Surgical procedure and initial radiographic results of a new augmentation technique for vertebral compression fractures.

PURPOSE: Recently, a new minimally invasive technique called 'vertebral body stenting' (VBS) was introduced for the treatment of osteoporotic vertebral fractures. The technique was developed to prevent the loss of reduction after deflation of the balloon and to reduce the complication rate associated with cement leakage. METHODS: The amount of kyphosis correction, improvement of vertebral body height and quantitative cement leakage rate by applying CT-based quantitative volumetry after VBS were measured in 27 patients (55 vertebra) and compared with a control group (29 patients, 61 vertebrae), which was treated with conventional vertebroplasty. RESULTS: After VBS, a significant improvement was seen in vertebral height, compared to conventional vertebroplasty. The mean improvement in segmental kyphosis and vertebral kyphosis were 5.8° (p < 0.05) and 3.5° (p < 0.05), respectively. In the VBS group, the mean injected volume of cement per vertebral body was 7.33 cm(3) (3.34-10.19 cm(3)). The average amount of cement outside the vertebrae was 0.28 cm(3) (0.01-1.64 cm(3)), which was 1.36% of the applied total cement volume. In the vertebroplasty group, the applied mean volume of the cement per level was 2.7 cm(3) (1-5.8 cm(3)) and the average amount of cement outside the vertebrae was 0.15 cm(3) (0.01-1.8 cm(3)), which was 11.5% (0.2-60%) of the applied total volume of cement. CONCLUSION: The frequency of cement leakage after VBS was 25.5% compared to 42.1% in the vertebroplasty group. VBS led to a significant decrease in the leakage rate compared with conventional vertebroplasty.

The use of beta-tricalcium phosphate and bone marrow aspirate as a bone graft substitute in posterior lumbar interbody fusion.

PURPOSE: Due to the disadvantages of iliac crest bone and the poor bone quality of autograft gained from decompression surgery, alternative filling materials for posterior lumbar interbody fusion cages have been developed. ß-Tricalcium phosphate is widely used in cages. However, data regarding the fusion rate of ß-TCP assessed by computer tomography are currently not available. MATERIALS: A prospective clinical trial involving 34 patients (56.7 years) was performed: 26 patients were treated with single-level, five patients double-level and three patients triple-level PLIF filled with ß-TCP and bone marrow aspirate perfusion, and additional posterior pedicle screw fixation. Fusion was assessed by CT and X-rays 1 year after surgery using a validated fusion scale published previously. Functional status was evaluated with the visual analogue scale and the Oswestry Disability Index before and 1 year after surgery. RESULTS: Forty-five levels in 34 patients were evaluated by CT and X-ray with a follow-up period of at least 1 year. Clinically, the average ODI and VAS for leg and back scores improved significantly (P < 0.001). CT assessment revealed solid fusion in 12 levels (26.67%) and indeterminate fusion in 15 levels (34.09%). Inadequate fusion (non-union) was detected in 17 levels (38.63%). CONCLUSION: The technique of PLIF using ß-TCP yielded a good clinical outcome 1 year after surgery, however, a high rate of pseudoarthrosis was found in this series therefore, we do not recommend ß-TCP as a bone graft substitute using the PLIF technique.

Footprint mismatch in total cervical disc arthroplasty.

