[Artificial discs: review, current status, outlook]. / Bandscheibenprothesen: Rückblick, Augenblick, Ausblick.

AIM: This paper gives an overview of the current status of artificial discs for the lumbar spine. METHODS: Recent publications and overviews in the literature with pro and contra opinions and the latest procedure of FDA approval are presented and discussed. Despite arguments to the contrary, an FDA panel is in favour of the premarket approval application for the Charité artificial disc because of good late follow-up results. Other lumbar artificial discs will follow. RESULTS: Follow-up studies only exist for the Charité and Prodisc endoprotheses. The results are comparable to those of lumbar fusion. However, randomized controlled studies are still missing. CONCLUSION: Proponents for lumbar artificial discs stand against the criticism of an unpredictable treatment for a condition that cannot be diagnosed with any precision. The current model should be a controlled indication with second opinions followed by professional surgery in spine centers.

[Effects of lumbar spinal nerve analgesia on the cardiovascular system]. / Auswirkungen der lumbalen Spinalnervenanalgesie (LSPA) auf das Herz-Kreislauf-System.

AIM: The frequency of cardiovascular adverse effects of lumbar paravertebral nerve root infiltration was investigated. METHOD: 117 patients with sciatic pain were included prospectively. 60 % of these suffered from known cardiovascular diseases. In 50 patients, cardiac rhythm was investigated by Holter monitoring. In 100 patients blood pressure, heart rate, respiratory rate and oxygen saturation were registered continuously from 5 minutes before to 15 minutes after the administration of a paravertebral nerve root infiltration by means of a non-invasive monitoring system. RESULTS: A minor rise in systolic and diastolic blood pressure, heart rate and respiratory rate as well as a normalization of these parameters after the nerve root infiltration, were found. These findings were similar for patients with and without pre-existing cardiovascular diseases. No relevant cardiac arrhythmias could be determined. 5 of the 117 patients suffered from presyncope after the nerve root infiltration. These individuals were significantly (p = 0.002) younger than those without presyncope (32.4 +/- 9.3 vs. 55.8 +/- 14.6 years). Presyncope was more frequent during the first treatment with lumbar paravertebral nerve root infiltration in comparison to repeated application of this therapy [4/27 (14.8 %) vs. 1/90 (1.1 %), p = 0.003]. 80 % of the patients who had experienced a presyncope reported a history of similar events. CONCLUSION: According to our findings, cardiovascular monitoring for lumbar paravertebral nerve root infiltrations in the treatment of sciatica does not appear to be required. Patients with a presyncope seem to be characterized by age, first treatment and a history of (pre-)syncopes. In these cases, intravenous fluid substitution might be of help in counteracting vasovagal circulatory reactions.

[Mid-term clinical results of in-patient conservative treatment of cervicobrachialgia syndromes]. / Mittelfristige klinische Ergebnisse der stationären konservativen Therapie des Zervikobrachialgie-Syndroms.

AIM: The aim of this study was to evaluate the mid-term results of an in-patient conservative therapy regimen for discogenic cervicobrachialgia. METHODS: A retrospective follow-up of 100 patients after an average of 4.01 years with clinical examination and a questionnaire was performed. RESULTS: The subjective outcome rating for pain on a scale from 0 (pain-free) to 10 (maximum imaginable pain) was reduced from 7.91 at beginning of the therapy to 3.19 at the end of the therapy and to 1.5 at follow-up (p < 0.005). Duration of pain, reductions of motion and palsy improved significantly. The patients' appraisal of required surgical therapy could be reduced from 26 % at beginning to 2 % at the end of the therapy. CONCLUSION: The intensive conservative in-patient treatment for discogenic cervicobrachialgia shows a high satisfaction of the treated patients even after a follow-up of four years. The natural course of the disease shows a rapid and stable remission after wearing off the acute or subacute complaints.

[Osteomyelitis after endoprostheses]. / Osteomyelitis nach Endoprothesen.

Today over 170,000 total hip arthroplasties and about 70,000 total knee arthroplasties are performed in Germany. An overall infection rate of 0.5-1.4% is reported in the literature. This means that 800-1700 infections after total hip arthroplasty and 300-850 infections after total knee arthroplasty can occur. The surgical treatment of early or late infections after arthroplasty of the hip or knee needs different intervention. Depending on when the infection develops, a simple Débridement, an allinone exchange arthroplasty, or the explantation of the endoprosthesis with implantation of a spacer followed by the reimplantation of a new prosthesis must be performed. The first hint of postoperative infection is the increase of the C-reactive protein. By correct treatment of the postoperative wound the first sign of an infection can be detected early.

[Computer-assisted navigated cup placement in primary and secondary dysplastic hips]. / Computerassistierte Hüftpfannennavigation bei primär- und sekundär dysplastischen Ausgangssituationen.

AIM: The positioning of an acetabular implant has great influence on the range of motion as well as the charger of dislocation of total hip arthroplasty. Using modern CAS systems the reproduction of the cup position after three-dimensional planning based on computed tomography is possible. We investigated the reliability of the position of the acetabular implant in primary and secondary dysplastic cases. METHOD: Within a prospective randomised study in a total of 100 hip replacements with postoperatively controlled cup position using a computed tomography, we reinvestigated especially the 18 dysplastic and two secondary dysplastic cases. RESULTS: In the dysplastic cases we could realise nearly the same anteversion angles (22.4 degrees to 21.5 degrees) with a bigger standard deviation (+/- 7.68 degrees to +/- 7.29) than in the normal collective. Even the inclination angles (44.5 degrees +/- 5.47 degrees) could be realized nearly the same as in the normal cases (42.3 degrees +/- 4.31 degrees). The depth of the cup implantation could be realised in 15 of 18 cases. CONCLUSION: The CAS system is helpful even in dysplastic cases. The advantage of three-dimensional preoperative CT-based planning is apparent. The surgeon is not able to plan and realise the ideal cup position in some individual.

