Longitudinal Assessment of Hair Cortisol as a Predictor of Psychological Symptoms During COVID-19.

BACKGROUND: There is a lack of evidence regarding enduring psychoneuroendocrine changes following an initial traumatic event, particular in the presence of an ongoing stressor. The coronavirus pandemic presents an opportunity to explore this matter. Consequently, the purpose of the present study was to investigate the impact of the ongoing pandemic (2021) on individuals, who experienced a first-time motor vehicle crash (MVC) at least 6 years earlier. To this end, we hypothesized that hair cortisol concentrations (HCC) following a first-time traumatic event positively predict symptoms of depression. METHOD: We investigated N = 69 individuals (18 - 65 yrs.), who were victims of a MVC during 2010 - 2014. Hair strands were collected 10 days (t1) and 3 months after the MVC (t2), as well during the pandemic in 2021 (t3). To assess symptoms of depression, the participants filled out the Beck Depression Inventory at t1 - t3 and were additionally interviewed (Structured Clinical Interview for DSM-IV Axis I) at t1 and t2. Exclusion criteria conveyed a lifetime or acute mental disorder (incl. past trauma exposure). RESULTS: Elevated pre-pandemic HCC following adversity (i.e., MVC) significantly predicted symptoms of depression in adults during the coronavirus pandemic (BDI: ß =.44, p =.010, R2 =.20), even after controlling for confounders. HCC significantly decreased over time, while in average psychological symptoms remained consistent. CONCLUSION: Cortisol dysregulation in the past presents an enduring vulnerability to ongoing stress. In this regard, vulnerable groups may benefit from preventive measures. This finding validates the predictive power of HCC and extended past evidence in this regard, at the same time reinforcing the concept of the diathesis-stress model.

[Atypical femoral fracture : Pitfalls in surgical treatment]. / Atypische Femurfraktur : Fallstricke bei der chirurgischen Versorgung.

Atypical femoral fractures are a very rare complication after treatment with bisphosphonates. This case report describes the diagnostic criteria and some particularities of the surgical treatment. Atypical femoral fractures are typically stabilized with intramedullary nails but some pitfalls in surgical treatment, e.g. the choice of implant, have to be considered. Basically, these fractures can be treated using conventional intramedullary nails, which, however, must be used by being adapted depending on the morphology of the femur. The fact that atypical femoral fractures can occur under bisphosphonate treatment should in no way influence the indications for starting anti-osteoporotic treatment.

[Patient-centered perioperative vigilance: perioperative process quality, effectiveness of pain treatment and mobilization progress after implementation of a treatment bundle for total knee endoprosthesis]. / Patient*innenzentrierte perioperative Versorgung: perioperative Prozessqualität, Effektivität von Schmerztherapie und Mobilisationsfortschritt nach Implementation eines Maßnahmenbündels bei Knietotalendoprothese.

BACKGROUND: The perioperative surgical home is a patient-centered, team-based model of care developed in the USA to coordinate diagnosis, treatment and follow-up; however, due to different healthcare systems, scientific findings in the USA cannot be simply transferred to Germany. OBJECTIVE: This preliminary study was carried out to evaluate the effects of a new interdisciplinary treatment bundle (patient-centered perioperative vigilance, PPV) in a German university hospital. MATERIAL AND METHODS: After IRB approval and written informed consent, 34 patients (PPV group) undergoing elective endoprosthetic surgery were enrolled after introduction of the PPV bundle (1. preoperative patient education, 2. specific surgical technique, 3. specific anesthesia technique, 4. start of mobilization on day of operation) and compared to historic matched pairs (HMP) for age cohort, ASA-PS, body mass index, and sex. We hypothesized that PPV shortens induction time (primary outcome). Secondary outcomes were length of hospital stay (LOS), resting pain and pain with movement on postoperative day 1 and mobilization progress on postoperative days 1, 3 and 6. Groups were compared with Wilcoxon-Mann-Whitney test for noninferiority. In the case of noninferiority, a Wilcoxon-Whitney-Mann test for superiority was additionally applied. RESULTS: The median anesthesia induction time was 13.5 min for PPV and 60 min for HMP (p < 0.0001). The LOS was 8 days for PPV and 12 days for HMP (p < 0.0001). Resting pain on postoperative day 1 was 20 for PPV (30 for HMP). Pain with movement was identical (median 40). Mobilization progress was better for PPV on days 1, 3 and 6 (p < 0.0001 for each day). CONCLUSION: The concept of patient-centered perioperative vigilance (PPV) shortens induction time and hospital length of stay. Mobilization improves with PPV on day 1. Higher pain scores in PPV seem to be clinically insignificant, which warrants further study.

