[Epidural injection shows no advantages over oral medication and physiotherapy in the treatment of sciatica, irrespective of the duration of symptoms]. / Kein Vorteil der epiduralen Injektion vs. oraler Medikation und Physiotherapie bei Ischialgie, unabhängig von der Beschwerdedauer.

BACKGROUND: The study presented here investigated the short-term effectiveness of one-off lumbar caudal epidural injection (EI) in sciatica in relationship to the reported duration of pain. MATERIALS AND METHODS: This retrospective analysis involved 106 consecutive in-patients who received either conservative treatment (Group I) or an additional EI on the first day of their treatment (Group II). Both groups were divided according to the duration of symptoms at the time of admission (less than three months, or more than six months). Propensity score matching was performed for the whole collective and the resulting subgroups. This incorporated gender, age and pain intensity at the time of admission. The target parameter were changes on a visual analogue scale (VAS) of pain intensity on days D1, D3, and D10 depending on the respective treatment. A routine evaluation of the mental variables anxiety, depression and somatisation was performed as part of the examination upon admission and their relationship to the success of treatment was later assessed. RESULTS: The mean age of the patients was 61.7 (± 11.6) in Group I and 63.6 (± 13.6) in Group II. 59 % of the patients were female (n = 63). The Lasègue sign was prevalent in 45 % of Group I and 51 % of Group II. The intensity of pain on the day of admission was similar in both groups (7.0 ± 1.0 for Group I, 6.7 ± 1.8 for Group II). The length of stay on the ward was also similar in both groups (10.2 ± 3.9 and 9.4 ± 3.7 d, respectively). It was found that, independent of the duration of symptoms, injection treatment was significantly more effective than conservative treatment only in the early stages (D1 and D3, p < 0.001). No differences could be found in the expression of these mental variables between treatment groups, as these factors showed no influence on the results of therapy. CONCLUSIONS: In the context of acute treatment a once only lumbar caudal epidural injection represents at most a short-term effectiveness for the therapy of sciatica. The results presented here indicate that neither the duration of symptoms nor the measured psychometric variables show any effect on the success of therapy.

Clinical application of shock wave therapy (SWT) in musculoskeletal disorders.

Currently the application of shock wave therapy (SWT) in musculoskeletal disorders has been primarily used in the treatment of tendinopathies (proximal plantar fasciopathy, lateral elbow tendinopathy, calcific tendinopathy of the shoulder, and patellar tendinopathy, etc.) and bone defects (delayed- and non-union of bone fractures, avascular necrosis of femoral head, etc.). Although the mechanism of their therapeutic effects are still unknown, the majority of published papers have shown positive and beneficial effects of using SWT as a treatment for musculoskeletal disorders, with a success rate ranging from 65% to 91%, while the complications are low or negligible. The purpose of this paper is to inform the reader about the published data on the clinical application of SWT in the treatment of musculoskeletal disorders. In this paper, with the help of a literature review, indications and success rates for SWT in the treatment of musculoskeletal disorders are outlined, while adequate SWT parameters (e.g., rate of impulses, energy flux density, etc.) are defined according to the present state of knowledge.

Risk factors for heterotopic ossification and spur formation after total knee arthroplasty.

INTRODUCTION: The present study investigated the incidence and risk factors of heterotopic ossification (HO) after implantation of knee prosthesis. MATERIALS AND METHODS: We undertook a retrospective cohort study in 434 cases (363 patients) treated with a total knee replant using a Press-Fit-Condylar (P.F.C.(®)Sigma(®)) prosthesis. The occurrence of HO in radiograph after a follow-up period of 11.2 ± 2.4 months was correlated in a regression model with a variety of influencing factors. RESULTS: 21 patients (4.8 %) developed heterotopic ossifications, all located in the area of the distal femur. The only risk factor found concerning the development of HO was osteoarthritis when compared to rheumatoid arthritis (OR = 4.07, 95 % CI 1.18-14.05; p = 0.0201) and postoperative wound healing problems (OR = 11.32, 95 % CI 3.26-39.33; p = 0.0001). Notching (OR = 2.22, 95 % CI 0.92-5.36; p = 0.0765) and osteophyte forming (hypertrophic) arthrosis (OR = 2.40, 95 % CI 0.97-5.95; p = 0.0596), however, were associated with the development of a bony spur in the contact area of the femoral component of the prosthesis. CONCLUSIONS: Our study has revealed that patients with rheumatoid arthritis are at lower risk of HO than patients with osteoarthritis. An impairment of wound healing would appear to promote the development of a HO. Notching and hypertrophic arthrosis are highly likely to be associated with the development of a bony spur in the ventral contact area of the prosthesis.

