[Findings in 67 patients with recurrent or persistent symptoms after implantation of a disc prosthesis for low back pain]. / Bevindingen bij 67 patiënten met recidiverende of persisterende klachten na het plaatsen van een discusprothese wegens lage rugpijn.

OBJECTIVE: To determine the symptoms in patients who presented with persistent or recurrent backache or leg pain after implantation of an artificial disc prosthesis. DESIGN: Descriptive. METHOD: During the past II years in the Maastricht University Hospital (n=65) and the Utrecht University Medical Centre (n=2), 67 patients were seen with persistent or recurrent backache or leg pain in whom, an average of 53 months previously, one or more SB Charité-III lumbar-disc prostheses had been implanted elsewhere. The results were evaluated. RESULTS: The most prominent findings were: migration of the prosthesis (n=6); subsidence into the vertebra (n=35); disc degeneration at one or more neighbouring levels (n=34) and arthrosis of facet joints (n=24). In 9 cases, rupture of the metal wire around the polyethylene core was observed and in 5 cases there were radiological signs of polyethylene wear. Re-operation (spondylodesis) was generally unsatisfactory if the prosthesis was left in place. In 21 patients, the prosthesis was removed; all specimens showed polyethylene wear or rupture. CONCLUSION: Published results are mostly case series and suffer from observer bias; moreover, the benefits are moderate. Given the uncertain role ofdisc degeneration in patients with chronic backache, the real risk of complications and the uncertain advantages, the implantation ofa disc prosthesis is difficult to defend.

[Surgical removal of debilitating neurogenic heterotopic ossifications of the hip]. / Chirurgisch verwijderen van invaliderende neurogene heterotope ossificaties van de heup.

Two men, aged 24 and 52 years, developed neurogenic heterotopic ossifications of the hip, the first following a cervical spinal-cord injury and the second after prolonged artificial ventilation following bowel surgery. The stiffness caused problems when sitting and when performing general daily activities; the second patient who was ambulatory, also had problems walking. CT investigation clearly showed the localisation of the ossifications. After surgical removal of the ossifications both patients were able to sit for longer periods without low-back pain and the ambulatory function of the second patient was much improved. Indomethacin was given postoperatively and no recurrence of the ossification was seen. A number of per- and postoperative complications are associated with the surgical removal of neurogenic heterotopic ossifications of the hip. These include damage to surrounding structures and infection. However taking into account the improved range of movement and increased independence of the patient, it is a useful intervention for this debilitating condition.

Surgical treatment of aspergillus spondylodiscitis.

Four cases of aspergillus spondylodiscitis were treated with operative debridement and fusion. In this rarely encountered mycotic infection of the spine in immunocompromised patients rapid destruction of the intervertebral disc and vertebral bodies can occur. In advanced cases antimycotic drug therapy is thought to be ineffective and a forcing indication for surgery exists when the destruction is progressive and spinal cord compression is imminent or manifest. Spinal instrumentation can be of help in maintaining or restoring spinal stability and maintaining spinal alignment. In our four patients the aspergillus spondylodiscitis was successfully eradicated and fusion achieved. In two of three patients with a neurologic deficit, this deficit disappeared. Two patients died within 6 months after the operative treatment, due to complications related to the underlying illness. One patient was left with a subtotal paraplegia.

Two sibs with an unusual pattern of skeletal malformations resembling osteogenesis imperfecta: a new type of skeletal dysplasia?

We report a 6 year old boy with multiple fractures owing to bilateral, peculiar, wave-like defects of the tibial corticalis with alternative hyperostosis and thinning. Furthermore, he had Wormian bones of the skull, dentinogenesis imperfecta, and a distinct facial phenotype with hypertelorism and periorbital fullness. Collagen studies showed normal results. His sister, aged 2 years, showed the same facial phenotype and dental abnormalities as well as Wormian bones, but no radiographical abnormalities of the tubular bones so far. The mother also had dentine abnormalities but no skeletal abnormalities on x ray. This entity is probably the same as that described in a sporadic case by Suarez and Stickler in 1974. In spite of the considerable overlap with osteogenesis imperfecta (bone fragility, Wormian bones, and dentinogenesis imperfecta), we believe this disorder to be a different entity, in particular because of the unique cortical defects, missing osteopenia, and normal results of collagen studies.

Cervical spondylodiscitis after removal of a fishbone. A case report.