[MALDI mass spectrometry of the meniscus. Objectification of morphological findings]. / MALDI-Massenspektrometrie am Meniskus. Objektivierung morphologischer Befunde.

BACKGROUND: The classification of meniscal lesions requires correlation with clinical data. For the standardization of histopathology reports a discrimination between normal, low-grade lesions and high-grade lesions is feasible. This classification can be further specified using other methods. MATERIAL AND METHODS: Formalin-fixed, paraffin-embedded specimens of meniscal tissue from 68 patients were analyzed by matrix-assisted laser desorption ionization (MALDI) imaging. RESULTS: The classification of meniscal lesions and differentiation between low-grade and high-grade and acute versus non-acute degeneration is possible by determination of the differential expression of mass-to-charge ratios by statistical comparisons using the P-value from combined Wilcoxon and Kruskal-Wallis (PWKW) tests and a predefined average two-fold difference in intensity. CONCLUSION: The concept of a "meniscus report" is introduced for documentation of meniscus tissue specimens integrating histological, histochemical and proteomic data, thereby specifying the degree of degeneration and the assessment of acute or non-acute lesions. Mass spectrometry contributes to an objective histopathology report. An advisory opinion should always be based on close correlation of clinical and morphological evaluations.

[Minimally invasive cement augmentation of osteoporotic vertebral compression fractures with the new radiofrequency kyphoplasty]. / Minimal-invasive Zementaugmentation von osteoporotischen Wirbelkörperfrakturen mit der neuen Radiofrequenz-Kyphoplastie.

OBJECTIVE: Minimally invasive cement augmentation of painful osteoporotic vertebral compression fractures in elderly patients. INDICATIONS: Painful osteoporotic vertebral compression fractures in elderly patients (> 65 years of age) after conservative therapy failure. Painful aggressive primary tumors of the spine or osteolytic metastases to the spine with high risk of vertebral fracture in the palliative care setting. CONTRAINDICATIONS: General contraindications for surgical interventions. Local soft-tissue infection. Osteomyelitis, discitis or systemic infection. Coagulopathy refractory to treatment or bleeding diathesis. Asymptomatic vertebral compression fractures. Burst of the posterior vertebral column with high degree of spinal canal stenosis. Primary or metastatic spinal tumors with epidural growth. SURGICAL TECHNIQUE: Prone position on a radiolucent operating table. Fluoroscopic localization of the fractured vertebra using two conventional C-arm devices (anteroposterior and lateral views). Fluoroscopic localization of the fractured vertebra using two conventional C-arm devices (anteroposterior and lateral views). An introducer is inserted through a small skin incision into the pedicle under fluoroscopic guidance. To create a site- and size-specific three-dimensional cavity in the center of the fractured vertebra, the navigational VertecoR™ MidLine Osteotome was inserted through the correctly sited introducer and guided fluoroscopically. As the MidLine Osteotome allows angulation of the tip up to 90° by rotating the handle, a cavity over the midline of the vertebral body can mainly be created through one pedicle. The radiofrequency activated cohesive ultrahigh viscosity PMMA cement (ER(2) bone cement) is injected stepwise on demand by remote control under continuous pressure from the hydraulic assembly into the vertebral body. POSTOPERATIVE MANAGEMENT: Bed rest for 6 h postoperatively in supine position. Early mobilization without a corset on the day of surgery. Specific back and abdominal exercises that strengthen the back and abdominal muscles. Pain dependent increase of weight bearing. Continue osteoporosis therapy and start specific drug therapy according to the local guidlines if necessary. RESULTS: In all, 44 patients (29 women, 15 men) with a mean age of 73.5 years with a total of 62 painful osteoporotic vertebral fractures were treated with RF kyphoplasty from May 2009 until July 2010, and followed over a period of 12 months. The mean operating time per patient was 36.2 min, the operating time per vertebra was 25.7 min. All the patients studied experienced an early and persistent significant pain relief even 12 months after therapy (8 ± 1.4 vs. 2.7 ± 1.9) according to the visual analogue pain scale. According to the Oswestry Disability Index (ODI) as a disease-specific disability measure all the patients improved significantly (p < 0.001) in the level of disability after operative treatment (56.2 ± 18.8 vs. 34.5 ± 16.6). Cement leakage was detected in 17 out of 62 (27.4 %) augmented vertebrae, whereas all the patients with cement leakage remained asymptomatic. One patient had subsequent vertebral fractures after a period of 6 months.