Application of local anesthesia inhibits effects of low-energy extracorporeal shock wave treatment (ESWT) on nociceptors.

OBJECTIVE: Clinical studies of extracorporeal shock wave therapy (ESWT) provided conflicting results depending on the use of local anesthesia (LA). DESIGN: The present study investigated whether the biological effects of ESWT differ between application with and without LA. SETTING AND PATIENTS: In 20 healthy subjects, ESWT was applied to the ventral surface of forearm skin, either after topical lidocaine pretreatment or without on the corresponding contralateral side. MEASURES: During and after ESWT ongoing pain, axon-reflex vasodilation (laser Doppler imaging), thresholds for pinprick, and blunt pressure were recorded. RESULTS: The results indicate that increasing ESWT energy flux density led to increasing pain (P < 0.001). LA reduced ESWT-related pain (P < 0.02) and in parallel inhibited local axon-reflex vasodilation (P < 0.001). In addition, LA prevented ESWT-related drop in pressure pain threshold (P < 0.001). CONCLUSION: This study provided evidence that ESWT dose-dependently activates and sensitizes primary afferent nociceptive C-fibers, and that both activation and sensitization were prevented if LA was applied locally. These results suggest that LA substantially alters the biological responses of ESWT.

Cell viability, osteoblast differentiation, and gene expression are altered in human osteoblasts from hypertrophic fracture non-unions.

Recent studies have provided evidence that the number and proliferation capacity of bone marrow-derived mesenchymal stem cells, as well as the number of osteoprogenitor cells are reduced in patients with fracture non-unions. For fracture non-unions that do not heal after appropriate surgical intervention, the question arises as to what extent systemic cellular dysfunctions should be considered as being pathogenetic factors. For this purpose, we have examined the hypothesis that the cell function of osteoblasts isolated from patients with fracture non-unions may differ from those of normal control individuals in an identical and controlled in vitro situation. We analyzed the osteoblast cell viability, formation of alkaline phosphatase-positive (CFU-ALP) and mineralization-positive (CFU-M) colony forming units, as well as global differences of gene expression in osteoblasts from patients with fracture non-unions and from control individuals. We found that cell viability and CFU-M-formation were significantly reduced in non-union osteoblasts. This was accompanied by significant differences in osteoblast gene expression as revealed by Affymetrix-microarray analysis and RT-PCR. We identified a set of significantly down-regulated factors in non-union osteoblasts that are involved in regulation of osteoblast proliferation and differentiation processes (canonical Wnt-, IGF-, TGF-beta-, and FGF-signaling pathways). The results of the present study strongly support the hypothesis that cell viability, differentiation, and gene expression of osteoblasts may be altered in patients who develop recurrent and recalcitrant fracture non-unions. Proteins involved in Wnt-, IGF, TGF-beta-, and FGF-signaling pathways may be of particular interest and may unveil new potential therapies.

The influence of bone allograft processing on osteoblast attachment and function.

In order to assess the influence of eight different sterilisation and disinfection methods for bone allografts on adhesion, proliferation, and differentiation of human bone marrow stromal cells (BMSC), cells were grown in culture and then plated onto pieces of human bone allografts. Following processing methods were tested: autoclavation (AUT), low-temperature-plasma sterilisation of demineralised allografts (D-LTP), ethylene oxide sterilisation (EtO), fresh frozen bone (FFB), 80 degrees C-thermodisinfection (80 degrees C), gamma-irradiation (Gamma), chemical solvent disinfection (CSD), and Barrycidal-disinfection (BAR). The seeding efficiency was determined after one hour to detect the number of attached cells before mitosis started. The cell viability was determined after 3, 7, and 21 days. Tests to confirm the osteoblastic differentiation included histochemical alkaline phosphatase staining and RT-PCR for osteocalcin. Human BMSC showed greatest attachment affinities for D-LTP-, 80 degrees C-, and CSD-allografts, whereas less cells were found attached to AUT-, EtO-, FFB-, Gamma-, and BAR-probes. Cell viability assays at day 3 revealed highest proliferation rates within the FFB- and 80 degrees C-groups, whereas after 21 days most viable cells were found in D-LTP-, 80 degrees C-, CSD-, and Gamma-groups. BAR-treatment showed a considerably toxic effect and therefore was excluded from all further experiments. Highest AP-activity and gene expression of osteocalcin were detected in the D-LTP-group in comparison with all other groups. In summary, our results demonstrate that cell adhesion, final population, and function of BMSC are influenced by different disinfection and sterilisation methods. Therefore, processing-related alterations of BMSC-function may be important for the success of bone grafting. The experimental setup used in the present work may be useful for further optimisation of bone allograft processing.

