[Nonsurgical and surgical management of osteoporotic vertebral body fractures : Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)]. / Nichtoperative und operative Behandlung der osteoporotischen Wirbelkörperfraktur : Empfehlungen der Sektion Wirbelsäule der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU).

STUDY DESIGN: Prospective clinical cohort study (data collection); expert opinion (recommendation development). OBJECTIVES: Treatment options for nonsurgical and surgical management of osteoporotic vertebral body fractures differ widely. Based on the current literature, the knowledge of the experts, and their classification for osteoporotic fractures (OF classification), the Spine Section of the German Society for Orthopaedics and Trauma has now introduced general treatment recommendations. METHODS: A total of 707 clinical cases from 16 hospitals were evaluated. An OF classification-based score was developed for guidance in the option of nonsurgical versus surgical management. For every classification type, differentiated treatment recommendations were deduced. Diagnostic prerequisites for reproducible treatment recommendations were defined: conventional X­rays with consecutive follow-up images (standing position whenever possible), magnetic resonance imaging, and computed tomography scans. OF classification allows for upgrading of fracture severity during the course of radiographic follow-up. The actual classification type is decisive for the score. RESULTS: A score of less than 6 points advocates nonsurgical management; in cases with more than 6 points, surgical management is recommended. The primary goal of treatment is fast and painless mobilization. Because of the expected comorbidities in this age group, minimally invasive procedures are preferred. As a general rule, stability is more important than motion preservation. It is mandatory to restore the physiological loading capacity of the spine. If the patient was in a compensated unbalanced state at the time of fracture, reconstruction of the individual prefracture sagittal profile is sufficient. The instrumentation technique has to account for compromised bone quality. We recommend the use of cement augmentation or high purchase screws. The particular situations of injuries with neurological impairment, the necessity to fuse, multiple level fractures, consecutive and adjacent fractures and fractures in ankylosing spondylitis are addressed separately. CONCLUSIONS: The therapeutic recommendations presented here provide a reliable and reproducible basis to decide for the treatment choices available. However, intermediate clinical situations with a score of 6 points remain, allowing for both nonsurgical and surgical options. As a result, individualized treatment decisions may still be necessary. In the subsequent step, the recommendations presented will be further evaluated in a multicentre controlled clinical trial.

[Thoracolumbar spinal fractures in the elderly : Classification and treatment]. / Thorakolumbale Wirbelsäulenfrakturen beim alten Menschen : Klassifikation und Therapie.

Thoracolumbar fractures in the elderly are frequently associated with osteoporosis. Osteoporosis can cause fractures or be a significant comorbidity in traumatic fractures. The OF classification is based on conventional X­ray, computed tomography (CT) scan and magnetic resonance imaging (MRI). It is easy to use and provides a clinically relevant classification of the fractures. Therapeutic decisions are made based on the clinical and radiological situation by using the OF score. The score takes the current clinical situation including patient-specific comorbidities into consideration. The treatment recommendations are based on an expert consensus opinion and include conservative and operative options. If surgery is indicated, vertebral body augmentation, percutaneous stabilization and even open surgery can be used.

[Cement augmentation of pedicle screws : Pros and cons]. / Zementaugmentation von Pedikelschrauben : Vorteile und Nachteile.

Cement augmentation of pedicle screws biomechanically increases screw purchase in the bone. However, clinical complications may occur. The pros and cons of the technique are discussed from different clinical perspectives.

[Percutaneous techniques in the thoracic and lumbar spine]. / Perkutane Techniken an der Brust- und Lendenwirbelsäule.

Techniques of percutaneous spinal instrumentation have in the meantime become standard methods in many hospitals. While several indications have been established that are excellently suited to this technique, uncertainty prevails for other indications. This contribution intends to clarify the technical prerequisites for performing percutaneous instrumentation in the region of the thoracic and lumbar spine in addition to describing customary indications and various techniques of percutaneous instrumentation. This is combined with a critical assessment of what intrinsically cannot or cannot yet be achieved with a percutaneous approach to illustrate that the percutaneous procedure can by no means be considered a mere evolution of the previous classic open techniques.

Anterior column reconstruction in thoracolumbar injuries utilizing a computer-assisted navigation system.

