Botulinum Toxin for Chronic Lateral Epicondylitis (LE). / Botulinumtoxin bei chronischer Epicondylitis humeroradialis.

Lateral epicondylitis is a common disease in orthopaedic practice. Although the majority of cases do not become chronic, patients who do not respond to the initial treatment may suffer from pain in the long term and effective treatment is challenging. The off-label use of botulinum toxin is one of the common potential indications for the substance in orthopaedics and traumatology. In a literature review of 2000 - 2019, eight EBM ≥ level 3 studies evaluating the use of botulinum toxin in lateral epicondylitis were found. Five of these studies evaluated botulinum toxin versus placebo in chronic cases; two other studies compared botulinum toxin with corticosteroids in acute cases and classic Hohmann surgery in chronic cases; the eighth study compared botulinum toxin in two different injection sites and corticosteroids by classic injection. Our findings suggest that the use of this substance may be a treatment option in refractory chronic cases before surgery is indicated. The working group on botulinum toxin in O & T of the International Musculoskeletal Pain Society (IMPS/IGOST) introduced an alternative injection schedule, which combines findings from the recent clinical literature with practical experience in order to reduce the risk of side effects while ensuring treatment effectiveness. Using 2 simple tests of function and, if necessary, sonographic verification, 2 separate injection sites in the extensor carpi radialis or the extensor digitorum can be identified by palpation. The tendon level on the lateral epicondyle acts as the third injection site. With optimal use of the ampoule content, the 3 injection sites can be infiltrated individually, depending on the muscle status. On the one hand, this enables treatment to take place after a dual therapy approach and, on the other hand, the risk of overdose in a muscle with subsequent unnecessary muscle weakening can be reduced.

MRI in patients with pacemakers: overview and procedural management.

BACKGROUND: Magnetic resonance imaging (MRI) is generally contraindicated for patients with a pacemaker (PM) or implantable cardiac defibrillator (ICD), because of the risk of life-threatening interference with the device. Nevertheless, the question whether to perform MRI despite the presence of these devices can still arise when MRI is vitally indicated. In some hospitals, special precautionary measures are taken so that MRI can be performed in such cases. METHODS: This review is based on the authors' experience in 42 patients who underwent MRI at our university hospital, on the pertinent literature, and on the recommendations of medical societies. RESULTS: Because of its excellent image quality, MRI is often an indispensable diagnostic tool. Structured multidisciplinary management enables it to be performed safely even in patients with a PM or ICD. Pre- and post-MRI checks of the device are recommended, as well as extensive monitoring and the availability of the necessary personnel to deal with an emergency. In general, the pacing and defibrillator functions should be deactivated; for pacemaker-dependent patients, the asynchronous pacing mode should be activated. No serious incidents have occurred when these precautions have been observed, either among our own patients or in the literature. Newer PM systems have been approved for MRI scanning under certain conditions. CONCLUSION: In patients with a PM or ICD, the benefit of MRI may far outweigh its risks if the indication has been established for the particular patient as an interdisciplinary decision and if the appropriate precautions are observed during scanning. Now that newer PM systems have been approved for MRI scanning, the problem seems close to being solved.

Relationship between human femorotibial joint configuration and the morphometry of the anterior cruciate ligament.

INTRODUCTION: Individual variations in the anatomy of the knee joint have been suggested to affect the ability to functionally compensate for ACL insufficiency or to put an individual at an increased risk of ACL injury. These variations include the posterior tibial slope, the concavity of the medial tibial plateau, the convexity of the lateral tibial plateau, and the configuration of the femoral condyles. METHOD: This anatomical study investigates if there is a correlation between the individual surface geometry of the femorotibial joint and the morphometry of the ACL. These data were assumed to provide evidence whether or not the functional stability of an ACL-insufficient knee may be derived from its radiographic surface geometry. Standardised measurement techniques were used to analyse the surface geometry of 68 human cadaver knees. Data were correlated with the cross-sectional area, the area of insertion and position of the footprint of the ACL and its functional bundles. RESULTS: Analysis revealed that there was a significant, but weak correlation between the femoral and tibial area of ACL insertion and the depth of the medial and lateral femoral condyle. No correlation was found between the surface geometry of the femorotibial joint and the cross-sectional area of the ACL. The results of this anatomical study suggest that the relationship between the joint surfaces and the morphometry of the ACL primarily is a function of size of the knee joint. CONCLUSIONS: Based on our results, there is no evidence that the stability of the knee can be derived from its radiographic surface geometry.

The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee.

