Development and validation of a simplified thoracolumbar spine fracture classification system.

STUDY DESIGN: Development and validation of fracture classification system. OBJECTIVE: To develop and validate a Simplified Classification System (SCS) for Thoraco-Lumbar (TL) fractures (SCS - TL fractures). SETTING: Tertiary Spinal Injuries Centre, New Delhi, India METHODS: Based on the International Spinal Cord Society Spine Trauma Study Group (ISCoS STSG, n = 23) experts' clinical consensus conducted by the senior author and on his own experience, the Denis classification for TL fractures was modified to develop a SCS-TL fractures that could guide the management. After Face and Content validation, Construct validation was done in two stages. First stage analyzed if management of 30 cases of TL fractures, as suggested by the SCS - TL fractures and ISCoS STSG (n = 9) as well as other (n = 5) experts, matched. Second stage was a one year prospective study analyzing if the management suggested matched the management actually carried out by different spine surgeons (n = 10) working at a single institution. RESULTS: In the first stage there was 100% agreement for management (conservative or surgical) as proposed by experts and that suggested by the proposed classification for TL fractures whereas for surgical approach there was 88% agreement. In the second stage, there was 100% agreement for the management as well as surgical approach as carried out at our centre and that proposed by the SCS for TL fractures. CONCLUSIONS: The proposed SCS-TL fractures helps in classifying and in decision making for management of TL fractures. The next phase of validation would involve multicentric reliability studies and prospective application of the SCS- TL fractures.

Association of clinical parameters of operatively treated thoracolumbar fractures with quality of life parameters.

PURPOSE: The intention of the current work was to assess the association between clinical parameters and seven different quality of life (QoL) instruments after surgical treatment of thoracolumbar spinal fractures after an average follow-up of 4.2 years. METHODS: The following human-related quality of life and PRO measures of 66 patients were correlated to clinical parameters such as fingertip-to-floor distance (FFD), Schober measurement, pressure and percussion pain in the lumbopelvine area (PPP), and paravertebral muscle tension: reALOS, SF-36, VAS, VAS spine score, BDI, the GBB-24, and the IES-R. RESULTS: Overall, there was a significant association between the clinical parameters of the thoracolumbar spine such as PPP, paravertebral muscle tension, FFD and Schober's sign on one side, and the seven tested instruments on the other side. CONCLUSIONS: PPP and FFD as well as a small Schober measurement are clinical parameters which significantly influence QoL after surgical treatment of thoracolumbar fractures.

The removal of Al2O3 particles from grit-blasted titanium implant surfaces: effects on biocompatibility, osseointegration and interface strength in vivo.

For the improvement of surface roughness and mechanical interlocking with bone, titanium prostheses are grit-blasted with Al(2)O(3) particles during manufacturing. Dislocated Al(2)O(3) particles are a leading cause of third-body abrasive wear in the articulation of endoprosthetic implants, resulting in inflammation, pain and ultimately aseptic loosening and implant failure. In the present study, a new treatment for the removal of residual Al(2)O(3) particles from grit-blasted, cementless titanium endoprosthetic devices was investigated in a rabbit model. The cleansing process reduces residual Al(2)O(3) particles on titanium surfaces by up to 96%. The biocompatibility of the implants secondary to treatment was examined histologically, the bone-implant contact area was quantified histomorphometrically, and interface strength was evaluated with a biomechanical push-out test. Conventional grit-blasted implants served as control. In histological and SEM analysis, the Al(2)O(3)-free implant surfaces demonstrated uncompromised biocompatibility. Histomorphometrically, Al(2)O(3)-free implants exhibited a significantly increased bone-implant contact area (p=0.016) over conventional implants between both evaluation points. In push-out testing, treated Al(2)O(3)-free implants yielded less shear resistance than conventional implants at both evaluation points (p=0.018). In conclusion, the new surface treatment effectively removes Al(2)O(3) from implant surfaces. The treated implants demonstrated uncompromised biocompatibility and bone apposition in vivo. Clinically, Al(2)O(3)-free titanium prostheses could lead to less mechanical wear of the articulating surfaces and ultimately result in less aseptic loosening and longer implant life.

Trust, social support and patient type--associations between patients perceived trust, supportive communication and patients preferences in regard to paternalism, clarification and participation of severely injured patients.