PURPOSE: Cervical disc arthroplasty has become a commonplace surgery for the treatment of cervical radiculopathy and myelopathy. Most manufacturers derive their implant dimensions from early published cadaver studies. Ideal footprint match of the prosthesis is essential for good surgical outcome. METHODS: We measured the dimensions of cervical vertebrae from computed tomography (CT) scans and to assess the accuracy of match achieved with the most common cervical disc prostheses [Bryan (Medtronic), Prestige LP (Medtronic), Discover (DePuy) Prodisc-C (Synthes)]. A total of 192 endplates in 24 patients (56.3 years) were assessed. The anterior-posterior and mediolateral diameters of the superior and inferior endplates were measured with a digital measuring system. RESULTS: Overall, 53.5 % of the largest device footprints were smaller in the anterior-posterior diameter and 51.1 % in the mediolateral diameter were smaller than cervical endplate diameters. For levels C5/C6 and C6/C7 an inappropriate size match was noted in 61.9 % as calculated from the anteroposterior diameter. Mismatch at the center mediolateral diameter was noted in 56.8 %. Of the endplates in the current study up to 58.1 % of C5/C6 and C6/C7, and up to 45.3 % of C3/C4 and C4/C5 were larger than the most frequently implanted cervical disc devices. CONCLUSION: Surgeons and manufacturers should be aware of the size mismatch in currently available cervical disc prostheses, which may endanger the safety and efficacy of the procedure. Undersizing the prosthetic device may lead to subsidence, loosening, heterotopic ossification and biomechanical failure caused by an incorrect center of rotation and load distribution, affecting the facet joints.

Interrater and intrarater reliability of the Kuntz et al new deformity classification system.

BACKGROUND: Kuntz et al recently introduced a new system for classifying spinal deformities. This classification of spinal deformity was developed from age-dependent deviations from the neutral upright spinal alignment. OBJECTIVE: To determine the interobserver and intraobserver reliabilities of the new Kuntz et al system for classifying scoliosis. METHODS: Fifty consecutive patients were evaluated. Three observers independently assigned a major structural curve, minor structural curve, curve type, apical vertebral rotation, spinal balance, and pelvic alignment to each curve following the guidelines described by Kuntz et al. Assignment of the curves was repeated 4 weeks later, with the curves presented in a different blinded order. The Kendall W and Holsti agreement coefficients were used to determine the interobserver and intraobserver agreement. RESULTS: The intraobserver value of agreement for all parameters was 0.85 (range, 0.28-1.0), and the mean Kendall W coefficient was 0.89 (range, 0.5-0.97), demonstrating perfect reliability. The interobserver agreement averaged 0.7 (range, 0.251-1.0). The mean Kendall W coefficient was 0.67 (range, 0.19-1.0), demonstrating substantial reliability. The average time for classification of 1 curve was approximately 8.4 minutes. CONCLUSION: The new Kuntz et al deformity classification system is comparable to the Lenke et al system in terms of reliability. However, the Kuntz et al classification system provides no recommendations for surgical interventions. It is more complex and time-consuming and therefore may be of limited value in daily clinical practice.

Quantitative volumetry of cement leakage in viscosity-controlled vertebroplasty.

STUDY DESIGN: This study was designed as a cohort study comparing a prospective sample to a historic control group. OBJECTIVE: The aim of the actual trial was to compare the rate of cement leakage by quantitative volumetry comparing viscosity-controlled and non-viscosity-controlled vertebroplasty. SUMMARY OF BACKGROUND DATA: Percutaneous vertebroplasty (PVP) is a widespread safe and effective technique in the treatment of osteoporotic compression fractures and vertebral metastatic lesions. However, cement leakage has been identified as a problem of this technique. The leakage rates are reported to range from 7% to 90%. The main influence factor for leakage has been demonstrated to be cement viscosity. Assessment of appropriate injection viscosity is highly subjective and observer dependent. Viscosity-controlled vertebroplasty (Vertecem system) has been developed to objectively measure cement viscosity before injection. It introduces a viscosimeter to measure the actual cement viscosity before injection into the vertebra, and therefore may prevent leakages resulting from low-viscosity cement injections. Despite more than 800 Pubmed citations on PVP, there is only 1 report on distinct measurement of cement leakage by semiquantitative volumetry. METHODS: A total of 111 vertebrae in 68 patients, in which PVP was performed for osteoporotic fractures, were included. Thirty-seven patients (76 operated vertebrae) were assessed prospectively using the viscosity-controlled vertebroplasty. The results were compared with a retrospective group of 31 patients (35 operated vertebrae) undergoing PVP without using a viscosimeter. RESULTS: : There were no significant differences between the 2 groups in the applied volume of cement per fractured vertebra (P=0.73). The frequency of cement leakage in viscosimete-assisted vertebroplasty was 42.1% and 58.3% in the historic group. Cement leakage into the basivertebral vein (type B), was detected in 6.6% with and in 11.1% without viscosimetry. CONCLUSIONS: The use of viscosity-controlled vertebroplasty led to a decrease in the leakage rate from 58.3% to 42.1%. Leakage into the basivertebral vein with the risk of compression of nerval structures was reduced to almost 50% when viscosimetry was performed. It revealed to be a helpful tool for more unexperienced surgeons to assess the appropriate viscosity for vertebroplasty.

