[Treatment strategies for pathological fractures of the spine]. / Versorgungsstrategien bei pathologischen Frakturen der Wirbelsäule.

BACKGROUND: Pathological fractures and instabilities of the spine are most often caused by primary tumors that hematogenously metastasize into the spine. In this context breast, prostate, kidney cell and bronchial carcinomas are the most relevant causative diseases. Furthermore, multiple myeloma is another frequent entity. Primary tumors of the spine are correspondingly rare and only make up a small proportion of all malignant processes in the spine. DECISION MAKING: The main symptom of pain is prognostically unfavorable in this context and is often associated with progressive instability or pathological fractures. To objectify the treatment approach the neurological status, an oncological assessment, the biomechanical stability and (systemic) general condition (NOMS criteria) of the patient have to be considered. Another major factor is the radiation sensitivity of the tumor. The spinal instability neoplastic (SIN) score is recommended to assess stability. Regardless of whether conservative or surgical treatment is carried out, interdisciplinary cooperation between the specialist departments must be guaranteed in order to achieve adequate treatment for the patient. TREATMENT: If a curative approach is followed an individualized and interdisciplinary surgical strategy must be performed to achieve an R0 resection, usually as a spondylectomy. In the case of palliative treatment, the goal of surgical treatment must be pain reduction, stability and avoidance or restoration of neurological deficits. This requires stabilization in a percutaneous or open technique, possibly in combination with decompression and local tumor debulking.

[Medical ID and emergency apps: A useful tool in emergency situations or a waste of time?] / Notfall-Apps: vergeudete Zeit oder sinnvolles Instrument in der präklinischen Versorgung von Traumapatienten?

BACKGROUND: In order to provide safe care to a patient in an emergency situation, it is useful to know something about the patient's previous medical conditions and medication. For this very reason smartphones have been equipped with so-called emergency apps (e.g. medical-ID, emergency-ID). The aim of our study was to find out whether the owners of smartphones are using the apps and whether medical professionals are trying to access this information. METHODS: We conducted a survey among patients in our outpatient clinic at a level one trauma center. We collected data over 3 months regarding the usage behavior of the aforementioned apps. We simultaneously asked emergency physicians at various hospitals about their experiences with these apps. RESULTS: We were able to interview 192 patients and 103 emergency physicians. The emergency apps were unknown to 45% (n = 79) of the respondents; only 10% (n = 19) of the respondents had the app with data stored. Furthermore, it was found that a total of 21% (n = 41) of the persons carried a note on themselves with previous illnesses and medication. Of the surveyed physicians, 42% (n = 44) stated that they had heard of the app before; however, only 6% (n = 5) routinely searched the smartphone for relevant information in the case of nonresponsive patients. Only 14% of physicians (n = 14) have successfully used the app so far. CONCLUSION: The collected data show that the emergency apps are still unknown to many patients and emergency physicians alike. Due to the low distribution it does not seem to be recommendable to search the smartphone for the apps in time-critical situations after accidents. For patients over 55 years of age, it currently seems more promising to search their wallets for information regarding their previous illnesses.

[Chronic instability of the pubic symphysis : Etiology, diagnostics and treatment management]. / Die Chronische Symphyseninstabilität : Ätiologie, Diagnostik und Behandlungsmanagement.

The most frequent causes of chronic instability of the pubic symphysis are sports-related continual overload and traumatic symphyseal injuries. Acute injury of the pubic symphysis may be the result of external forces acting on the anterior pelvic ring or the result of internal forces, such as those arising during parturition. The postpartum form of instability following a complication-free birth is reversible and usually returns to normal within a few months through strengthening of the pelvic floor muscles. Residual instability of the pubis symphysis is on the whole a rare complication. Although established therapy options for acute symphyseal separation can be found in the literature, there are only a few case reports on chronic symphyseal instability. There are no guidelines on standardized therapy options. This review article examines the etiology, clinical findings, diagnostic techniques and management options for patients suffering from chronic symphyseal instability.

