Three-dimensional acetabular orientation during periacetabular osteotomy: a video analysis of acetabular rim position using an external fixator as navigation tool during reorientation procedure.

INTRODUCTION: Bernese periacetabular osteotomy is an effective procedure for treating acetabular dysplasia. However, limited visual control of the acetabular position during surgery may result in under- or overcorrection with residual dysplasia or femoroacetabular impingement. Thus, we wanted to find a simple method to control the effect of correction in the sagittal and coronal plane. METHOD: The acetabular coordinates are shown by two perpendicular tubes of an external fixator mounted onto a third tube that is fixed to the acetabular fragment with two Schanz screws. This method enables the isolated acetabular reorientation in the coronal, sagittal, and transverse plane. In a sawbone pelvis model, the acetabular rim is marked with a copper wire and a silicon adherent. To show the radiographic effect on acetabular parameters and the rim position, we visualized correction in the coronal and sagittal plane under fluoroscopic control. RESULTS: Lateral rotation of the acetabular fragment had the highest impact on radiographic lateral coverage of the femoral head. But also ventral coverage increased during isolated lateral rotation. Anterior rotation showed almost no effect on lateral coverage and just a little effect on ventral coverage but caused severe total acetabular retroversion. CONCLUSION: Three-dimensional control of the acetabular orientation during periacetabular osteotomy is important to avoid over- and under-correction. Isolated lateral rotation of the acetabular fragment should be the predominant direction of correction during periacetabular osteotomy. Ambitious anterior correction may be the main source for severe acetabular retroversion following periacetabular osteotomy.

[Treatment recommendations for protracted hip immaturity in infants : Conservative approach versus open reduction]. / Behandlungsempfehlungen bei fortbestehender Säuglingshüftunreife : Konservatives Vorgehen versus offene Reposition.

The healthy upright posture is a result of a continuous maturation process of the locomotor system throughout skeletal growth rendering muscle strength and stability: The hip joint in its central position plays a key role for unimpaired and pain-free gait. Nonetheless, it is also regularly affected by delayed maturation, thus being of special interest for the disease screening procedures of every newborn child. Structured screening examinations in the first 3 postnatal months will ideally detect any dysplasia, therefore simple conservative interventions will usually accelerate the maturation process. Effective hip screening programs in Austria and Germany have reduced the necessity for open surgical hip reductions to a worldwide all-time low. Perinatal risk factor awareness in doctors and parents triggers an increased sensitivity to possible immature hip structures. Nevertheless, severe hip dysplasia in toddlers is regularly presented in pediatric orthopedic centers with or without hip dislocation, mostly due to the delay of or inefficiency of treatment options. This review deals with highly effective strategies for quick treatment and provides a balanced view on conservative and surgical methods.

Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios.

INTRODUCTION: In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. METHODS: Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°. RESULTS: No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. CONCLUSION: The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

[Conservative treatment of idiopathic scoliosis : Influence of archetypical Cheneau-Corsets on trunk asymmetry]. / Konservative Behandlung der idiopathischen Skoliose : Beeinflussung der Rumpfasymmetrie mit Cheneau-Korsettarchetypen.

BACKGROUND: The vertical posture of the growing child requires minute central nervous control mechanisms to maintain the symmetry of the torso in its various activities. Measuring only static parameters such as the Cobb angle does not describe the dynamic changes of scoliotic deformities in gait. A constant deviation in the frontal, transverse, and sagittal planes from the dynamic symmetry of the trunk is described in motion analysis and the surface changes of the spinopelvic complex. METHODS: Early intervention with effective bracing, physiotherapy and sport can reverse curve progression in growth spurts, once these are identified by screening. Modern braces have a derotating and reducing effect ("mirror effect") on asymmetric body volumes, thus influencing the growing torso and restoring lasting symmetry. These braces can be reduced for archetypical designs. Latest data support the use of braces to reverse progressing scoliosis.

[Surgical treatment of scoliosis in childhood and adolescence: Age group and etiology-related indications and choice of instrumentation]. / Operative Behandlung der Skoliose im Kindes- und Jugendalter: Differenzialindikation und Verfahrenswahl bei verschiedenen Altersgruppen und in Abhängigkeit der Ätiologie.