[Minor amputations - a maxi task. Part 1: From the principles to transmetatarsal amputation]. / Minor-Amputationen - eine "Maxi-Aufgabe". Teil 1: Von den Grundlagen bis zur transmetatarsalen Amputation.

A threatening major amputation represents a fateful turning point for diabetics. This occurs in 50% of cases of amputations in diabetics. This increases the demand for another therapeutic route not only because of the limitations in quality of life but also due to substantially higher mortality. Even if an osteomyelitic ischemic situation is often present specialized centers have succeeded in substantially reducing the rate of major amputations in such patients. The term "minor amputation" commonly used in vascular surgery is not uniformly understood. Following the "vascular surgery working model" developed by Rümenapf, the significance of "minor amputations" for retention of extremities and the associated controversies have been shown. "Minor amputations" therefore represent a maxi-task if patients undergoing such a procedure are to be timely and competently treated. The necessary interdisciplinary cooperation with other specialists should in the future also include orthopedic surgeons.

[Minor amputations: a maxi task : Part 2: From transmetatarsal amputation to hindfoot amputation]. / Minor-Amputationen - eine "Maxi-Aufgabe" : Teil 2: Von der transmetatarsalen Amputation bis zur Rückfußamputation.

The definitive aim of a minor amputation is limited resection with retention of feet and legs resulting in a completely loadable extremity, in contrast to the lower leg stump. A shift in the amputation level in the sense of a shortening is inevitably accompanied by a reduction in the stand area, an increase in axial pressure and a disruption of muscle equilibrium in the extent of movement of the rest of the foot. This knowledge forms the central issue for further treatment of minor amputations in addition to the subtle treatment of the skin of the sole for coverage of a tension-free tip of the stump. Advantageous are longitudinal partial amputations of the forefoot and midfoot.

Bone mineral density and vitamin D status in female and male patients with osteoarthritis of the knee or hip.

OBJECTIVE: Osteoporosis (OP), osteoarthritis (OA) and vitamin D deficiency are age-related disorders. We investigated the association between bone mineral density (BMD), vitamin D and OA in patients undergoing total hip or knee replacements. METHOD: In total, 82 women and 35 men with mean ages of 70 and 68 years, respectively, were recruited for the study. The BMD of the lumbar spine and the proximal femur were measured by dual-energy X-ray absorptiometry. The vitamin D status was assessed by 25(OH)D levels, with a cut-off of

CT-guided vertebroplasty in osteoprotic vertebral fractures: incidence of secondary fractures and impact of intradiscal cement leakages during follow-up.