[The Anterior "Triple-/Quadruple" Technique for C1/C2 Trauma in the Elderly: First Experience with 16 Patients]. / Die ventrale "Triple-/Quadruple"-Schraubenosteosynthese für die traumatische C1-C2-Kombinationsverletzung des geriatrischen Patienten: erste operative Erfahrungen mit 16 Patienten.

INTRODUCTION: In geriatric patients the management of odontoid type II fractures is complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2) with an increased lever arm. Furthermore, a few of the odontoid fractures are accompanied by an atlas fracture resulting in the "atlantoaxial unhappy triad". Posterior C1/C2 spondylodesis with bilateral Magerl screws and C1 hooks is a strong biomechanical construct, however, the posterior approach is associated with several drawbacks such as increased risk of infection and increased blood loss. In contrast, the anterior bilateral C1/C2 transarticular screw fixation with additional odontoid screw fixation is also a known technique. Advantages of the anterior approach are shorter surgery time, lower intraoperative blood loss and lower risk of infection. MATERIALS AND METHODS: In this retrospective study, all geriatric patients with an atlantoaxial arthritis and odontoid or combined atlantoaxial fracture treated at our institution between 01/2012 and 12/2014 with an anterior screw fixation were included. Following closed reduction, the surgical management was performed over a standard right anterior approach. At the end of surgery, operation time and blood loss were documented. During the hospital stay radiological follow-up of the upper cervical spine were performed to analyse the screw position. We also report the length of stay on intensive care unit, the hospital course and demographic data of the patients. Follow-up was planned after 6 weeks, 6, 12 and 18 months. During follow-up COMI evaluation and X-rays of the cervical spine were made. RESULTS AND CONCLUSION: This study included 16 patients who underwent surgery for C1-C2 lesions. There were 9 females and 7 males. Median age at the time of operation was 76 years. At the time of surgery, fractures were classified as follows: 8 patients showed an "atlantoaxial unhappy triad", 8 patients had a type II odontoid fracture complicated by osteoporosis and atlantoaxial arthritis (spondylarthritis C1/C2). Average time for operative treatment was 100 ± 36.35 minutes with a median intraoperative fluoroscopy time of 161 seconds. The intraoperative blood loss was minimal (45 ± 22.80 ml). Length of stay was documented with 10 (± 4.60) days whereby the patients spent on average 0.8 days in the intensive care unit postoperatively. No serious morbidities, such as esophageal perforation, carotid artery laceration, neurological deterioration, and airway obstruction were reported. All cases of transient dysphagia resolved gradually and spontaneously without therapy. In 4 cases (25 %) we detected a penetration of the atlantooccipital joint without functional impairment. In one case we have seen an implant failure. The technique of anterior screw fixation of odontoid and bilateral transarticular C1-C2 anterior screw fixation provides a fast surgery without higher morbidity. Based on our findings, this technique and its feasibility is an alternative to known posterior C1/C2 spondylodesis in the elderly.

Ultrasound-guided diagnosis of fractures of the distal forearm in children.

PURPOSE: Distal radius and forearm fractures are injuries that are frequently seen in trauma surgery outpatient clinics. Usually, the wrist is X-rayed in 2 planes as standard diagnostic procedure. In contrast, we evaluate in our study the accuracy of ultrasonography (US) in diagnosing these fractures. METHODS: This prospective study includes the patients who presented at two trauma surgery clinics with a presumptive diagnosis of distal radius or forearm fracture between January and December 2012. After a clinical examination, US imaging of the distal forearm was first carried out on 6 standardized planes followed by radiographs of the wrist made in two planes. The age limit was set at the end of 11 years. RESULTS: In total, 201 patients between 4 and 11 years of age were recruited with an average age of 9.5 years at the time of the trauma. There were 104 (51.7%) fractures distributed as follows: 89 (85.9%) injuries of the distal radius, 9 (8.7%) injuries of the distal ulna, and 6 (5.8%) combined injuries (radius and ulna). Sixty-five greenstick fractures were detected. Surgery was necessary in 34 cases. Specificity and sensitivity of ultrasound diagnosis were 99.5%. CONCLUSION: Ultrasound imaging is suitable to demonstrate fractures of the distal forearm. It is a highly sensitive procedure in detecting distal forearm fractures. In our opinion, a negative result in ultrasound may reduce the need for further radiographs in children with distal forearm lesions. But in any doubtful situation the need for conventional radiographs remains.