BACKGROUND: Discectomy, corpectomy, and resection of isolated posterior wall fragments are technically demanding steps requiring maximum surgical precision during anterior reconstruction of the unstable thoracolumbar spine. PURPOSE: This study investigates the feasibility of computer-aided guidance for these steps. It also analyzes the precision, advantages, and disadvantages of the procedure. STUDY DESIGN: Controlled clinical trial. PATIENT SAMPLE: 21 patients were included in the trial group; the control group consisted of 10 patients. OUTCOME MEASURES: Total time for surgery was noted. To assess surgical precision, decentralization of the cage was measured in postoperative X-rays. Additionally, parallel alignment of vertebral body endplates with the cage was evaluated in postoperative CT scans. METHODS: Vertebral body fractures of the thoracolumbar spine addressed by disc-/corpectomy and subsequent cage interposition for anterior reconstruction were included. All surgical steps were performed under endoscopic assistance. In the trial group, disc- and corpectomy were performed under computer-aided guidance; in the control group, no computer navigation was utilized. In cases of initial neurological deficit after trauma, the patients underwent emergency laminectomy during the initial posterior stabilization procedure. During the second-stage anterior procedure, resection of the posterior wall fragment with the aid of computer-aided navigation was performed. RESULTS: Fractures were localized between Th9 and L1 in the trial group, and Th10 and L1 in the control group. Time for surgery was significantly shorter in the control group: 1.7 h ± 0.5, as opposed to 3.8 h ± 1.0 in the trial group (p < 0.0005). In contrast, data on surgical precision did not show statistically significant differences between both groups for either decentralization or parallel endplate alignment of cages. Remarkably, we noted two cases of subsidence in bilevel cages in the control group, whereas this was only noted in one case in the trial group. However, this difference was not statistically significant. There were five patients with initial neurological deficits. At the time of follow-up, the neurological statuses of all five had improved by at least one Frankel grade. CONCLUSIONS: Computer-aided guidance in anterior reconstruction of the thoracolumbar spine is a technically feasible option that may aid in the performance of disc- and corpectomy, as well as the resection of isolated posterior wall fragments in cases with initial neurological compromise. However, total time for surgery is significantly prolongated by this technique. There were no differences in the precision of cage positioning between groups. However, during discectomy, the use of computer navigation may aid in the protection of adjacent endplates, as there was a trend towards fewer cases with cage subsidence in the navigated group.

[Are there therapy algorithms in isolated and combined atlas fractures?]. / Gibt es Therapiealgorithmen bei isolierten und kombinierten Atlas-Frakturen?

AIM: Injuries of the atlas are always a challenge in diagnostics and therapy. Different clinical manifestations, inconspicuous neurological results, uncertain findings of radiological diagnostics and possible accompanying injuries require individual therapeutic concepts. METHODS: Patients with injuries of C1 and C2 seen between 2001-2007 were evaluated and especially the morbidity and treatment of the C1-injured patients were verified. To systematise the injuries, a subdivision in isolated and combined trauma took place. Furthermore, the post-traumatic as well as post-therapeutic accompanying neurological deficits were evaluated. RESULTS: Altogether 121 fractures/injuries of the upper cervical spine (C1/C2) were counted, 22 (18.2 %) concerning the atlas. There were 11 fractures of type Gehweiler I, 9 of type III and 1 each of types II and IV. Isolated fractures of type I (5/11) were treated conservatively, combined injuries (6/11), depending on the stability and location of the attendant injuries, were treated with semi-rigid collars, anterior or posterior fusions. Stable fractures of type III (2/9) were primarily treated in Halo extension. Because of an attending dens fracture type Anderson II in 1 case, a spondylodesis of the dens was additionally performed in the conservative treatment of the atlas. The therapy of isolated unstable atlas fractures of type III (4/9) ranged, depending on the general conditions, from Halo extension, transoral C1 stabilisation, anterior transarticular C1/C2 fusion to posterior occipitocervical fusions. The therapeutic regime of combined unstable type III injuries (2/9) depended on the additional trauma: anterior fusion in C6/7 luxation fracture combined with Halo extension for C1, posterior C0/C3 fusion in unstable dens fractures of type Anderson II. CONCLUSION: The therapy for atlas fractures orientates on the type of the C1 fracture, the accompanying injuries and the general condition of the patient. Isolated stable C1 fractures without dislocation can be treated conservatively (cervical collar), unstable fractures, depending on the general condition, should be referred to surgical therapy or halo extension. In combined atlas fractures the strategy of treatment has to take the stability of the C1 fractures into consideration, but also the additional injuries of the rest of the cervical spine and the attendant circumstances.