The purpose of this study was to analyse the number and types of secondary fractures, and to investigate the impact of intradiscal cement leaks for adjacent vertebral fractures. Patients with osteoporotic vertebral fractures were treated with vertebroplasty. Results were documented and prospectively followed by means of computed tomography (CT) and magnetic resonance imaging. The frequency and the types of cement leakages were analysed from multiplanar CT images and secondary fractures were characterised as follows: (1) adjacent fracture in the immediate vicinity of an augmented vertebra; (2) sandwich fracture, fracture of an untreated vertebra between two vertebrae that had been previously augmented, and (3) distant fractures not in the vicinity of augmented vertebrae. A total of 385 osteoporotic vertebral fractures were treated in 191 patients (61 men, 130 women, age 70.7 +/- 9.7 years). The overall rate of cement leaks was 55.6%, including all leaks detectable by CT. Intradiscal leaks through the upper, the lower, and both endplates occurred in 18.2%, 6.8%, and 2.6%, respectively. In 39 patients (20.4%), a total of 72 secondary fractures occurred: 30 adjacent fractures in 23 patients (12.0%) with a time to fracture of 2 months [median; 1.0/4.0 months, first/third quartile (Q1/Q3)]; 11 secondary sandwich fractures in 11 patients (5.8%) after 1.5 months (median; 0.25/7.5 months, Q1/Q3); and 31 distant fractures in 20 patients (10.5%) after 5 months (median; 2.0/8.0 months, Q1/Q3). Ten of 30 adjacent fractures occurred in the presence of pre-existing intradiscal cement leaks and 20 where there was no leakage. Six of 11 sandwich fractures occurred in the presence of intradiscal leaks (five leaks in both adjacent disc spaces, one leak in the lower disc space) and five where there was no leakage. The rate of secondary adjacent and non-adjacent fractures is quite similar and there is no specific impact of intradiscal leakages on the occurrence of adjacent secondary fractures. Adjacent fractures occur sooner than distant secondary fractures. Sandwich fractures are associated with specific biomechanical conditions, with a 37.9% fracture rate in sandwich constellations.

[Diagnosis and therapy of osteogenesis imperfecta]. / Diagnostik und Therapie der Osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a congenital connective tissue disorder with an incidence of up to 1:30,000. Patients suffer from deformities and fractures, and many of them never reach ambulation. The therapy consists of conservative, medicamentous and operative procedures that are described in this article.

[Hyperphosphatasia and hypophosphatasia in childhood]. / Hyperphosphatasie und Hypophosphatasie im Kindesalter.

The treatment of phosphate diabetes and hyperphosphatasia requires an interdisciplinary therapy concept between paediatricians and orthopaedic surgeons. The surgical challenge is the correction of the multiplanar bending deformities and the pathological fractures. Different techniques are discussed in the literature without an outstanding recommendation for a special approach. This contribution gives an overview of the published methods and discusses various surgical concepts in view of our own clinical experience.

[Surgical treatment concepts for femoral head necrosis]. / Operative Therapiekonzepte der Hüftkopfnekrose.

Osteonecrosis of the femoral head eventually leads to the destruction of the femoral head, if it remains untreated. Depending on the localization and the extent of the osteonecrosis several surgical treatment options can be considered. For early small and medium-sized pre-collapse lesions, core decompression is the treatment of choice. Osteotomies and bone grafting procedures can be utilized in medium pre-collapse, as well as in small post-collapse lesions. Cartilage lesions of the femoral head allow limited femoral resurfacing arthroplasty. If the acetabulum reveals cartilage lesions, a total hip replacement should be preformed.

[Standardised postoperative analgesic system in orthopaedic surgery]. / Standardisiertes postoperatives Schmerztherapieschema in der Orthopädie.

In order to treat patients with postoperative acute pain effectively, we have developed a standardised algorithm for analgesia. This process includes three levels and the appropriate supply of medication. The therapy level is defined based on the scale of the operation. Accordingly, the prescription and handling of the pain medication is simplified for the attending physician and nurses. The pain level has to be measured by the nursing staff sing a visual analogue scale (VAS). Thus, the efficiency of the analgesics will be continuously evaluated and controlled. The standardised supply medication can be applied in those cases with pain levels > or = 4 (VAS). It is possible to up- or down-grade the level within the system depending on the actual pain experienced by the patient. With this structured pain therapy algorithm we now have a guideline for the consistent postoperative analgesic treatment of patients.

Correlation of quantitative histopathological morphology and quantitative radiological analysis during aseptic loosening of hip endoprostheses.