The indications for a corrective surgical procedure for the complex 3-dimensional deformations of the spine collectively known under the term scoliosis, essentially depend on knowledge of the underlying etiology, the time of initial diagnosis in relation to the growth curve of the child and on considerations about the general operability of the patient. An early onset of scoliosis in childhood under defined diagnostic criteria is usually associated with a fast progression of spinal curvature and requires early surgical intervention during the growth period, while scoliosis in adolescence often allows a delayed surgical intervention until all conservative means have been taken into consideration. Corrective measures in the growing spine require procedures and adjustable hardware which can be adapted to vertebral and thoracic growth and thus anticipate the threat of pulmonary insufficiency due to postural and spinal collapse. Towards the end of puberty when spinal growth slowly comes to an end, corrective spinal fusion procedures are considered in those cases of early and late onset scoliosis, where curvature progression is likely to occur.

[Lumbar spinal stenosis. From diagnosis to correct therapy]. / Lumbale Spinalkanalstenose. Von der Diagnose bis zur richtigen Therapie.

The number of patients with a diagnosis of lumbar spinal stenosis (LSS) is steadily increasing and the expectations of patients are high; however, valid data for an appropriate therapy are lacking. Treatment is mostly the result of the surgeon's experience and the clinical focus. The findings in magnetic resonance imaging (MRI) often do not correlate with the patient's symptoms. It is proposed that treatment should start with a conservative multimodal approach. Increased pain with neurogenic claudication symptoms under conservative treatment should be treated surgically. Absolute indications for surgery, such as a conus cauda syndrome are rare. The goal of all surgical procedures is to decompress the spinal canal without compromising the stability of the motion segment. This can also make an additional fusion necessary.

[Conservative treatment of idiopathic scoliosis with effective braces: early response to trunk asymmetry may avoid curvature progress]. / Konservative Therapie der idiopathischen Skoliose mit dem Korsett : Hohe Korrekturraten bei frühzeitiger Beobachtung und Behandlung der Rumpfasymmetrie.

Vertical posture of the growing child requires minute central nervous control mechanisms in order to maintain symmetry of the torso in its various activities. Scoliosis describes a constant deviation in the frontal, transverse and sagittal planes from the dynamic symmetry of the trunk. Early intervention with effective bracing, physiotherapy and sports can reverse curve progression during growth spurts, once these are identified in screening. Modern braces have a derotating and reducing effect (mirror effect) on asymmetric body volumes, thus influencing the growing torso and restoring lasting symmetry. Recent data support the use of braces to reverse progressing scoliosis.

[Flexible flatfoot in children: variation within normal range or need for treatment?]. / Der kindliche Knick-Senk-Fuß: Normvariante oder therapiebedürftige Deformität?

Flexible flatfoot in childhood is a common cause for repetitive consultations and the diagnosis is verified by the clinical examination. In most cases the findings are age-dependent variants of the norm and if asymptomatic there is no need for treatment. In the first decade of life symptomatic flexible flatfoot should initially be treated with shoe inserts. Further diagnostic steps are required once conservative treatment is unsuccessful or a rigid structural deformity is found in the clinical examination. The underlying reasons may be neuropathic or structural anatomical in origin. Lateral column lengthening as described by Evans or minimally invasive arthroereisis are well established surgical options but for arthroereisis the number of long-term studies is low. In general the indications for surgical and conservative therapy have to be judged with caution although parents often see an urgent need for treatment.

[Treatment of patellar instability in children and adolescents]. / Therapie der patellaren Instabilität bei Kindern und Jugendlichen.

To address recurrent patellar instability in children and young adolescents a variety of therapeutic options exist either as non-operative or operative treatment. Recent options, such as reconstruction of the medial patellofemoral ligament have evoked a new focus of attention on this topic. The intention of this article is to present diverse therapeutic options and to evaluate them by reference to the current literature.

[Clinical pathway - conservative back pain treatment]. / Klinischer Behandlungspfad - konservative Wirbelsäulenbehandlung.

Back pain is a very common clinical picture. The causes are often not only somatic, which generally has led to a biopsychosocial understanding of this disease. Therefore, it is necessary to employ a multimodal treatment approach to achieve effective and longer-lasting relief. Such a concept requires the cooperation of multiple disciplines in a sophisticated and strongly organized manner. In our clinic we have developed a clinical pathway for conservative back pain treatment that avoids the use of too much time by careful coordination of the therapy elements. It has proven to be a successful tool for the efficient treatment of patients with primarily somatically caused back pain. The following article describes this clinical pathway.

[Orthotic methods for osteoporosis and osteoporotic vertebral fracture]. / Orthesenversorgung bei Osteoporose und osteoporotischen Wirbelkörperfrakturen.