[Shock wave treatment for tennis elbow]. / Stosswellentherapie bei Tennisellenbogen Literaturüberblick.

Randomized controlled trials were evaluated to assess the effectiveness of extracorporeal shock wave treatment in the management of tennis elbow. Five trials had a mediocre methodology and four trials had a high-quality design. Well-designed randomized control trials have provided evidence of the effectiveness of shock wave intervention for tennis elbow.

[Evidence-based evaluation of present guidelines for the treatment of tennis elbow -- a review]. / Evidenz-basierte Uberprüfung der Therapieempfehlungen bei Epicondylopathia humeri lateralis (Tennisellenbogen) -- eine Ubersicht.

The guidelines of the German Orthopaedic Societies regarding the treatment of lateral elbow epicondylitis were analysed on the ground of recently published reviews or randomised placebo-controlled trials (RCT). For the acute phase, reviews or RCTs failed to show a clinical effect beyond placebo if follow-up was extended over 6 weeks. For the chronic phase a current Cochrane review failed to identify any controlled trial regarding surgical procedures during the last decades. Without an adequate control group, it is not possible to draw any meaningful conclusions about the value of this modality of treatment. Therefore surgery is not indicated before repetitive low-energy extracorporeal shock wave therapy (ESWT) has been applied. This novel treatment, under strictly standardized conditions, showed effects beyond placebo in independent randomised placebo-controlled trials for follow-up periods of 3 and 6 months. To date there exists no evidence-based therapeutic algorithm for the treatment of acute and chronic tennis elbow. Even medium-term effects should be regarded as either a placebo effect or natural regression to the mean.

[BWS-mobility in patients with an impingement syndrome compared to healthy subjects--an inclinometric study]. / Die BWS-Beweglichkeit von Impingementpatienten im Vergleich zu Gesunden -- eine inklinometrische Studie.

AIM: The aim of this study was to analyse the relation between the mobility of the thoracic spine and an impingement syndrome of the shoulder. METHOD: In a prospective study, 50 patients with an impingement syndrome and 50 healthy test subjects were examined for the mobility of their thoracic spines. All patients and test subjects were examined according to a standardized protocol. The experiments were carried out in the biomechanical laboratory of our clinic with the Plurimetercompass and the Inclinometer of Rippstein. RESULTS: In 23 patients a tendinosis calcarea was diagnosed radiologically, 27 patients suffered from a plain impingement without calcification, hence both groups were analyzed separately. The mobility of the thoracic spine in the sagittal and frontal planes and in rotation was significantly different between the three groups. The highest mobility was found in the healthy test subjects, the lowest in patients with a plain impingement. No differences were found concerning the initial posture of the thoracic spine. CONCLUSION: There is a relation between mobility of the thoracic spine and an impingement syndrome. This should be respected in diagnosis and therapy.

Individual bone cement spacers (IBCS) for septic hip revision-preliminary report.

BACKGROUND: Two-stage septic hip revision with intermediate resection arthroplasty leads to temporary poor function and difficult reimplantation. Antibiotic-loaded cement spacers improve patient mobility and maintain stability of the joint as well as length of the limb. Prefabricated spacers are readily available but lack adaptability. We developed modular moulds separately for stem and head to create more individual spacers with optimised femoral press-fit and smooth head surface. METHODS: Moulds are fabricated preoperatively by forming 4 mm polyethylene over trial stems and cups under vacuum (MS 30, Centerpulse, Switzerland). After gas sterilization, Refobacin Palacos (Merck, Darmstadt, Germany) is poured into stem and head moulds of appropriate size. A double K-wire is inserted as a rod. Fluoroscopy is used to check for air inclusions, which might impair resistance. For mechanical resistance testing trials, 5 spacers were resin-fixed with 80% stem insertion and loaded in a craniocaudal direction at 20 N/s (universal testing machine, Zwick, Germany) until failure. RESULTS: The static testing showed an average failure load of 1550 N (range 1350-2000 N). The K-wires prevented complete dislocation of the fragments. CONCLUSION: Partial weight-bearing is possible with this system, but a fall might lead to an acute fracture. New materials for the core can be tested with our biomechanical model. Following the presented craniocaudal static testing, torsion testing and dynamic testing in Ringer's solution are planned.