OBJECTIVE: Aseptic hip prosthesis loosening is the most important long-term complication in total hip arthroplasty. Polyethylene (PE) wear is the dominant etiologic factor in aseptic loosening, which together with other factors induces mechanisms resulting in bone loss, and finally in implant loosening. The single-shot radiograph analysis (EBRA, abbreviation for the German term ""Einzel-Bild-Röntgenanalyse"") is a computerized method for early radiological prediction of aseptic loosening. In this study, EBRA parameters were correlated with histomorphological parameters of the periprosthetic membrane. METHODS: Periprosthetic membranes obtained from 19 patients during revision surgery of loosened ABG I-type total hip pros-theses were analyzed histologically and morphometrically. The pre-existing EBRA parameters, the thickness of the PE debris lay-er and the dimension of inclination and anteversion, were compared with the density of macrophages and giant cells. Addi-tionally, the semiquantitatively determined density of lymphocytes, plasma cells, giant cells and the size of the necrotic areas were correlated with the EBRA results. RESULTS: All periprosthetic membranes were classified as debris-induced type membranes. We found a positive correlation between the number of giant cells and the thickness of the PE debris layer. There was no significant correlation between the number of macrophages or all semiquantitative parameters and EBRA parameters. The number of giant cells decreased with implant duration. CONCLUSION: The morphometrically measured number of foreign body giant cells more closely reflects the results of the EBRA. The semiquantitative estimation of giant cell density could not substitute for the morphometrical analysis. The density of macrophages, lymphocytes, plasma cells and the size of necrotic areas did not correlate with the EBRA parameters, indicating that there is no correlation with aseptic loosening.

[The common occurrence of osteoarthritis and osteoporosis and the value of markers of bone turnover]. / Das gemeinsame Auftreten von Osteoporose und Arthrose und der Nutzen der Knochenstoffwechselmarker.

OBJECTIVE: Increasing bone mineral density (BMD) has been found in several studies in patients with osteoarthritis. Therefore, many clinicians deny the simultaneous occurrence of osteoporosis (OP) and osteoarthritis (OA). Because of our clinical impression however, we suggested that we have to consider a common occurrence. Furthermore, the value of markers of bone turn over with a view to early diagnosis of OP and or as an assessment for bone metabolism in OA is still a matter debate and their clinical use has not been clearly defined in the management of the individual patient. METHOD: The BMD of the lumbar spine and the proximal femur of 119 OA patients (83 postmenopausal female patients aged 50-83 and 35 male patients aged 36-86 years) who subsequently required hip or knee replacements, but were otherwise healthy, were measured by dual energy X-ray absorption (DXA), Hologic QDR-2000. We also measured biochemical markers of bone turn over, i. e., CICP, ICTP, DPD, PTH, estrogen, testosterone, bAP, hydroxy vitamin D and the normal blood count. RESULTS: There was a high occurrence of a low BMD among the patients. A total of 28.9% of women were affected by OP and 52.9% by osteopoenie. This reflects the normal distribution of OP in the female population. Of the male patients 20% had OP and 38.8% osteopoenie. This is astonishing high. Age proved to be a significant factor in the degree of BMD. An association between disuse osteoporosis and degree of BMD in the OA affected joint could not be proven. The use of the biochemical markers for an earlier diagnosis or to assess bone metabolism in OP and OA was not possible. CONCLUSION: We can not support the hypotheses that OA prevents OP. Moreover, the occurrence of OP in our study reflected the incidence of OP in the average female and the astonishingly high incidence in the male population; however does not mean that the two conditions are mutually exclusive. We did not find that the biochemical markers of bone turn over could deliver additional information with respect to bone metabolism and an earlier diagnosis of OP.

[Osteoporosis and osteoarthritis--is there really an inverse relation?]. / Arthrose und Osteoporose -- Wirklich eine inverse Relation?

OBJECTIVE: Increasing bone mineral density (BMD) has been found in several studies in patients with osteoarthritis (OA). Therefore, the simultaneous occurrence of osteoporosis (OP) and OA is denied by many clinicians. Because of our clinical impression, however, we suggest that we have to consider a common occurrence. In the present study we have examined the relationship between osteoathritis of the knee or the hip and osteoporosis. METHOD: The BMD of the lumbar spine and the proximal femur of 117 OA patients (82 postmenopausal female patients aged 50-83 and 35 male patients aged 36-86 years) who subsequently required hip or knee replacements, but were otherwise healthy, was measured by dual-energy X-ray absorptiometry (DXA; Hologic QDR-2000). The results are given as required by the WHO and the new German guidelines of the DVO. The BMD was measured and categorised in a sex-related manner and the occurrence of disuse osteoporosis on the affected limb was examined. Furthermore, a comparison was made in the level of BMD between the OA of the involved hip or knee. RESULTS: There was a high occurrence of low BMD among the patients. 23.2 % of the women were affected by OP. This reflects the normal distribution of OP in the female population. 20 % of the male patients had occult OP. This is astonishingly high. Osteopenia was measured for 37.1 % of the male patients and 42.7 % of the female patients. Age proved to be a significant factor in the degree of BMD. Neither a disuse osteoporosis, nor a significance in the OA-affected joint to the degree of BMD, could be proven. CONCLUSION: We cannot support the hypotheses that OA prevents OP. Moreover, the occurrence of OP in our study reflected the incidence of OP in the average female and was astonishingly high in the male population; this does not support the hypothesis that the two conditions are mutually exclusive. Also a lower risk of fractures among OA patients cannot be concluded. There is current open discussion whether a known BMD should influence the decision for a cemented or an uncemented prosthesis.