Even in times of kyphoplasty and vertebroplasty, braces remain an efficient option in the treatment of osteoporotic hyperkyphosis due to imminent or manifest vertebral wedging with the obligatory pain and fracture risk of adjacent vertebraes. In the same fashion, acute osteoporotic fractures with considerable backpain can be treated with an adequate orthosis besides analgetics and osteological drugs. Essential is the careful selection of the right brace for a given type of osteoporotic fracture: Overall brace-frames (Stagnara type) should be used only in highly unstable or multiple osteoporotic fractures with impact onto the spinal canal where surgery is not possible. These brace frames should be administered only for the shortest possible period (8-12 weeks) to reduce muscle atrophy and immobilization. However, in the typical stable osteoporotic wedge fracture, light weight constructions like the Jewett or Bähler-Vogt brace or - in less severe cases - dynamic braces (e.g. TorsoStretch brace or SpinoMedActive brace) should be used to minimize muscle atrophy and demineralisation. Brace treatment at its best though, can be only one step in the cascade of measures to fight demineralisation and the clinical consequences: General physiotherapy, analgetics and specific osteological drugs and minerals add essentially to the treatment.

[Minimally invasive injection therapy for patients with radicular lumbar spine syndrome. First results of an minimally invasive treatment for patients with lumbar radiculopathy]. / Minimalinvasive Injektionstherapie beim radikulären Lumbalsyndrom. Erste Ergebnisse bei Patienten mit lumbaler Radikulopathie.

BACKGROUND: There are few studies on minimally invasive injection therapy (MIT) combined with multimodal conservative therapeutic options. Here, we evaluate the results of MIT in a clinical study. METHODS: A total of 61 patients with radicular lumbar symptoms treated with MIT were examined before and 14.5 months after treatment. Subjective, objective, clinical and anamnestic parameters were considered. RESULTS: In most cases, protrusions and prolapses were seen. Radicular pain, sensible and motoric deficits and also functionality of the spine could be rectified after MIT. No major complications were seen during treatment. CONCLUSION: MIT is an effective approach with few complications for the treatment of patients with radicular syndromes.

[Minimal-invasive injection therapy for cervical syndromes]. / Minimal-invasive Therapie bei Zervikalsyndromen.

The specific minimal-invasive injection therapy is a key-procedure for cervical spine syndromes when performing a multimodal pain-therapy. Due to the exactly placed injections pain can be overcome. Indication is given in cases of continuing spine pain and is an alternative to operative procedure, as for as no absolute indication for operation is given. The complex injection technique affords knowledge and expertise. The exact application and the specific complications are presented in detail.

[Minimally invasive injection therapy in lumbar syndromes]. / Minimal-invasive Injektionstherapie beim Lumbalsyndrom.

Minimally invasive injection therapy is an effective approach for the treatment of sciatica with less complications. This therapy is a sufficient option in cases without absolute indications for operation.The paper describes in detail the different injection techniques like spinal nerve analgesia, epidural dorsal/perineural injections, vertebral joint infiltrations, and radiculographies.

Long-term results of ventro-dorsal versus ventral instrumentation fusion in the treatment of spondylitis.

This study examines prospectively the randomised, long-term, clinical and radiological results of the treatment of spondylitis patients by ventro-dorsal or ventral spine fusion. Group 1 consisted of 12 patients who (after ventral removal of the focus of infection and autologous bone grafting) were treated by dorsal instrumentation. Group 2 consisted of ten patients who, after similar ventral removal and bone interposition, were stabilised by ventral instrumentation. The patients prospectively underwent clinical and radiological studies. In addition, they were asked to fill in self-assessment questionnaires such as the short-form (SF)-36 health survey, the Oswestry questionnaire, and the visual analog scales (VAS). The postoperative follow-ups were at 6 months, 2 years and 5.4 years. It proved possible to demonstrate clinically that patients with an isolated ventral spondylodesis feel significantly better and experience significantly less pain in the area of spinal fusion than patients with ventro-dorsal fusion 2 and 5.4 years after the operation. Over a number of years a stable fusion can be achieved through either operation. Ventral stabilisation yields more advantages than dorsal instrumentation in the long term. These advantages result in a clinically smoother course after the operation. If, in the individual case, ventral instrumentation is feasible, this method should be used.

[Pullout resistance of conventional pedicle screw implantation in comparison to fluoroscopic computer-assisted technique]. / Ausrissfestigkeit implantierter Pedikelschrauben in konventioneller und fluoroskopisch-navigierter Technik.