OBJECTIVE: Trust is an important aspect of physician-patient-interaction, both in terms of compliance and patient- and physician-reported outcomes. Trust-building communication is especially important in terms of severely injured patients because of severity of their injuries and frequently associated physical and psychological consequences. Patients preferences concerning medical treatment (patient type) is also regarded to be important in terms of trust. The objective of this study was to investigate the relationships between patients perceived trust, supportive communication of physicians and patient type of severely injured patients. METHODS: Seventy-one severely injured patients, who were predominantly injured in the workplace or in traffic accidents and were treated in one of four hospitals in Northrhine-Westfalia between 2001 and 2005, completed a self-administered questionnaire. "Trust in physicians_short form" (TRIP_sf) describes different aspects, such as general trust, competence of doctors and the feeling to be in good hands. "Informational support" and "emotional support" comprise verbal and non-verbal aspects, such as clear and understandable information or devotion and empathic manner. "Patient type" measures patients preferences in regard to paternalism of physician, clarification of medical facts and participation in treatment. RESULTS: Trust is strongly correlated with informational (.628**) and emotional support (.542**) and is less correlated with patients preferences of "paternalism" (.250*)", "clarification" (.438**) and participation" (.378**). Informational and emotional support are in general not significantly correlated with type of patient, all correlations were adjusted for age, gender, marital and socioeconomic status, length of hospital stay, and severity of injury. CONCLUSIONS: Trust is significantly related to patient type but more related to doctor support: the results confirm the importance of supportive communication in terms of emotional and informational support. PRACTICE IMPLICATIONS: Medical education should integrate sound knowledge about the psychosocial aspects of physician patient interaction to enable doctors to provide effective social support and to identify and consider patients preferences.

The effect of surface modification of a porous TiO2/perlite composite on the ingrowth of bone tissue in vivo.

The porous TiO2/perlite composite Ecopore is a synthetic biomaterial with possible clinical application in bone substitution. In our previous work, we demonstrated that surface modification of Ecopore with fibronectin (FN) enhanced spreading and growth of human osteoblasts in vitro. In the present study, we implanted untreated, alkaline-etched and FN-coated Ecopore cylinders into critical size defects of rabbit femora and applied pulsed polychrome sequence staining. After 6 weeks, sections of the implants were investigated via conventional and fluorescence microscopy. A partial ingrowth of bone matrix into the pore system of the Ecopore implants was observed. At the contact zones, the bone appeared to be directly connected to the implant without detectable gaps. Defect healing was complete within 6 weeks, while fibrous tissue generation or inflammation were absent in the implant modification groups, demonstrating basic Ecopore biocompatibility. The mean bone apposition rates within the implant cross-section were 4.1+/-0.6 microm/day (p<0.001) in the FN-coated group and 3.3+/-0.5 microm/day (p<0.05) in the NaOH-etched group. In both treated Ecopore modification groups, the apposition rates were significantly higher than in the non-modified control (2.9+/-0.6 microm/day), indicating bone growth stimulation by pre-treatment. Energy-dispersive X-ray analysis confirmed that significantly more bone tissue was formed inside the pores of the FN-coated implants compared to the unmodified control. The cross-sectional areas identified as ingrown bone amounted to 18.5+/-6.1% (p<0.05) in the FN group, 13.4+/-5.1% (p>0.05) in the NaOH-etched group and 10.2+/-5.5% in the unmodified group. In summary, we conclude that bone tissue tolerates Ecopore well and that tissue ingrowth can be enhanced by etching and coating with FN.

Structural, mechanical and in vitro characterization of individually structured Ti-6Al-4V produced by direct laser forming.