Stem cell factor receptor KIT (CD117) in aseptic hip prosthesis loosening.

OBJECTIVE: This study aimed to investigate specific inflammatory pathomechanisms, i.e. the expression of the stem cell factor receptor KIT (CD117) in tissue specimens from patients with aseptic hip prosthesis loosening (AHPL) with special emphasis on colocalization with the mast cell specific marker tryptase. METHODS: Immunohistochemical analysis of CD117 was performed in tissue specimens from 10 patients with aseptically loosened acetabular components of failed non-cement total hip replacements and compared to control samples obtained at primary hip surgery (n=4). The CD117 expressing cells were characterized further with mast cell tryptase (MCT) by serial section analysis and a double staining method. CD117 and MCT expression was examined by semi-quantitative analysis. Additionally, double labeling of the CD117 or MCT expression by immunohistochemistry and of polyethylene (PE) particles by Oil Red reaction was performed. RESULTS: In AHPL, CD117 was almost exclusively detected in MCT positive cells. Co-expression tended to be highly correlated (r=0.86, p<0.01). CD117 was found mainly in two regions: first, in perivascular lymphocyte-rich areas and; secondly, near macrophages and multinucleated giant cells (MGC). PE particles were not detected in CD117 and MCT positive cells. In control samples, CD117/MCT positive cells were less frequent. CONCLUSION: This is the first report on CD117 expression in AHPL. CD117 is almost exclusively expressed in a distinct mast cell subgroup. As an important growth factor receptor, CD117 could play a major role in recruitment and activation of mast cells in AHPL. Furthermore, mast cells do not contain significant amounts of PE particles. However, it remains to be investigated whether this cell population could influence phagocytosis of PE particles. (Journal of Applied Biomaterials and Biome-chanics 2005; 3: 11-7).

[Evaluation of percutaneous vertebroplasty in osteoporotic vertebral fractures using a combination of CT fluoroscopy and conventional lateral fluoroscopy]. / Perkutane Vertebroplastie osteoporosebedingter Wirbelkörperfrakturen: Erfahrungen mit der CT-Fluoroskopie.