[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.

[High energy extracorporeal shockwave therapy (ESWT) in pseudarthrosis]. / Die hochenergetische extrakorporale Stosswellentherapie (ESWT) bei Pseudarthrose.

The gold standard for treatment of pseudarthrosis is operation with osteosynthesis and grafting. More than 10 years ago, extracorporeal shock wave therapy (ESWT) was additionally introduced as a noninvasive and low-risk treatment for pseudarthrosis. The aim of our prospective study was to analyze the treatment effect in a homogeneous group of patients and to develop prognostic factors. Forty-three consecutive patients were included in this study. All patients had been operated on for trauma or undergone selective osteotomy and had developed pseudarthrosis that persisted for 9 months. All patients received high-energy ESWT (0.6 mJ/mm2) with 3000 impulses (Siemens Osteostar) in one session under regional anesthesia. To differentiate active from inactive pseudarthrosis, a bone scintigraphy was compulsory. Clinical and radiological follow-ups were done at 4-week intervals starting 8 weeks after ESWT for 9 months. Cortical bridging was found in 31 of 43 (72.1%) pseudarthroses at 4.0 +/- 0.6 months after ESWT. Of 31 (80.6%) successfully treated patients, 25 had a positive scintigraphy compared to 4 of 12 (33.3%) treatment failures. Of 35 (82.9%) patients with a positive bone scintigraphy, 29 had bony healing compared to 2 of 8 (25%) patients with a negative bone scintigraphy. Six of these eight patients smoked more than 20 cigarettes a day. ESWT is still a clinically experimental treatment method. The absence of complications justifies its use for pseudarthrosis treatment. Further controlled studies are mandatory.

[Basic research of applying extracorporeal shockwaves on the musculoskeletal system. An assessment of current status]. / Grundlagenforschung zur Applikation extrakorporaler Stosswellen am Stütz- und Bewegungsapparat. Eine Standortbestimmung.

Detailed knowledge concerning the action of extracorporeal shock waves on the locomotor system as well as concerning possible side effects of extracorporeal shock wave therapy (ESWT) are crucial to optimize the clinical use of ESWT for the treatment of illnesses such as calcific tendinitis of the shoulder, tennis elbow, plantar fasciitis, aseptic pseudarthrosis, and aseptic hip necrosis. This study presents the current knowledge gained from animal experiments, which have yielded important findings, in particular concerning possible side effects of ESWT. Very recent studies have also provided valuable insights into the molecular actions of extracorporeal shock waves on the locomotor system. Further intensified experimental animal research will greatly improve the scientific basis for the clinical use of ESWT in the near future.

[Effect of design and implantation technique on risk of progressive sintering of various cervical vertebrae cages]. / Einfluss von Design und Implantationstechnik auf das Risiko der progredienten Sinterung verschiedener HWS-Cages.

The aim of this study was to compare the subsidence of differently designed cervical interbody fusion devices under defined conditions. Forty-five bovine vertebral bodies were dissected from soft tissue and cartilage. The bony end plate was then taken off by 0, 1, and 2 mm. Five vertebral bodies of each abrasion depth were prepared for the uptake of a fusion device. Thus, three different fusion devices of comparable size underwent biomechanic testing in a Zwick testing machine with 4000 cycles of axial compression between 50 and 1000 N. Every 1000 cycles, the subsidence into the vertebral body was measured. Abrasion of the end plate resulted in an increased subsidence. The cage with rectangular shape and the cage with cylindric body and lateral wings showed better resistance to axial compression as long as the end plate remained intact. When the end plate was taken off, the subsidence was as high as in the cylindric cage, of which the subsidence did not correlate to the end plate abrasion. During preparation of the implant bed, the cortical bone of the end plate must be treated carefully. In cases of intact end plate, rectangular supporting areas can decrease the risk of subsidence.

[Musculoskeletal shock wave therapy--current database of clinical research]. / Muskuloskeletale Stosswellenapplikation - Aktueller Stand der klinischen Forschung zu den Standardindikationen.