Five-year results from chemonucleolysis with chymopapain or collagenase: a prospective randomized study.

STUDY DESIGN: A 5-year clinical follow-up assessment of a prospective randomized study of chemonucleolysis using chymopapain (4000 IU) or collagenase (400 ABC units) was performed. SUMMARY OF BACKGROUND DATA: Intradiscal therapy can be performed for patients with contained discs by chemonucleolysis, percutaneous discectomy, or laser ablation. The oldest intradiscal therapy is chemonucleolysis with chymopapain. OBJECTIVE: The purpose of this study was to compare prospectively the efficacy of chymopapain and collagenase for intradiscal injection. METHODS: In this study, 100 patients with indication for intradiscal therapy were prospectively randomized to treatment with either chymopapain or collagenase. All the injections were performed by the double-needle technique with the patient under general anesthesia. The mean age of the patients was 35.5 years in the chymopapain group and 38 years in the collagenase group. An equal number of injections was performed at L4-L5 and L5-S1. RESULTS: After 5 years, good and excellent results were observed in 72% of the chymopapain group and 52% of the collagenase group when the surgically treated and lost patients were graded as poor. Using a scale of 0 (no pain) to 10 (intractable pain), the pain level dropped from 8.5 to 0.7 in the chymopapain group and from 8.6 to 0.9 in the collagenase group. Microdiscectomy at the injected level was required for 23 patients (14 in the collagenase group and 9 in the chymopapain group). CONCLUSIONS: After 5 years, no deterioration had occurred, as compared with the 1-year follow-up assessment. Chymopapain has proved to be safe, with one minor anaphylactic reaction, and effective even over the long term. Collagenase may need further study and cannot be recommended at this time.

Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis--a matched-pair analysis of 100 patients.

Conservative or operative treatment for rotator cuff calcifying tendinitis was investigated in 100 patients in a matched-pair analysis. They were examined clinically and ultrasonographically 35-60 months after the initial visit. The mean Patte score was 91.8 for the patients who underwent surgical treatment and 81 for the ones who received conservative therapy (p < 0.004), while the age-related Constant-score was 103.4 and 95, respectively. Ultrasonography showed 28% calcifications in the surgical group, 18% newly formed and 10% that did not resolve after surgery. In the conservatively treated group, 33% calcifications were seen, of which 67% resolved. The number of rotator cuff ruptures was significantly higher in the conservative group. In the surgical group, 2% of partial tears and in the conservative group 5% of partial and 4% of complete cuff ruptures were found. Conservative treatment for calcifying tendinitis leads to less favourable pain results in the long term than surgical treatment. Surgery shortens the painful period and may reduce the number of future rotator cuff ruptures. Finally, the subjective functional outcome is significantly better after surgery.

[A prospective double blind study of cervical nerve infiltration with isotonic saline and local anaesthetic]. / Isotone Kochsalzlösung gegen Lokalanästhetika. Prospektiv randomisierte Doppelblindstudie bei zervikalen Spinalnervenanalgesie.

PURPOSE OF THE STUDY: Aim of this investigation was the examination of the therapeutic effect of cervical nerve infiltration with mepivacaine in comparison to local applications of isotonic sodium chlorid solution in a prospective randomised double blind study. METHODS: 57 patients with cervicocephalgia or cervicobrachialgia were injected daily with mepivacaine ( n=28) or physiological sodium chlorid solution ( n=29). The success was judged through the blinded patients and blinded therapists first after three days of treatment. If no improvement occurred a single injection of mepivacaine and triamcinolonacetonid was given. This injection could be repeated if required. At the end of the inpatient treatment, after a mean of 14 days, the patients assessed the treatment according to a scale of 1-4 (painfree - no improvement). RESULTS: The average therapeutic effect, in the subjective appraisal of 1-4 by the patients, was 2.15 in the mepivacaine-group and 2.54 in the sodium chlorid - group. In the mepivacaine-group no pain (note 1) was achieved two times and 21 times a clear improvement (note 2), while in the sodium chlorid - group 18 times a clear improvement was achieved and never freedom of pain ( p<0,038). In the mepivacaine-group twice a steroidinjection was required, while in the sodium chlorid - group this was necessary in 16 cases ( p<0,01). CONCLUSION: Cervical injections with mepivacaine improve the subjective pain perception in cervicocephalgia and cervicobrachialgia significantly better than isotonic sodium chlorid - solution in short term results and can therefore be prefered. After an inpatient treatment good and excellent subjective results could be achieved in a high percentage.

[Intermediate-term follow-up of surgically managed tendinosis calcarea (calcifying subacromion syndrome--SAS) of the shoulder joint]. / Mittelfristige Nachuntersuchungsergebnisse der operativ versorgten Tendinosis calcarea (kalzifizierendes Subakromialsyndrom-SAS) des Schultergelenkes.

PURPOSE: Investigation of clinical und ultrasonographical results after operatively treated calcifying tendinitis. METHODS: 131 patients with calcifying tendinitis were treated by surgical decompression and, if necessary and possible, calcific deposit removal. 93% of these patients were clinically and ultrasonographically examined after an average time of 4 years and 5 months. RESULTS: Pain rating on a visual analogue scale 0-no pain to 10-maximum pain was 8.7 before surgery and 1.4 at follow-up. 88% of the patients rated the operation excellent or good. The Constant Score results corresponded to the average results of a normal population (100.3). At the time of examination in 16.4% of the cases new calcific deposits could be discovered. CONCLUSION: According to the clinical results operative treatment shows good and excellent results in a high degree even after unsuccessful non-operative therapy.