BACKGROUND: Osteoarthritis is the most common joint disease of adults worldwide. Its incidence rises with age. Both intrinsic and extrinsic risk factors promote its development. In men aged 60 to 64, the right knee is more commonly affected; in women, the right and left knees are affected with nearly equal frequency. METHODS: The PubMed, Medline, Embase and Cochrane Library databases were selectively searched for current studies (up to September 2009; case reports excluded) on the epidemiology, etiology, diagnosis, staging, and treatment of osteoarthritis of the knee. The search terms were "gonarthrosis," "prevention," "conservative treatment," "joint preservation," "physical activity," "arthroscopy," "osteotomy," "braces," "orthoses," and "osteoarthritis knee joint." RESULTS AND CONCLUSION: Osteoarthritis is not yet a curable disease, and its pathogenesis remains unclear. The best treatment for osteoarthritis of the knee is prevention. The goal of therapy is to alleviate clinical manifestations. The therapeutic spectrum ranges from physiotherapy and orthopedic aids to pharmacotherapy and surgery.

Indications and contraindications for vertebroplasty and kyphoplasty.

INTRODUCTION: Vertebral fractures (VF) are a leading cause of morbidity in the elderly. In the past decade, minimally invasive bone augmentation techniques for VF, such as percutaneous vertebroplasty (VP) and kyphoplasty (KP) have become more widespread. According to the literature, both techniques provide significant pain relief. However, KP is more expensive and technically more demanding than VP. The current study surveyed German surgeons who practice percutaneous augmentation to evaluate and compare decisions regarding the implementation of these techniques. Is there a difference in the indications and contraindications of VP and KP compared with the interdisciplinary consensus paper on VP and KP of the German medical association in the treatment of VF? METHODS: A multiple choice questionnaire was designed with questions regarding diagnostic procedures, clinical and radiologic (AO classification) indications, as well as contraindications for both VP and KP. A panel of five experts refined the initial questionnaire. The final version was then sent to 580 clinics registered to practice KP in Germany. The statistical analysis was done by two authors, who collected the questionnaire data and Wilcoxon's signed ranks test was performed for non-parametric variables with SPSS. RESULTS: 327 of 580 questionnaires (56.4%) were completed and returned. 151 (46.2%) of participants were performing both procedures, and 176 (53.8%) performed KP only. Median duration from onset of acute pain to intervention was 3 weeks. For most participants (95.4%), consistent back pain at the fracture level with a visual analog scale score over 5 was the main clinical indication for VP and KP. A1 and A3.1 fractures from osteoporosis and metastasis were considered indications for KP. Osteoporotic A1.1 fractures were an indication for VP. Traumatic A3.2 fractures were not an indication for either procedure. Major contraindications to both procedures were active infection (94.7%), cement allergy (86.8%), and coagulation disorders (80.3%). CONCLUSION: Vertebroplasty and kyphoplasty both have roles in the treatment of vertebral fractures. However, we could see differences in the indications for the two percutaneous techniques. Participants of this study found more indications for KP versus VP in cases of painful A1.2 and A3.1 fractures due to osteoporosis, metastasis, and trauma. About half of the respondents reported that VP is indicated for osteoporotic and pathologic A1.1 fractures. This study offers only limited conclusions. Open questionnaires and prospective data from all clinicians performing these procedures should be analyzed to offer more specific information.

Spondylodiscitis in the elderly patient: clinical mid-term results and quality of life.

INTRODUCTION: Focusing on spondylodiscitis in elderly patients current literature does not contain much information. METHOD: We performed a retrospective case series (n = 32) comparing conservative (group 1; n = 16) versus operative (group 2; n = 16) treated spondylodiscitis patients aged > or =65 years (mean age 74.9 years) from January 2002 to April 2004. The review of the medical records provided information about the pre-hospital time, the inpatient course and the time after discharge. At follow-up (FU) (mean 3.6 years) disease specific and general quality of life (QOL) questionnaires (COMI back patient self-assessment, ODI and SF-36) were administered. RESULTS: Altogether, 71.9% of the patients could be contacted; 12.5% had died since hospitalisation and 15.6% could not be contacted anymore. At FU based on the visual analogue scale, patients indicated an average of 3.2 for back pain and 2.5 for leg pain. ODI scoring yielded minimal disability for 38.9%, a moderate disability for 22.2%, a severe disability for 22.2% and for 11.1% a crippled situation; 5.6% were bed-ridden or exaggerated their symptoms. The SF-36 PCS amounted to an average of 38.2, the MCS 50.6. Owing to additional surgery-associated risks, operative treatment of spondylodiscitis feature a complication rate twice as high in the respective group, but general complications do not differ. At FU, no statistically remarkable difference concerning QOL and remaining pain became evident between the groups, the operated patients being more satisfied with regard to the treatment of spondylodiscitis. CONCLUSION: Ultimately, if surgery is indicated the operative risks should be borne in mind, but advanced age should not be the crucial factor in decision-making.

Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine.

In the treatment of multilevel degenerative disorders of the lumbar spine, spondylodesis plays a controversial role. Most patients can be treated conservatively with success. Multilevel lumbar fusion with instrumentation is associated with severe complications like failed back surgery syndrome, implant failure, and adjacent segment disease (ASD). This retrospective study examines the records of 70 elderly patients with degenerative changes or instability of the lumbar spine treated between 2002 and 2007 with spondylodesis of more than two segments. Sixty-four patients were included; 5 patients had died and one patient was lost to follow-up. We evaluated complications, clinical/radiological outcomes, and success of fusion. Flexion-extension and standing X-rays in two planes, MRI, and/or CT scans were obtained pre-operatively. Patients were assessed clinically using the Oswestry disability index (ODI) and a Visual Analogue Scale (VAS). Surgery performed was dorsolateral fusion (46.9%) or dorsal fusion with anterior lumbar interbody fusion (ALIF; 53.1%). Additional decompression was carried out in 37.5% of patients. Mean follow-up was 29.4±5.4 months. Average patient age was 64.7±4.3 years. Clinical outcomes were not satisfactory for all patients. VAS scores improved from 8.6±1.3 to 5.6±3.0 pre- to post-operatively, without statistical significance. ODI was also not significantly improved (56.1±22.3 pre- and 45.1±26.4 post-operatively). Successful fusion, defined as adequate bone mass with trabeculation at the facets and transverse processes or in the intervertebral segments, did not correlate with good clinical outcomes. Thirty-five of 64 patients (54%) showed signs of pedicle screw loosening, especially of the screws at S1. However, only 7 of these 35 (20%) complained of corresponding back pain. Revision surgery was required in 24 of 64 patients (38%). Of these, indications were adjacent segment disease (16 cases), pedicle screw loosening (7 cases), and infection (one case). At follow-up of 29.4 months, patients with radiographic ASD had worse ODI scores than patients without (54.7 vs. 36.6; P<0.001). Multilevel fusion for degenerative disease still has a high rate of complications, up to 50%. The problem of adjacent segment disease after fusion surgery has not yet been solved. This study underscores the need for strict indication guidelines to perform lumbar spine fusion of more than two levels.

Interspinous implants (X Stop, Wallis, Diam) for the treatment of LSS: is there a correlation between radiological parameters and clinical outcome?

Neurogenic intermittent claudication, caused by lumbar spinal stenosis (LSS), usually occurs after the age of 50 and is one of the most common degenerative spinal diseases in the elderly. Among patients over the age of 65 with LSS, open decompression is the most frequently performed spinal operation. The recently introduced interspinous spacers are a new alternative under discussion. In this retrospective study, we reviewed medical records and radiographs of patients with LSS and NIC treated from June 2003 to June 2007. All included patients (n = 129) were treated with interspinous implants (X Stop Wallis, or Diam). Evaluations of pain, using a visual analog scale (VAS), and radiographic signs, using two-plane X-rays of the lumbar spine, were performed preoperatively (preop), postoperatively (postop) and after discharge (FU 2-3). Gender ratio (m:w) was 1.1:1. Mean age of the patients was 60.8 +/- 16.3 years. Foraminal height, foraminal width, foraminal cross-sectional area, intervertebral angle, as well as anterior and posterior disc height changed significantly (P < 0.0001) after implantation of the interspinous device. Postoperatively, symptom relief (VAS) was significant (P < 0.0001). The X Stop implant improved (in some cases significantly) the radiographic parameters of foraminal height, width, and cross-sectional area, more than the Diam and Wallis implants; however, there was no significant difference among the three regarding symptom relief. FU 1 was on average 202.3 +/- 231.9 and FU 2 527.2 +/- 377.0 days postoperatively. During FU, the radiological improvements seemed to revert toward initial values. Pain (VAS) did not increase despite this "loss of correction." There was no correlation between age and symptom improvement. There was only very weak correlation between the magnitude of radiographic improvement and the extent of pain relief (VAS). The interspinous implant did not worsen low-grade spondylolisthesis. Provided there is a strict indication and fusion is not required, implantation of an interspinous spacer is a good alternative to treat LSS. The interspinous implant offers significant, longlasting symptom control, even if initially significant radiological changes seem to revert toward the initial values ("loss of correction").