[Computer-aided discectomy and corpectomy in anterior reconstruction of the injured thoracolumbar spine. A prospective, controlled clinical trial]. / Navigationsgestützte Rekonstruktion der vorderen Säule bei Verletzungen im Brustwirbel- und thorakolumbalen Ubergangsbereich. Eine prospektive, kontrollierte klinische Studie.

BACKGROUND: In anterior reconstruction of the unstable thoracolumbar spine, discectomy and corpectomy are technically demanding steps requiring maximal surgical precision. This study investigated the feasibility of computer-aided guidance for discectomy and corpectomy. It also analysed the precision, advantages, and disadvantages of the procedure. PATIENTS AND METHODS: Vertebral body fractures of the non-osteoporotic thoracolumbar spine addressed by discectomy/corpectomy and subsequent implant interposition (cage, tricortical strut graft) for anterior reconstruction were included. All surgical steps were done under endoscopic assistance. In the trial group, discectomy and corpectomy were performed with computer-aided guidance; in the control group, no computer navigation was used. The time required for surgery was noted. To assess surgical precision, decentralization of the implant in the frontal plane was measured in postoperative x-rays and computed tomography. Additionally, parallel alignment of vertebral body end plates with the implant was evaluated. RESULTS: The trial group (TG) consisted of 16 patients, and the control group (CG) of 10 patients. Fractures were localized between T10 and L1 in TG, and between T9 and L1 in CG. Operating time was significantly shorter in CG: 104+/-28 min compared with 229+/-64 min in TG (p<0.0005). In contrast, data on surgical precision showed no statistically significant differences between the 2 groups for either decentralization or parallel endplate alignment of implants. Remarkably, for CG we noted 2 cases of cage subsidence into an adjacent end plate, whereas for TG this was noted in only 1 case. However, this difference was not statistically significant. CONCLUSION: Computer-aided guidance for anterior reconstruction of the thoracolumbar spine is a technically feasible option that may help in performing discectomy and corpectomy. However, this technique significantly prolongs the operating time. There were no differences in the precision of implant positioning between the groups. However, during discectomy the use of computer navigation may possibly add to the protection of adjacent end plates.

Interlocking nailing of forearm fractures.

INTRODUCTION: With the exception of forearm fractures, intramedullary techniques are preferred for osteosynthesis in the case of long-bone fractures. For the latter, however, the main problem remains insufficient stability against torsional forces resulting in high rates of non-union. This is why plate osteosynthesis by means of a DCP 3.5 or LC-DCP 3.5 is still being described as the standard procedure. MATERIALS AND METHODS: In a prospective study, 32 patients (33 forearms) with fractures of one or both forearm bones were treated by implantation of 40 intramedullary ForeSight nails (ulna: 23; radius: 17). Clinical and radiographic follow-up was performed at 6, 12, 26, and--if needed--52 weeks postoperatively. Time to follow-up was 31.4 months on average (range 24-44 months). RESULTS: The average time to fracture healing for 36 fractures of 29 patients was 4.4 months. A free range of motion was seen in 86%, and only four forearms had a loss of pronation and supination. DASH score averaged at 13.7. There were few complications: non-union 1, delayed union 2, radioulnar synostosis 2, and infections 0. No refracture was seen after 19 implant removals so far. Average time needed per operation was 67 min, average time for fluoroscopy was 4.4 min. CONCLUSION: This intramedullary nail can do justice to the specific anatomical needs in the case of the forearm. Static interlocking guarantees adequate stability in all fracture types. The surgical technique is demanding. Nonetheless, this system can yield results of comparable quality to those of plate osteosynthesis. So far, no refractures after removal of the implants and no complications connected with the actual implants have been observed.

Evaluation of an injectable calcium phosphate cement as an autograft substitute for transpedicular lumbar interbody fusion: a controlled, prospective study in the sheep model.