Peripartum pubic symphysis separation--Current strategies in diagnosis and therapy and presentation of two cases.

BACKGROUND: During spontaneous vaginal delivery, pubic symphyseal widening is normal. Common changes are reversible after complication-free birth. However, cases of peripartum symphysis separation are rare. There is no consensus in the literature on how to treat pregnancy-related pubic symphysis separation. METHODS: This review used a literature-based search (PubMed, 1900-2013) and analysis of 2 own case reports. Studies with conclusions regarding management were particularly considered. RESULTS: Characteristic symptoms, suprapubic pain and tenderness radiating to the posterior pelvic girdle or lower back, may be noted 48 h after delivery. Pain on movement, especially walking or climbing stairs, is often present. Conservative treatments, such as a pelvic brace with physiotherapy and local interventions such as infiltration, are successful in most cases. Symptom reduction within 6 weeks is the most common outcome, but can take up to 6 months in some cases. Surgical intervention is needed in cases of persistent separation. Anterior plate fixation is offered as a well-known and safe procedure. Minimally invasive SI joint screw fixation is required in cases of combined posterior pelvic girdle lesions. SUMMARY: Postpartum symphyseal rupture can be indicated with the rare occurrence of pelvic pain post-delivery, with sciatica or lumbago and decreased mobility. The diagnosis is made on clinical findings, as well as radiographs of the pelvic girdle. Conservative treatment with a pelvic brace is the gold standard in pre- and postpartum cases of symphysis dysfunction.

Injuries in competitive boxing. A prospective study.

Boxing remains a subject of controversy and is often classified as dangerous. But the discussion is based mostly on retrospective studies. This survey was conducted as a prospective study. From October 2012 to September 2013, 44 competitive boxers were asked to report their injuries once a month. The questionnaire collected general information (training, competition) and recorded the number of bouts fought, injuries and resulting lost days. A total of 192 injuries were recorded, 133 of which resulted in interruption of training or competition. Each boxer sustained 3 injuries per year on average. The injury rate was 12.8 injuries per 1 000 h of training. Boxers fighting more than 3 bouts per year sustain more injuries (p=0.0075). The injury rate does is not a function of age (age≤19 vs. > 19a, p=0.53). Injuries to the head and the upper limbs occur most frequently. The most common injuries are soft tissue lacerations and contusions. Head injuries with neurological symptoms rarely occur (4.2%). Boxing has a high injury rate that is comparable with other contact sports, but most injuries are minor. Injury frequency is not a function of whether the boxer competes in the junior or adult category. Athletes fighting many bouts per year have a greater risk of injury.

[Influencing factors on the length of stay in lumbar spine surgery : analysis of the German spine registry]. / Einflussfaktoren auf die Verweildauer in der Wirbelsäulenchirurgie : Eine Datenanalyse des Deutschen Wirbelsäulenregisters.

INTRODUCTION: Spinal disc herniation, lumbar spinal stenosis and spondylolisthesis are known to be leading causes of lumbar back pain. The cost of low back pain management and related operations are continuously increasing in the healthcare sector. There are many studies regarding complications after spine surgery but little is known about the factors predicting the length of stay in hospital. The purpose of this study was to identify these factors in lumbar spine surgery in order to adapt the postoperative treatment. MATERIAL AND METHODS: The current study was carried out as a post hoc analysis on the basis of the German spine registry. Patients who underwent lumbar spine surgery by posterior surgical access and with posterior fusion and/or rigid stabilization, whereby procedures with dynamic stabilization were excluded. Patient characteristics were tested for association with length of stay (LOS) using bivariate and multivariate analyses. RESULTS: A total of 356 patients met the inclusion criteria. The average age of all patients was 64.6 years and the mean LOS was 11.9 ± 6.0 days with a range of 2-44 days. Independent factors that were influencing LOS were increased age at the time of surgery, higher body mass index, male gender, blood transfusion of 1-2 erythrocyte concentrates and the presence of surgical complications. CONCLUSION: Identification of predictive factors for prolonged LOS may allow for estimation of patient hospitalization time and for optimization of postoperative care. In individual cases this may result of a reduction in the LOS.