CT angiography for anterior lumbar spine access: high radiation exposure and low clinical relevance.

BACKGROUND: Some spine surgeons perform CT angiography for detailed planning of anterior access to the lumbar spine. However, the value of this imaging method and its influence on surgeons' decisions are unclear. QUESTIONS/PURPOSES: We determined (1) the dose of radiation used in preoperative CT angiography and (2) whether CT angiography affects planning of anterior lumbar spine surgeries. PATIENTS AND METHODS: We assessed preoperative CT angiograms of 28 patients undergoing anterior spine surgery. The level of aortic bifurcation, iliac vein confluence, course of the ascending lumbar vein, central sacral vessels, and any vascular variation were mapped. We determined the effective dose of radiation and recorded whether the preoperative CT angiography influenced surgical planning. RESULTS: We observed variations in the location of the aortic bifurcation and the iliac vein confluence. In 32% of patients, there were accessory renal arteries originating from the aorta; 7% had a rudimentary persistent left-sided caval vein. The findings did not change the plan for surgery in any patient. We detected high organ radiation dosages (mSv) for the stomach (63 mSv), liver (58 mSv), urinary bladder (47 mSv), and colon (46 mSv); other high exposure dosages involved the lungs, bone marrow, ovaries, and uterus. CONCLUSIONS: About one in 1919 men and one in 2971 women undergoing CT angiography therefore are expected to have colon cancer develop, and one in 2781 men and one in 2856 women are expected to have cancer of the urinary bladder develop. CT angiography is of low value for preoperative planning for anterior access to the lumbar spine and should be avoided to prevent radiation-induced damage. LEVEL OF EVIDENCE: Level II, diagnostic study.

Balance ability and muscle response of the preferred and nonpreferred leg in soccer players.

The aim of this study was to evaluate balance abilities and electromyographic (EMG) latency times of the preferred and nonpreferred leg in soccer players. Whereas side differences between the two legs in force, kicking speed, and joint laxity have been demonstrated in athletes in previous studies, no data are so far available on balance differences. Low balance ability is generally associated with an increased risk of ligament injuries, and the detection of a possible asymmetry in balance is important because a bilateral difference may be a contributing factor to injury. Twenty-one amateur soccer players were tested. Two different balance test instruments were used: the Biodex Stability System and the Tetrax System. For the evaluation of muscle latency times, EMGs were recorded by means of the EquiTest system. None of the tests performed in this study revealed statistically significant differences in balance ability between the preferred and the nonpreferred leg. The investigations of balance function and muscle response in amateur soccer players did not reveal significant differences between the preferred and nonpreferred leg in the current study. However, a certain tendency to better balance in the nonpreferred leg was observed.

Correlation between radiographic assessment and quality of life after total knee arthroplasty.

The correlation between radiographic and clinical outcome was investigated for total knee arthroplasty. One hundred three total knee arthroplasties in 98 patients were investigated at an average follow-up of 10.8 years (range, 2-17 years). For radiographic evaluation the Radiographic Evaluation System of the Knee Society was used. For assessment of clinical outcome four disease-specific scores, and the Nottingham Health Profile were applied. A significant correlation was found between the extent of radiolucent lines of the tibial component and the Nottingham Health Profile (correlation coefficient: 0.61, p<0.0001). For the disease-specific scores the correlation was low (correlation coefficient: 0.30-0.50). For the prosthetic alignment no significant correlation was found (p<0.05). The current results show that a correlation was found between radiological assessment and several clinical scores. We suggest that a quality-of-life score should be included in the follow-up evaluation of total knee arthroplasty.