Anteroposterior procedures for lumbar interbody fusion usually combine posterior instrumentation with anterior techniques that achieve primary stability for compressive loading: tricortical strut-graft, anterior plating systems, or cages. In comparison to transpedicular lumbar interbody fusion (TLIF), these methods bear the burden of the additional anterior approach. TLIF with autograft, in contrast, does not prove to be clinically sufficient because of its lack of primary compressive stability. In a sheep model, we therefore developed a TLIF method providing primary stability for axial loading. In 24 sheep, L4-L6 were instrumented posteriorly. An endoscopically assisted L4/L5 TLIF procedure was performed via a bilateral approach. In 12 sheep, the defect was filled with an injectable calcium phosphate cement. After setting, this cement gains a stability against axial loading comparable to healthy vertebrae. Another 12 sheep were treated with autograft. The animals were killed at 8 weeks and evaluated by radiologic (plain X-ray, computed tomography), histologic and histomorphometric analysis, and fluorochrome labeling. Only ten autograft sheep were available for evaluation. Radiologically and histologically, TLIF with calcium phosphate led to a 2/12 fusion rate compared to autograft (1/10 fused) (P=0.70). Semiquantitative radiologic and histologic scoring did not reveal significant differences (P=0.88). In 4/12 calcium phosphate sheep, excessive resorption was responsible for local aseptic inflammation. The findings of this study show that calcium phosphate cement is not superior to autograft, despite enabling primary stability against compressive loading. Biointegration of the osteoconductive cement does not occur fast enough, and shear forces cause early cement fracture, subsequent fragmentation, and gross resorption with the possibility of severe inflammation.

[Pediculoscopic assisted transpedicular spongioplasty for interbody fusion of the lumbar spine. An animal experiment study of the sheep model]. / Pedikuloskopisch assistierte transpedikuläre Spongiosaplastik zur interkorporellen Fusion an der lumbalen Wirbelsäule. Eine tierexperimentelle Unterschung am Schafsmodell.

OBJECTIVE: Failure of transpedicular bone-grafting in thoracolumbar burst-fractures has been proven. Possible reasons are insufficient disc-removal and difficult decortication of endplates. Methodical improvements are sought to make the procedure succeed in a sheep-model. METHOD: 12 sheep with posterior instrumentation L4/L6 and transpedicular disremoval L4/L5 underwent auto-grafting. Classical surgical technique was modified by bilateral approach and transpedicular endoscopic control. Animals were sacrificed 8 weeks p.op. For evaluation, radiology, histology, histomorphometry, and fluorochrome-analysis were employed. RESULTS: 10 animals could be evaluated. All revealed sufficient disc-removal and decortication with autograft-impaction into the lower vertebra L4. Main restoration took place before week 4 p.op. Fusion rate was 1/10. For 9/10 animals, defects in the disc-space were filled with metaplastic chondral-tissue; autograft was almost entirely resorbed. CONCLUSIONS: Reason for failure of the method seems to be the insufficient primary stability of the posterior instrumentation, since satisfactory disc-removal and decortication alone cannot successfully modify the method.

[Reducing approach-associated morbidity in fracture dislocation of the femoral head--a longitudinal study (1982-2000)]. / Reduktion der zugangsassoziierten Morbidität bei Pipkinfrakturen - Eine Verlaufsbeobachtung (1982-2000).

Fractures of the femoral head occur during displacement injuries of the hip joint (Pipkin-type fractures). Reasons are high-energy traumas, usually dash-board injuries. Typical complications are posttraumatic necrosis of the femoral head (prevalence according to the literature: 15-66 %), and arthritis of the hip joint. It is yet uncertain, however, whether the type of surgical approach can influence the rate of necrosis. From June 1982 to December 2000, a total of 30 patients underwent surgery for Pipkin-type fractures, with 28 of them being posterior displacements, and 2 being anterior ones. Average age was 35.8 years, 2/3 were male, and 1/3 female. Total hip prosthesis was implanted primarily in 4 cases. 26 underwent osteosynthesis. Anterior displacements were stabilized via a lateral approach, whereas posterior ones were managed via a posterior approach. Reason for this procedure was the intention to use the one side of the joint-capsule for approach, that had been torn already by the displacement-injury. 21 of 26 operatively stabilized patients were followed-up between 6 and 54 months postoperatively. With this regimen of treatment, we had to face no case of necrosis of the femoral head. For fracture displacement of the femoral head we therefore suggest a posterior approach in posterior displacement, as well as an anterior approach for anterior displacement. Using this principle, rate of necrosis of the femoral head may clearly diminish (in our series 0 out of 21).