[Special prosthesis implant with partial femoral replacement. Operation after periprosthetic femoral fracture and ipsilateral long-stem knee prosthesis and fixed-angle osteosynthesis]. / Implantation eines Femurteilersatzes nach periprothetischer Femurfraktur. Operation bei einliegender Knietotalendoprothese und winkelstabiler Plattenosteosynthese.

The development of modular prostheses is becoming increasingly important in revision surgery due to the rising need of arthroplasty in knee and hip joints. The demand for suitable prostheses is high because of the desire for a higher mobility and a good postoperative functionality, whereby preliminary experience with megaprostheses using modular implant systems in orthopedic oncology have already been obtained. Considering the clinical outcome of our 58-year-old patient (obesity III, BMI 58) and the third revision operation after two periprosthetic fractures, a megaprosthesis was implanted (Mega C-system, co. Link, Hamburg). We aimed both at good clinical functionality and good stability of the knee joint. After the implant, a good functional result was observed at the beginning; however, there were some indices for prosthesis loosening. During the fourth revision we implanted a total femoral replacement. Postoperatively, a good clinical outcome after intensive physiotherapy was observed. Nevertheless, the use of megaprostheses has to be judged cautiously because of a lack of long-term results. In addition, it should not be used as a standard implant in periprosthetic joint surgery because of the risk of aseptic loosening during its course.

Injuries and overuse syndromes in competitive and elite bodybuilding.

Competitive bodybuilding is a weightlifting sport similar to powerlifting, strongman competition and Olympic weightlifting, which aims to increase muscle mass, symmetry, and body definition. Although data regarding rates of injury, overuse syndromes and pain during routine training is available for these other disciplines, it is rare for competitive bodybuilding. The aim of this study was to investigate rates of injury, pain during workouts and/or overuse syndromes, as well as the influence of particular intrinsic and external factors. Data was collected using questionnaires from 71 competitive and elite bodybuilders. The information included training routines and prior injuries. Participants were recruited from bodybuilding clubs in Germany. 45.1% of athletes reported symptoms while training. The overall injury rate was computed to be 0.12 injuries per bodybuilder per year (0.24 injuries per 1 000 h of bodybuilding). Athletes over 40 exhibited higher rates of injury (p=0.029). Other investigated parameters showed no effects. Most injuries occurred in the shoulder, elbow, lumbar spine and knee regions. A large proportion of bodybuilders complained of pain not resulting in interruptions of training/competition. The injury rate is low compared to other weightlifting disciplines such as powerlifting, Olympic weightlifting or strongman competition. In comparison to team or contact sports the injury rate is minimal.

[Complication analysis of spinal interventions in adult central movement disorders and scoliosis]. / Komplikationsanalyse von spinalen Eingriffen bei adulten zentralen Bewegungsstörungen und Skoliosen.

BACKGROUND: Adult central movement disorders, malpostures, and scolioses can have their cause in various neurological underlying diseases such as Morbus Parkinson, Pisa syndrome, or segmental dystonia. Important clinical characteristics are marked postural distortions such as camptocormia (bent spine) or laterocollis. In cases of these adult scolioses, surgical spine treatment puts high demands on the surgeon. Surgery in Parkinson's disease, for example, is associated with serious surgery-specific as well as general complications. The more rarely occurring Pisa syndrome is an entity primarily requiring medical therapy. PATIENTS AND METHODS: A series of ten case reports of patients with Morbus Parkinson and Pisa syndrome who underwent spinal surgery is presented and discussed. From these reports, treatment recommendations have been derived and complemented by references from the literature. An extensive MEDLINE search was performed for this purpose. RESULTS AND CONCLUSION: In patients suffering from Parkinson's disease, even minor surgical interventions can lead to instability of whole spine segments or even the entire spine. Implant loosening, adjacent segment instability, general perioperative complications, and progressive malposture due to disease progress can bring forth disastrous treatment courses. Spinal fixation should be performed long-segmented in combination with ventral stabilisation. Due to osteoporosis, pedicle screw cement augmentation is recommended in this collective. If the diagnosis of Pisa syndrome is established, an optimised preoperative preparation should be initiated in close cooperation with neurologists. In many cases medical therapy is sufficient and surgical interventions can be avoided.