Antimicrobial activity of dexamethasone and its combination with N-chlorotaurine.

OBJECTIVE: To investigate the antimicrobial effect of dexamethasone phosphate, the endogenous antiseptic N-chlorotaurine (NCT), and their combination on ear, nose, and throat microorganisms. DESIGN: In vitro study. SUBJECTS: Strains of Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus milleri, Aspergillus flavus, and Aspergillus fumigatus. INTERVENTIONS: Bacterial and fungal strains were cultured with 0.1% dexamethasone with and without a low (0.1%) or high (1%) concentration of NCT. The killing effects of dexamethasone, NCT, and the combination were monitored. RESULTS: Dexamethasone killed S. milleri and A. flavus after incubation times of 24 to 48 hours. The low concentration of NCT caused a 90% reduction of S. aureus and P. aeruginosa within 30 minutes and 99.9% reduction within 50 minutes. The high concentration of NCT reduced viable counts of S. aureus and P. aeruginosa to the detection limit within 10 minutes. The low-concentration combination (0.1% dexamethasone and 0.1% NCT) showed significant (P < .01) synergistic killing of S. aureus with 2- to 3-fold shorter killing times. The high-concentration combination (0.1% dexamethasone and 1% NCT) demonstrated more rapid killing than NCT alone in both S. aureus and P. aeruginosa. CONCLUSIONS: With short and intermediate exposure times, the combination of dexamethasone and NCT showed significantly stronger antimicrobial effects than treatment with NCT alone. Significant killing of S. milleri, A. flavus, and A. fumigatus was observed after extended exposure to dexamethasone. The combined application of dexamethasone and NCT might be a promising therapeutic option, producing high efficacy with low side effects.

Antibacterial activity of mometasone furoate.

OBJECTIVE: To test the antibacterial properties of the topical corticoid mometasone furoate, which is used as a nasal spray. DESIGN: The activity of mometasone (0.01%, 0.1%, and 0.5%) in buffer solution against Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Streptococcus pyogenes, and Streptococcus milleri was tested by quantitative killing assays. SETTING: In vitro study. MAIN OUTCOME MEASURE: Reduction of viable bacteria and fungi in quantitative killing assays. RESULTS: Mometasone (0.5%) reduced viable counts of S pyogenes and S milleri by 99.99% and 99.00%, respectively, after 24 hours of incubation, whereas colony-forming units (CFUs) of S aureus, P aeruginosa, and E coli were not affected by the corticoid. Mometasone (0.1%) caused a decrease in CFUs of S pyogenes of 99.90% to 99.99%, while it led to a 99.00% reduction in CFUs of S milleri, but only if low bacterial counts of 1 x 10(4) CFUs/mL were incubated. By contrast, the use of mometasone at a low concentration (0.01%) demonstrated an increase in CFUs of S milleri if the baseline bacterial count was low (1 x 10(4) CFUs/mL). CONCLUSION: Mometasone demonstrates antimicrobial activity against streptococci.

Influence of essential and fatty oils on ciliary beat frequency of human nasal epithelial cells.

BACKGROUND: In alternative and complementary medicine, the use of essential and fatty oils has become more and more popular. In addition to conventional medical therapies, self-medication is showing increasing popularity, using agents with unclear compounds and poorly controlled dosages. Among other disorders, these alternative treatments are used in bronchitis and rhinitis, including some topical applications. Thus, the influence on ciliated epithelia should be evaluated, because a disturbance of the ciliary function can lead to recurrent sinusitis and chronic rhinosinusitis. The aim of this study was to test the influence of fatty and essential oils on the ciliary beat frequency (CBF) of nasal mucosa in vivo. METHODS: The influence of sesame oil, soy oil, peanut oil, Miglyol 840, thyme oil, lavender oil, eucalyptus oil, and menthol on the ciliary activity of nasal brushings was evaluated by digital high-speed imaging. RESULTS: The presence of most fatty oils resulted in an increase in CBF, the effect being highest for peanut oil. Miglyol 840 had no significant influence on CBF. The essential oils were tested at a concentration of 0.2 and 2%. Thyme oil did not affect CBF, whereas the presence of all other essentials oils resulted in an increase in CBF; the effect was higher at 0.2% than at 2%. CONCLUSION: Except thyme oil and Miglyol 840, all tested oils caused an increase in CBF. Interestingly, the 0.2% concentrations of essential oils resulted in stronger effects when compared with the 2% concentrations.

