN: Controlled clinical trial. PATIENT SAMPLE: 21 patients were included in the trial group; the control group consisted of 10 patients. OUTCOME MEASURES: Total time for surgery was noted. To assess surgical precision, decentralization of the cage was measured in postoperative X-rays. Additionally, parallel alignment of vertebral body endplates with the cage was evaluated in postoperative CT scans. METHODS: Vertebral body fractures of the thoracolumbar spine addressed by disc-/corpectomy and subsequent cage interposition for anterior reconstruction were included. All surgical steps were performed under endoscopic assistance. In the trial group, disc- and corpectomy were performed under computer-aided guidance; in the control group, no computer navigation was utilized. In cases of initial neurological deficit after trauma, the patients underwent emergency laminectomy during the initial posterior stabilization procedure. During the second-stage anterior procedure, resection of the posterior wall fragment with the aid of computer-aided navigation was performed. RESULTS: Fractures were localized between Th9 and L1 in the trial group, and Th10 and L1 in the control group. Time for surgery was significantly shorter in the control group: 1.7 h ± 0.5, as opposed to 3.8 h ± 1.0 in the trial group (p < 0.0005). In contrast, data on surgical precision did not show statistically significant differences between both groups for either decentralization or parallel endplate alignment of cages. Remarkably, we noted two cases of subsidence in bilevel cages in the control group, whereas this was only noted in one case in the trial group. However, this difference was not statistically significant. There were five patients with initial neurological deficits. At the time of follow-up, the neurological statuses of all five had improved by at least one Frankel grade. CONCLUSIONS: Computer-aided guidance in anterior reconstruction of the thoracolumbar spine is a technically feasible option that may aid in the performance of disc- and corpectomy, as well as the resection of isolated posterior wall fragments in cases with initial neurological compromise. However, total time for surgery is significantly prolongated by this technique. There were no differences in the precision of cage positioning between groups. However, during discectomy, the use of computer navigation may aid in the protection of adjacent endplates, as there was a trend towards fewer cases with cage subsidence in the navigated group.

[Are there therapy algorithms in isolated and combined atlas fractures?]. / Gibt es Therapiealgorithmen bei isolierten und kombinierten Atlas-Frakturen?

AIM: Injuries of the atlas are always a challenge in diagnostics and therapy. Different clinical manifestations, inconspicuous neurological results, uncertain findings of radiological diagnostics and possible accompanying injuries require individual therapeutic concepts. METHODS: Patients with injuries of C1 and C2 seen between 2001-2007 were evaluated and especially the morbidity and treatment of the C1-injured patients were verified. To systematise the injuries, a subdivision in isolated and combined trauma took place. Furthermore, the post-traumatic as well as post-therapeutic accompanying neurological deficits were evaluated. RESULTS: Altogether 121 fractures/injuries of the upper cervical spine (C1/C2) were counted, 22 (18.2 %) concerning the atlas. There were 11 fractures of type Gehweiler I, 9 of type III and 1 each of types II and IV. Isolated fractures of type I (5/11) were treated conservatively, combined injuries (6/11), depending on the stability and location of the attendant injuries, were treated with semi-rigid collars, anterior or posterior fusions. Stable fractures of type III (2/9) were primarily treated in Halo extension. Because of an attending dens fracture type Anderson II in 1 case, a spondylodesis of the dens was additionally performed in the conservative treatment of the atlas. The therapy of isolated unstable atlas fractures of type III (4/9) ranged, depending on the general conditions, from Halo extension, transoral C1 stabilisation, anterior transarticular C1/C2 fusion to posterior occipitocervical fusions. The therapeutic regime of combined unstable type III injuries (2/9) depended on the additional trauma: anterior fusion in C6/7 luxation fracture combined with Halo extension for C1, posterior C0/C3 fusion in unstable dens fractures of type Anderson II. CONCLUSION: The therapy for atlas fractures orientates on the type of the C1 fracture, the accompanying injuries and the general condition of the patient. Isolated stable C1 fractures without dislocation can be treated conservatively (cervical collar), unstable fractures, depending on the general condition, should be referred to surgical therapy or halo extension. In combined atlas fractures the strategy of treatment has to take the stability of the C1 fractures into consideration, but also the additional injuries of the rest of the cervical spine and the attendant circumstances.