PURPOSE: Evaluation of vertebroplasty using a combination of CT-fluoroscopy and conventional lateral fluoroscopy in patients with osteoporotic vertebral fractures. MATERIALS AND METHODS: Fifty-eight patients (23male, 35 women, age 69.7 +/- 10.2 years) with painful osteoporotic vertebral fractures were treated with vertebroplasty in conscious sedation and local anesthesia. Spiral-CT with sagittal reconstructions of the respective vertebral bodies was used for classification of the fracture. The cannula was placed under CT-guidance in the ventral third of the respective vertebral bodies and cement instilled under CT fluoroscopy and lateral fluoroscopy. When cement migrated towards the vertebral canal, the injection was immediately stopped for 30 - 60 seconds. After polymerization in this location, the injection was continued until sufficient filling of the vertebra. Results were documented by spiral CT with sagittal reconstructions. RESULTS: A total of 123 vertebral bodies were treated, comprising 39 thoracic and 84 lumbar vertebral bodies, with a mean of 2.1 +/- 1.3 (range 1 to 6) vertebral bodies in each patient and a maximum of 3 vertebral bodies per session. All interventions were successfully completed in conscious sedation and local anesthesia. A mean volume of 5.9 +/- 0.6 ml (range 2 to 14 ml) cement was applied for each vertebra, with 79.7 % of procedures performed using a unilateral access. To achieve a sufficient cement deposit, a bilateral access was used in 20.3 %. The dorsal wall of the vertebra was included in 23.6 % of the fractures. In one case, cement migration into the spinal canal was detected, reducing the diameter of the canal by 30 %. In two other cases, cement leakage was seen at the puncture site of the vertebra (one intercostotransversally in the 10 (th) thoracic vertebra and one dorsolaterally in the 1 (st) lumbar vertebra) with retrograde cement migration through the neuroforamen into the epidural space. In one of these cases, the cannulation of the vertebra had been changed before cement application resulting in a hole in the dorsolateral vertebral wall. However, all patients were discharged without evidence of neurologic complications. Multiplanar reconstructions of CT scans were used for the detection of extraosseous cement leaks: The incidence of extraosseous cement leaks was 4.1 % in epidural veins, 6.5 % in paravertebral vessels (6 veins, 2 arteries), and 17.9 and 11.4 %, respectively, for upper or lower end plates. At discharge, 25 patients (43.1 %) were free of pain and 28 (48.3 %) significantly improved with a considerable reduction of analgetic drugs. Significant complaints persisted in 5 patients (8.6 %) with concomitant degenerative disease in four and vasculitis in one case. CONCLUSION: Percutaneous vertebroplasty is effective for stabilization and pain management of osteoporotic vertebral fractures. The procedure can be safely performed in conscious sedation and local anesthesia. Compared to conventional fluoroscopy alone, CT fluoroscopy provides an excellent additional monitoring of the procedure and probably contributes to the safety of the procedure.

Preserving the abductor mechanism in robotic THR: the influence of stem design and cutterpath.

OBJECTIVE: The tip of the greater trochanter is the attachment site for the abductor muscles of the hip joint. Its preservation in robotic and conventional THR is important for normal gait. The effect of different stem designs and robotic cutterpaths on the preservation of the trochanter tip is examined. MATERIALS AND METHODS: One anatomical stem, one straight stem, and one stem specifically designed for robotic THR were implanted virtually in CT scans of osteoarthrotic hip joints using the Torch preoperative planning unit (URS-ortho). In transverse sections of the trochanter tip, dimensions of the trochanter area removed by the milling tool were recorded for each stem design and different cutterpaths (3-axis versus 5-axis milling). RESULTS: Five-axis milling showed significantly better results than 3-axis milling. For straight stems, more bone was removed than for anatomic stems. The most favorable results were achieved with 5-axis milling and a curved stem specifically designed for robotic THR. CONCLUSIONS: The introduction of 5-axis milling in robotic THR is an improvement of the technique and makes preservation of the abductor mechanism at the tip of the greater trochanter easier for the surgeon.

[Undercutting decompression versus laminectomy. Clinical and radiological results of a prospective controlled trial]. / "Undercutting decompression" vs. Laminektomie Klinische und radiologische Ergebnisse einer prospektiv-kontrollierten Studie.

The aim of the current study was to evaluate the clinical outcome after laminectomy or undercutting decompression in patients with lumbar spinal stenosis (LSS) without apparent signs of instability. In a prospective controlled, nonrandomized trial 1 year after operation, two groups of patients were compared. Out of 85 consecutive patients, treated from 1998 to 1999 in an orthopedic university clinic for symptomatic LSS, decompression without simultaneous fusion was performed in 40 cases. In group I ( n=13) a laminectomy was done and in group II ( n=27) an undercutting of the vertebral arch and facet joints. The main outcome measure was the Oswestry Low Back Disability Score. Subjective complaints, visual analog scale (VAS), claudication distance, analgesic demands, and radiomorphometric parameters following the procedure of Dupuis and Nash/Moe at 6 and at 12 months after the operation were secondary objective criteria. One year postoperatively the main outcome measure showed no significant difference between the two groups, although group II had shown better results ( p=0.0195) 6 months postoperatively. The required analgesics could be significantly lowered in group II compared with group I at 12 months ( p=0.0011). The remaining secondary outcome measures showed no statistically significant differences. The extent of decompression in LSS without apparent instability did not influence the outcome. If there is any doubt intraoperatively about the adequate amount of decompression of the lumbar spinal canal, undercutting decompression should be extended to laminectomy without fear of consecutive segmental instability.