Long-term outcome after high tibial osteotomy.

INTRODUCTION: The frequency of tibial osteotomy in the treatment of osteoarthritis of the knee has decreased due to the demanding surgical procedure and the rising number of total knee replacements (TKR). Only few data exist concerning survival rates after high tibial osteotomy (HTO) with a follow-up exceeding 10 years. We want to present long-term results with a follow-up of more than 18 years after operation. MATERIALS AND METHODS: Survival rates and the influence of age, gender and the mechanical axis were investigated in 134 lateral closing-wedge osteotomies in 111 patients. RESULTS: The survival rate was 94% after 5 years, 79.9% after10 years, 65.5% after 15 years, and 54.1% after 18 years. Age had a significant influence on the survival and gender and the mechanical axis had no significant influence. CONCLUSION: We conclude, that with a 54.1% survival after 18 years HTO is a useful facility to protract the implantation of a total knee prosthesis.

N-chlorotaurine--a new safe substance for postoperative ear care.

OBJECTIVES: The new endogenous substance N-chlorotaurine (NCT), which for the first time was synthesized and introduced into clinical practice by our research group, was now used for postoperative ear care following tympanoplasty. The antiseptic and drying effect of NCT was evaluated and compared to the standard postoperative procedure in our department. METHODS: Prospective randomized trial on 10 patients. Local irrigations of the external auditory canal with 1% NCT solution were performed once daily until the canal was dry. RESULTS: NCT was well tolerated. The external auditory canal showed no signs of infections and dried significantly more rapidly than the control group. In contrast to previous suppositions, epithelialization proceeded without complications and was identical in both groups. CONCLUSIONS: As NCT in our first postoperative patient study was effective in preventing infections and drying of the outer ear canal was faster without impairing epithelialization, this agent seems useful for postoperative ear care.

A novel N-chlorotaurine-corticosteroid combination as a preservative-free local disinfectant: influence on the ciliary beat frequency in vitro.

CONCLUSIONS: The combination of N-chlorotaurine (NCT) and a corticosteroid seems to be a very promising substance for the local therapy of ENT infections. As it can be used without any preservatives, the effect on the ciliary beat frequency (CBF) is much less than that of products containing benzalkonium chloride (BAC). The in vitro results obtained in this study encourage us to perform clinical trials on this novel combination for intranasal application. OBJECTIVE: To investigate the influence of a novel mixture of NCT and a corticosteroid [fluticasone propionate (FP)] on the CBF of human ciliated cells in vitro. MATERIAL AND METHODS: The study was designed as an in vitro study. CBF was measured by means of a photometric technique involving the combination of a light microscope, a photometer, a photographic multiplier and a computerized analyzing unit. RESULTS: The combination of 1% NCT + 0.5 mg/ml FP decreased the CBF to 42.17% of its original value after 20 min. Treatment with BAC lowered the CBF depending on the concentration to 96.61% of its original value with 0.04 mg/ml, to 91.90% with 0.1 mg/ml, to 63.46% with 0.2 mg/ml and to 0% with 0.5 mg/ml. After rinsing in saline, the CBF of samples treated with 1% NCT + 0.5 mg/ml FP recovered to 68.93% of its original value.

Tolerability of N-chlorotaurine in chronic rhinosinusitis applied via yamik catheter.