Direct laser forming (DLF) is a rapid prototyping technique which enables prompt modelling of metal parts with high bulk density on the base of individual three-dimensional data, including computer tomography models of anatomical structures. In our project, we tested DLF-produced material on the basis of the titanium alloy Ti-6Al-4V for its applicability as hard tissue biomaterial. To this end, we investigated mechanical and structural properties of DLF-Ti-6Al-4V. While the tensile and yield strengths of untreated DLF alloy ranged beyond 1000 MPa, a breaking elongation of 6.5+/-0.6% was determined for this material. After an additional post-DLF annealing treatment, this parameter was increased two-fold to 13.0+/-0.6%, while tensile and yield strengths were reduced by approx. 8%. A Young's modulus of 118.000+/-2.300 MPa was determined for post-DLF annealed Ti-6Al-4V. All data gained from tensile testing of post-DLF annealed Ti-6Al-4V matched American Society of Testing and Materials (ASTM) specifications for the usage of this alloy as medical material. Rotating bending tests revealed that the fatigue profile of post-DLF annealed Ti-6Al-4V was comparable to casted/hot isostatic pressed alloy. We characterized the structure of non-finished DLF-Ti-6Al-4V by scanning electron microscopy and observed a surface-associated layer of particles, which was removable by sandblasting as a finishing step. We manufactured porous specimens with nominal pore diameters of 500, 700 and 1000 microm. The diameters were reduced by the used DLF processing by approx. 300 microm. In an in vitro investigation, we cultured human osteoblasts on non-porous and porous blasted DLF-Ti-6Al-4V specimens to study morphology, vitality, proliferation and differentiation of the cells. The cells spreaded and proliferated on DLF-Ti-6Al-4V over a culture time of 14 days. On porous specimens, osteoblasts grew along the rims of the pores and formed circle-shaped structures, as visualized by live/dead staining as well as scanning electron microscopy. Overall, the DLF-Ti-6Al-4V approach proved to be efficient and could be further advanced in the field of hard tissue biomaterials.

In vitro behavior of a porous TiO2/perlite composite and its surface modification with fibronectin.

In this study, we introduce a porous composite material, termed "Ecopore", and describe in vitro investigation of the material and its modification with fibronectin. The material is a sintered compound of rutile TiO2 and the volcanic silicate perlite with a macrostructure of interconnecting pores. It is both inexpensive and easy to manufacture. We first investigated Ecopore for corrosion and leaching of elements in physiological saline. The corrosion supernatants did not contain critical concentrations of toxic trace elements. In an in vitro model, human primary osteoblasts (HOB) were cultured directly on Ecopore. HOB grew on the composite as well as on samples of its single constituents, TiO2 and perlite glass, and remained vital, but cellular spreading was less than on tissue culture plastic. The pro-inflammatory cytokines IL-1 and TNF-alpha were below detection limits in HOB culture supernatants, whereas IL-6 was detectable on a low level. To enhance cellular attachment and growth, the surface of the composite was modified by etching, functionalization with aminosilane and coupling of fibronectin. This modification greatly enhanced the spreading of HOB, indicated by vital staining and Sodium 3'-[1-(phenylaminocarbonyl)-3,4-tetrazolium]-bis (4-methoxy-6-nitro) benzene sulfonic acid hydrate (XTT) metabolism assays. HOB grew on the entire visible surface of porous fibronectin-modified composite, expressing alkaline phosphatase, a mature osteoblast marker. We conclude that Ecopore is non-toxic and sustains HOB growth, cellular spreading being improvable by coating with fibronectin. The composite may be usable in the field of bone substitution.

Surface modification of poly(vinylidenefluoride) to improve the osteoblast adhesion.

Cell adhesion to biomaterials is mediated primarily by the interaction between surface bound proteins and corresponding receptors on the membrane of the cells. The attachment of fibronectin onto poly(vinylidenefluoride) (PVDF) surface and the application of PVDF as biomaterial in bone contact was the subject of our study. PVDF is a biomaterial established for soft tissue applications. Surface modifications of PVDF were performed by plasma induced graft copolymerisation of acrylic acid or CVD polymerisation of 4-amino[2.2]paracyclophane. The provided functionalised PVDF surface was used to immobilise fibronectin using different techniques. All modification steps were verified by means of X-ray photoelectron spectroscopy (XPS), attenuated total reflection infrared spectroscopy (IR-ATR) and contact angle measurements. Surface topology was studied by atomic force measurements (AFM). Protein adsorption was controlled by enzyme linked immunosorbent assay (ELISA). Cell attachment was enhanced if physically adsorbed fibronectin was used, while enhanced attachment and proliferation were induced by covalently binding fibronectin to the surface modified PVDF.

Bipolar hemiarthroplasty for treatment of femoral neck fractures in geriatric patients--surgical technique and outcome.

Fractures of the femoral neck are frequent in the elderly population. The reduced general health status and presence of concomitant diseases, in many cases, make the treatment of these patients demanding. Early mobilization is mandatory to avoid secondary infections, which were often lethal in the past. Surgical intervention has become the standard treatment for these patients. Only a few patients with stable fracture-types allow early mobilization without operation.