AIM: Aim of the study was to compare pullout resistance of pedicle screws after conventional and fluoroscopic computer-assisted implantation in the cadaveric thoracic and lumbar spine. METHODS: Pedicle screws were inserted in a total of 10 vertebrae of different human specimens: 10 screws were placed using conventional technique (group 1) and 10 screws were inserted with fluoroscopic computer-assisted system contralaterally (group 2). Then pedicle screws were evaluated for biomechanical axial pullout resistance. RESULTS: Mean pullout force was 232 N (range 60-600 N) in group 1 and 353 N (range 112-625 N) in group 2. The difference was significant (p=0,0425). CONCLUSION: Fluoroscopic navigated implantation of pedicle screws increases the pullout strength in thoracic and lumbar cadaveric spines as compared with conventional methods.

Stability of anterior vertebral body screws after kyphoplasty augmentation. An experimental study to compare anterior vertebral body screw fixation in soft and cured kyphoplasty cement.

The goal of this cadaver study was to compare the stability of anterior vertebral body screws after implantation in soft or cured kyphoplasty cement. Anterior vertebral body screws were inserted in a total of 30 thoracolumbar vertebrae of ten different human specimens: ten screws were implanted in non-augmented vertebrae (group 1), ten screws were placed in soft cement (group 2), and ten screws were placed in cured cement (group 3). The screws were then tested for biomechanical axial pullout resistance. Mean axial pullout strength was 192 N (range: 10-430 N) in group 1, 364 N (range: 65-875 N) in group 2, and 271 N (range: 35-625 N) in group 3. The paired Student's t-test demonstrated a significant difference between pullout strength of groups 1 and 2 (p= 0.0475). No significant difference was seen between pullout strength of groups 1 and 3 (p= 0.2646) and between groups 2 and 3 (p= 0.3863). We achieved a 1.9 times higher pullout strength with kyphoplasty augmentation of osteoporotic vertebrae compared with the pullout strength of non-augmented vertebrae. Implantation of anterior vertebral body screws in cured cement is a satisfactory method. With this method we found a 1.4 times higher pullout strength than non-augmented vertebrae.

[Stability of pedicle screws in comparison to anterior vertebral body screws after kyphoplasty augmentation]. / Stabilität von Pedikelschrauben versus ventral eingebrachter Schrauben nach Kyphoplastie-Augmentation.

AIM: Aim of the study was to compare stability of pedicle screws and ventral implanted screws after insertion in soft or cured kyphoplasty cement. METHODS: Pedicle screws were inserted in a total of 40 thoracolumbar vertebrae of 10 different formalin-fixed human specimens: each 10 pedicle screws were implanted in soft (group 1) and cured cement (group 2), each 10 ventral screws were placed in soft (group 3) and cured (group 4) cement. Pedicle screws were then evaluated for biomechanical axial pullout resistance. RESULTS: Mean pull-out force was 452 N (range 60-1 125 N) in group 1, 367 N (range 112-840 N) in group 2, 364 N (range 65-875 N) in group 3 and 271 N (range 35-625 N) in group 4. CONCLUSION: Implantation of pedicle screws and ventral implanted screws in soft and cured kyphoplasty cement is a sufficient method. We achieved more stability with pedicle screws compared with ventral implanted screws in soft and cured cement. No significant difference was seen.

[Postoperative autologous retransfusion of collected shed blood after total knee arthroplasty with the cell saver]. / Postoperative Drainageblutretransfusion mit dem Cellsaver bei endoprothetischem Kniegelenkersatz.

AIM: The purpose of this study was to examine if it is possible to reduce transfusion of blood units by collecting shed blood with the Cell Saver for autologous retransfusion in total knee arthroplasty (TKA). METHOD: In 186 patients drainage blood was collected over a 6-h period after total knee arthroplasty with a Cell Saver system in order to make retransfusions if necessary. A tourniquet was used routinely throughout the operation. No preoperative blood donation was performed. In 19 patients preoperative haemoglobin levels were below 12 g/dL (group A, anaemic patients). In the other 167 patients (group B) the preoperative haemoglobin levels were higher. RESULTS: 4 patients (21 %) in group A received a homologous blood transfusion. Only 1 patient (0.6 %) in group B received one unit of erythrocyte concentrate (difference statistically significant, P < 0.001). In group A 8 patients (42 %) received 284 ml (145-621 ml) Cell-Saver concentrate on average, 38 patients (23 %) in group B received 358 mL (147-776 ml) Cell-Saver concentrate on average. CONCLUSION: With a risk lower than 1 % for patients without anaemia to get a homologous blood transfusion one can do without the more expensive preoperative blood donation in total knee arthroplasty if a tourniquet is used for the operation and a Cell Saver is used for facultative retransfusion of drainage blood.