OBJECTIVES: A rational approach in the treatment of chronic rhinosinusitis (CRS) is the intranasal application of antiseptic agents, due to the pathogenetic role of bacteria and fungi. N-Chlorotaurine (NCT), a mild endogenous oxidant with broad-spectrum antimicrobial activity, has been tested for the first time in CRS. METHODS: This one-arm phase IIa clinical study is the first step in the clinical development of this promising substance for local therapy of CRS. The nasal and paranasal cavities of 12 patients were rinsed with 10-20 ml of 1% aqueous NCT solution, applied via a novel catheter system (YAMIK). Treatment consisted of three lavages per week for 4 weeks. RESULTS: NCT caused neither alterations of the mucosa nor burning pain during application. Nevertheless, the insertion of the catheter, the insufflation of the posterior cuff and the overpressure inside the sinuses after infiltration led to moderate pain in some patients. Mucosal swelling decreased in all subjects, nasal breathing could be improved in nine patients and impaired olfaction in seven. Polyps did not disappear within the 1-month period of the study. CONCLUSIONS: The good tolerability and possible beneficial effects of NCT encourage its further investigation in CRS. Despite some limitations the YAMIK catheter proved to be a convenient and safe device for rinsing the nasal and paranasal sinuses.

Solitary subglottic neurofibroma: a report of an unusual manifestation.

Neurofibromas of the larynx are extremely rare, especially in the subglottic part. Most of the patients with neurofibromas suffer from neurofibromatosis type 1 (NF1, von Recklinghausen's disease), which is characterized by cafe-au-lait spots and neurofibromas of any type. We present a case of a solitary neurofibroma in the subglottic region that relapsed 4 years after the primary diagnosis. The clinical findings, histological results and therapy are discussed.

Acute otitis externa: efficacy and tolerability of N-chlorotaurine, a novel endogenous antiseptic agent.

OBJECTIVE: The study's objective was to test the tolerability and efficacy of the endogenous antiseptic N-chlorotaurine (NCT) in comparison with a standard clinical treatment according to a phase IIb clinical trial protocol. STUDY DESIGN: The antimicrobial agent NCT was compared with the antibiotic component drops Otosporin (containing neomycin, polymyxin B, and hydrocortisone) for topical treatment of acute otitis externa in a randomized and rater-blinded clinical study. METHODS: Fifty patients suffering from acute otitis externa were divided into two groups according to a randomized list. The test group was treated with 1 mL of 1% aqueous NCT solution, the reference group with 1 mL of Otosporin. The substances were applied to the external ear canal at one daily session until the signs of infection disappeared. Efficacy and tolerability were evaluated daily by visual analogue scale and a six-step infection score. In addition, smears were analyzed to identify the causative pathogens. RESULTS: Both medications were equally well tolerated by the patients. The treatment was successful for all patients of the NCT group, whereas in one patient from the reference group, the infection did not disappear. The inflammation score improved more rapidly in the NCT group, which resulted in an earlier termination of the therapy. This difference became highly significant on days 4 to 7 (P <.01 each). Time needed for disappearance of inflammation (score 0) was 5.6 +/- 1.6 (mean +/- SD, range 3-9) days in the NCT group and 7.4 +/- 1.6 (range 4-10) days in the Otosporin group (P <.001). As expected, microbiologic cultures from ear swabs revealed Pseudomonas aeruginosa (58%) followed by Staphylococcus aureus (18%) as the main causative pathogens. CONCLUSIONS: NCT appears to be well tolerated and more effective than the therapy using antibiotic component drops. Because of its endogenous nature and its higher efficacy, NCT appears to be a good choice for topical treatment of acute otitis externa.

Refractory rhinosinusitis complicating immunosuppression: application of N-chlorotaurine, a novel endogenous antiseptic agent.

Severe infections are a frequent complication in immunosuppression following transplantations. In the case reported here, a heart-transplanted patient was treated for refractory rhinosinusitis with a combination of sinus surgery and rinsing with N-chlorotaurine (NCT). The daily rinse was well tolerated and effective. The combination of functional endonasal sinus surgery and topical treatment with NCT appeared effective and well tolerated in antibiotic-resistant sinusitis under immunosuppression.