Biomimetic modification of the TiO(2)/glass composite Ecopore with heparinized collagen and the osteoinductive factor BMP-2.

The porous TiO(2)/glass composite Ecopore has potential applications in hard tissue replacement. We describe the modification of Ecopore with the growth factor bone morphogenetic protein-2 (BMP-2) to add osteoinductive properties. Ecopore covalently coated with BMP-2 caused a weak induction of alkaline phosphatase in murine embryonal fibroblasts. In a rabbit bone defect model, BMP-2-coated Ecopore had moderately higher bone apposition rates and ingrown bone quantities at 6 weeks after implantation. To overcome loss of function due to chemical surface coupling, we filled the pore system of Ecopore with heparinized collagen sponge and loaded this secondary matrix with BMP-2. Heparinization of collagen filling increased the BMP-2 loading capacity of the matrix approximately 1.28-fold. Within 96 h, 17.0+/-0.1 and 10.1+/-0.2% of the used BMP-2 was released from non-modified and heparinized Ecopore/collagen, respectively, indicating that the heparin modification retarded BMP-2 release. Revealed by energy-dispersive X-ray spectroscopy analysis of implant cross-sectional areas, BMP-2-loaded Ecopore/collagen had significantly higher bony ingrowth quantities in rabbits, with the heparinized modification yielding the highest value (16.09+/-3.51%, p<0.005) compared with the non-heparinized matrix (10.72+/-4.07%, p<0.05) and the BMP-2-free controls (5.60+/-1.47%). This suggested a beneficial effect of the biomimetic modification of Ecopore with heparinized collagen for bone healing and integration.

Clinical treatment of ectodermal dysplasia: a case report.

Ectodermal dysplasia is both physically and emotionally devastating to patients. With proper restorative intervention, the quality of life can be improved for patients with ectodermal dysplasia. This case report outlines a method of restoring function and esthetics for a 14-year-old boy with ectodermal dysplasia. It is important that these patients be treated at an early age to aid in their social interactions.

Obsessive compulsive disorder: a case report.

A general dentist often will find the most challenging aspect of dentistry is patient management. In the controlled environment of a dental school, many students are not exposed to certain patient populations. It is likely that their first experience with particular patient pools will be in private practice. One such group of patients is those suffering from Obsessive Compulsive Disorder (OCD). This article reviews the clinical signs and symptoms of this group of patients.

Efficacy of tiamulin against experimentally induced Streptococcus suis type-2 infection in swine.

Eighteen 4-week-old pigs were used in a study to evaluate tiamulin in drinking water for control of experimentally induced Streptococcus suis type-2 infection. Pigs in groups A and B (n = 6 pigs/group) were aerosolized with a logarithmic-growth phase culture of S suis type 2, whereas pigs in group C (n = 6 pigs) served as noninfected and nonmedicated controls. After exposure to S suis, pigs in group B were given 180 mg of tiamulin/L of drinking water for 5 days. Pigs in group B consumed more feed (P = 0.009) and gained body weight faster (P = 0.02) than did pigs in group A. Pigs in group A had higher rectal temperature (P = 0.05) for up to 7 days after S suis exposure, higher clinical sign scores (P = 0.008), higher serum cortisol concentration on days 7 and 14, higher gross lesion scores (P = 0.03), and higher microscopic lesion scores (P = 0.01) than did pigs in groups B and C. Gross and microscopic lesions in pigs of groups A and B included meningitis, pneumonia, pleuritis, pericarditis, peritonitis, and synovitis of variable severity. Streptococcus suis type 2 was recovered from tissue specimens of 2 group-A pigs and 1 group-B pig. Data indicated that tiamulin administered via drinking water significantly reduced the effects of S suis type-2 infection.