[Additional treatment in chronic pain syndrome due to hip and knee arthritis with the selective serotonin reuptake inhibitor fluvoxamine (Fevarin]. / Eine additive Therapie chronischer Schmerzen bei fortgeschrittener Gon-/Coxarthrose mit dem selektiven Serotonin-Reuptake-Hemmer Fluvoxamin (Fevarin).

OBJECTIVE: The aim of this study was to investigate the effectiveness and safety of the selective serotonin reuptake inhibitor fluvoxamine (Flevarin) in patients with a chronic pain syndrome due to hip and knee arthritis. METHODS: We prospectively investigated 60 patients in a single-centre double-blind study. The group was divided into two groups (M1 fluvoxamine; M2 placebo) each containing 30 patients, age ranging from 30 to 80 years. During treatment results were evaluated using several scales once at the beginning (V1) followed by weekly evaluations (V1-V8) and one final investigation at the end of treatment (V9). The investigated medication consisted of 50-150 mg fluvoxamine. In addition other drugs such as NSAID were administered (diclofenac, piroxicam, ibuprofen). RESULTS: Both groups (M1 and M2) showed a reduction of pain during treatment using the visual analogue scale (VAS). However, no statistical difference was found between both groups concerning pain reduction at any time. A significant pain relief was monitored in the patients of the M1 group towards the end of treatment. Concerning the daily impairment because of pain measured by the Griss scale an improvement was seen in 70 % of the patients receiving fluvoxamine versus 44 % in patients receiving placebo. Additionally, an improvement in the M1 group was seen in the WOMAC scale and in factors such as pain, stiffness and mobility compared to the M2 group. Using the CGI scale, 56.6 % of the M1 group compared to 37.9 % of the M2 group were stating that their overall status had improved "much" or "very much" at the end of the treatment (V9). A depression had been excluded in all patients. No statistical differences were seen in the Bf scale (von Zerssen) during all evaluations (V1 to V9). During the whole study 127 side effects were registered in 49 patients. None of the 5 severe events were related to the investigated drug. CONCLUSION: Considering the good effects in combination with very few side effects, a positive cost-effectiveness relation for the usage of fluvoxamine can be stated in patients with chronic pain syndrome due to hip and knee arthritis.

[Therapeutic efficiency in multisegmental fusions of the lumbar spine]. / Therapeutische Effizienz langstreckiger Fusionen im Bereich der LWS.

AIM: The aim of this study was to evaluate of the efficiency of an internal fixateur used since 1998 in multisegmental spondylodesis of the lumbar spine. METHOD: The prospective study included 105 patients with degenerative changes or instabilities of the lumbar spine, who underwent an anterior and posterior stabilisation of more than two segments. The minimum period of follow-up was more than 6 months. There were several objective scores used for the evaluation of the efficiency (Oswestry score/visual analogue scale [VAS]). In addition, the quality of the new internal implant was assessed concerning the rate of loosening and failure of the implant. This new internal fixateur, produced as a titanium alloy, consists of pedicle screws and longitudinal rods with 5 mm diameter and connection elements. Upon pulling the nut a square stabilised situation is created. Altogether the three-segmental stabilisations predominated (n=77), 23 patients received a four-segmental, four patients a five-segmental stabilisation and one received a stabilisation of six levels, mainly involving the segments L3/4 to L5/S1. Because of severe deformities in 14 cases the pedicle screws were applied by computer-assisted navigation (Navitrak). RESULTS: In 12 patients (11.4%) radiological signs of loosening of the inserted pedicle screws in the vertebra were diagnosed. The radiological analysis resulted in pseudarthrosis of 4 (1.2%) of the 349 amalgamated segments. There were no cases of material failure. The average value of the pain score preoperatively (VAS) was 7.7 (5-10, SA 1.3) and postoperatively 4.6 (1-10, SA 1.8). With regard to the Oswestry disability index the preoperative average value amounted to 51.9% (30-91, SA 11.8) and postoperatively 35% (12-74, SA 11.8). In all 98 (93.3%) patients were satisfied, 7 (6.7%) patients reported a decline of the subjective outcome. CONCLUSION: This system achieved a high degree of patient satisfaction and showed a low rate of pseudarthrosis. Furthermore, it can be inserted for short and long fusions, as well in deformities.