STUDY DESIGN: A case report of cervical spondylodiscitis after removal of a lodged fishbone. OBJECTIVES: To present a rare case of cervical spondylodiscitis and to inform the readers that a lodged fishbone can give rise to this complication after its removal. SUMMARY OF BACKGROUND DATA: In the literature, only one mention of this complication was found. METHODS: The literature, clinical presentation, technical examinations, and treatment are reviewed. RESULTS: Prolonged antibiotic treatment and immobilization of the cervical spine resulted in a cure of the spondylodiscitis. CONCLUSIONS: After removal of a lodged fishbone, a cervical spondylodiscitis is possible, but this is a very rare complication. In this patient, conservative treatment resulted in a cure of the infection. Successive magnetic resonance imaging investigations showed the extent of the destruction of the vertebral bodies and disc very well, as well as the curation of the spondylodiscitis after 5 months.

[One hundred years of orthopedics in the Netherlands. IV. Spinal abnormalities]. / Honderd jaar orthopedie in Nederland. IV. Wervelkolomaandoeningen.

In recent years there has been spectacular progress in the approach to various disorders of the spinal column. Owing to improved methods of osteosynthesis there is no longer so much need for long periods of postoperative bed rest. Of all the scolioses, idiopathic scoliosis is most common. The vast majority of these cases are not clinically significant. What is seen in the remaining cases if left untreated is a progression in the curvature during growth. Progressive idiopathic scoliosis can be effectively treated using conservative methods. Screening at school is an important part of this process. If the curvature proves progressive and skeletal growth is not complete a brace can be prescribed. Use of this strategy and form of treatment can avoid progression of the curvature and development of serious deformities. This conservative therapy has markedly reduced the need for corrective surgery. Scheuermann's disease is characterized by a fixed dorsal thoracic kyphosis. Progressive Scheuermann's kyphosis can be effectively treated using a brace. The majority of fractures of the vertebral bodies can be treated conservatively. However, serious fractures normally require surgical intervention. In the industrialised Western world, low back pain is a major health problem and the foremost cause of disability and unfitness for work. Low back pain caused by degenerative disease of the spinal column should be treated using a multidisciplinary approach. The development of advanced operative techniques and osteosynthesis methods has made it possible to treat metastases of the spine surgically. The effects of this treatment on the quality of life are encouraging.

Cost-variance analysis by DRGs; a technique for clinical budget analysis.

In this article it is shown how a cost accounting system based on DRGs can be valuable in determining changes in clinical practice and explaining alterations in expenditure patterns from one period to another. A cost-variance analysis is performed using data from the orthopedic department from the fiscal years 1993 and 1994. Differences between predicted and observed cost for medical care, such as diagnostic procedures, therapeutic procedures and nursing care are analyzed into different components: changes in patient volume, case-mix differences, changes in resource use and variations in cost per procedure. Using a DRG cost accounting system proved to be a useful technique for clinical budget analysis. Results may stimulate discussions between hospital managers and medical professionals to explain cost variations integrating medical and economic aspects of clinical health care.

Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor-system disorders.

Joint consultation sessions between general practitioners (GPs) and specialists to examine patients for whom decisions about referral are difficult are thought to be helpful, but their effects have not been evaluated. In a randomised, controlled trial we studied the effects of joint sessions of GPs and orthopaedic surgeons on referral and intervention rates. During 1.5 years, 12 GPs (in groups of three) held monthly joint consultation sessions with four participating orthopaedic surgeons: patients were seen by one orthopaedic surgeon in the presence of three GPs. Patients were included in the trial if the GP was uncertain about the diagnostic or therapeutic management and if referral was considered; and excluded if referral was urgently necessary or if there was some other clear indication for referral. By a randomised consent design, patients were assigned to joint consultation sessions (n = 144) or a usual-care control group (n = 128). A year later the patients were examined by an independent orthopaedic surgeon. There were significantly fewer referrals (51/144 [35%] vs 87/128 [68%], p < 0.01) and diagnostic actions in the intervention group than in the control group, without negative effects on health or functional status. More patients in the intervention group were symptom-free at 1 year (35% vs 24%, p < 0.05). Joint consultation sessions of GPs and orthopaedic surgeons within the framework of general practice resulted in more efficient care, with better targeted examination, treatment, and referrals.

[Results of allogeneic bone transplants in spondylodesis of the spine]. / Resultaten van allogene bottransplantaten bij spondylodese van de wervelkolom.

The use of allogeneic bone bank bone was evaluated in 67 patients, operated for disorders of the spine. In 26 patients with paralytic scoliosis a pseudarthrosis developed three times and there was one infection. In 28 patients with other causes of scoliosis there were also three cases with pseudarthrosis. In the group of posterolateral arthrodesis of the lumbar spine we saw four patients out of 13 with pseudarthrosis. The results are in accordance with the literature. The use of allogeneic bone in scoliosis surgery is justified in view of the acceptable pseudarthrosis rate and the low incidence of infection. In the lumbar spine group, however, the use of bone bank bone gives less satisfactory results. The use of autologous bone is recommended for this group. There were no signs of transmission of infectious diseases in the total group of patients.