During the past decade application of extracorporal shock waves became an established procedure for the treatment of various musculoskeletal diseases in Germany. Up to now the positive results of prospective randomised controlled trials have been published for the treatment of plantar fasciitis, lateral elbow epicondylitis (tennis elbow), and of calcifying tendinitis of the rotator cuff. Most recently, contradicting results of prospective randomised placebo-controlled trials with adequate sample size calculation have been reported. The goal of this review is to present information about the current clinical database on extracorporeal shock wave treatment (ESWT).

Side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of tennis elbow.

Apart from a few observational reports, there are no studies on the side-effects of extracorporeal shock wave therapy (ESWT) in the treatment of insertion tendopathies. Within the framework of a randomised, placebo-controlled, single-blind, multicentre study to test the effectiveness of ESWT in the case of lateral epicondylitis (LE), side-effects were systematically recorded. A total of 272 patients from 15 centres was allocated at random to active ESWT (3 x 2000 pulses, energy flux density ED(+) 0.04 to 0.22 mJ/mm(2) under local anaesthesia) or placebo ESWT. In all, 399 ESWT and 402 placebo treatments were analysed. More side-effects were documented in the ESWT group (OR = 4.3, CI = [2.9; 6.3]) than in the placebo group. Most frequently, transitory reddening of the skin (21.1%), pain (4.8%) and small haematomas (3.0%) were found. Migraine was registered in four and syncopes in three instances after ESWT. ESWT for LE with an energy flux density of ED(+) 0.04 to 0.22 mJ/mm(2) is a treatment method which has very few side-effects. The possibility of migraine being triggered by ESWT and the risk of a syncope should be taken into account in the future. No physical shock wave parameters could be definitely identified as the cause of the side-effects observed.

Health-related quality of life and somatization in patients with long-term low back pain: a prospective study with 109 patients.

STUDY DESIGN: For this study, a prospective cohort of 109 patients was recruited consecutively at an orthopedic inpatient unit of a university hospital. Three self-report instruments were administered to patients with sciatica believed to be caused by a herniated lumbar disc to examine their quality of life and psychic stress at baseline and at the 1-year follow-up visit. OBJECTIVES: To investigate whether patients who have undergone a previous discectomy experience greater psychic stress than patients with no surgery, and to determine whether the groups differed regarding their health-related quality of life at the follow-up visit. SUMMARY OF BACKGROUND DATA: Previous studies have described psychic abnormalities in patients with long-term back pain, particularly patients with severe chronicity (i.e., history of surgeries and persistent problems) or those who underwent a previous discectomy. Additionally, a series of studies has shown that psychic and psychosocial parameters exert a significantly greater influence on the success of treatment than do clinical and imaging findings or the extent of disc abnormality. METHODS: The Short Form Health Survey 36, the Symptom Checklist 90, and Screening for Somatoform Disorders were administered to 109 patients consecutively treated in the authors' orthopedic university clinic, at baseline and at the 1-year follow-up visit. RESULTS: In all the patients examined, the physical and mental quality of life improved regardless of their group classification. The psychological distress, according to the Symptom Checklist 90, was clearly reduced in both groups at the follow-up visit, with the exception of somatization, as indicated by Symptom Checklist 90 and Screening for Somatoform Disorders. Whereas the patients who had undergone surgery remained nearly unchanged with regard to their somatization, the patients with no previous surgery improved significantly, as indicated by Screening for Somatoform Disorders and Symptom Checklist 90. Somatization, particularly that surveyed by the comprehensive Screening for Somatoform Disorders, proved to be quite a stabile factor over time in both groups. The extent of the physical impairment before treatment was nearly the same in both groups, as indicated by Short Form Health Survey 36. Despite a markedly higher chronicity of reported problems, patients who had undergone surgery were hardly more greatly impaired in terms of their mental quality of life and psychological distress, as indicated by Symptom Checklist 90, than those without a history of surgery. At the follow-up visit, the differences tended to be minimal as well. As compared with those who had no previous surgeries, the patients who had undergone surgery were significantly more heavily impaired in their physical quality of life despite significant improvements. CONCLUSIONS: Patients with sciatica demonstrated less abnormality in terms of the psychopathologic markers investigated than described in previous studies. Nevertheless, the predisposition to somatize influences health-related quality of life to a high degree.