[Induction of arthritis in healthy knee joints after intra-articular injection of the proteolytic enzyme elastase - An experimental investigation in the rabbit]. / Arthroseinduktion im gesunden Kniegelenk durch intraartikuläre Injektion des proteolytischen Enzyms Elastase - eine tierexperimentelle Untersuchung.

AIM: Humoral aspects are being discussed in the initiation of arthritis. Therefore, the effects of the proteolytic enzyme elastase on the cartilage of knee joints in rabbits have been investigated. The enzyme was evaluated using activities comparable to those in post-traumatic knee joint hemarthrosis in humans. METHOD: Polymorphonuclear leukocyte elastase was injected into one of the knee joints of 10 rabbits. In 5 animals (first study group), joints were then immobilized with a cast for 6 weeks. In the other 5 (second study group), no immobilization was applied. In the first zero group (2 animals), 0.9 % NaCl was injected intra-articularly without immobilization, whereas in the second zero group (2 anmals) knees were immobilized for 6 weeks without prior injection. Thus, the effect of immobilization could be evaluated additionally. Joint specimens were then examined histologically and electron microscopically. RESULTS: There was clear evidence of elastase having severe destructive effects on cartilage regardless of additional joint-immobilization. In neither zero group was there prearthritic damage to the cartilage. CONCLUSION: To prevent the initiation of cartilage damage by humoral factors, early elimination of the pathological intra-articular effusion is necessary.

[Solution to the problem of extra-articular, femoral hip fracture by the "sliding screw-nail principle". Results of 2 different systems (classical nail and gamma nail)]. / Problemlösung der extraartikulären, koxalen Femurfraktur durch das "Gleitschrauben-Nagel-Prinzip". Ergebnisse zweier verschiedener Systeme (classic nail und gamma-Nagel).

Between January 1993 and December 1995 we treated 109 patients (median age: 75 years) with 112 extraarticular hip fractures including combined trochanteric and shaft fractures using two different "sliding-screw-nail implants" (intramedullary hip screw = classic nail: n = 61; gamma nail: n = 51). Comparing the two systems in detail certain advantages and disadvantages were seen, with both being equivalent. We encountered the following complications: secondary varus malalignment of the collum femoris with "cut out" of the sliding-screw (1.8%) and without "cut out" (1.8%), fissure of the femoral shaft occurring intraoperatively and being treated conservatively (1.8%), femoral perforation by the nail (0.9%), infection (2.7%). Thus, 5 reoperations (4.5%) were necessary. None of these complications were attributable to the principle itself or to the different implants used. Each patient was followed-up for a minimum of 12 months postoperatively. In 59% of all patients the pre-trauma range of mobility could be fully restored. Intramedullary hip screw and gamma nail are excellent and equivalent systems, which fully satisfy the biomechanical needs of above mentioned fractures.

[Injury sequelae and late damage of dislocation fracture of the head of the tibia]. / Verletzungsfolgen und Spätschäden der Luxationsfraktur des Tibiakopfes.

Consequences of injury as well as succeeding joint-impairment after fracture dislocation of the tibial head are analysed. Of 38 patients who had undergone operative therapy for fracture dislocation of the tibial head between 1982 and 1991, 30 were followed up after a mean of 6.3 years. With an average age of 46.8 years and a distribution between sexes of 26 men vs. 12 women, types II (17) and V (14) (classification acc. to Moore) clearly outweighed types III (3) and IV (3) as well as type I (1). Causes of injury were dominated by traffic accidents (22/38), 9 patients suffered from accompanying ipsi-, another 9 from contralateral injuries of their lower extremities. For evaluating follow-up results, both Lysholmscore and IKDC-knee-evaluation-form were employed. The latter qualifies the overall result as "normal", "nearly normal", "abnormal" or "severely abnormal". None of the knee-joints assessed was evaluated normal. There were only 2 patients to be qualified nearly normal, whereas 5 had to be assessed abnormal and 23 severely abnormal. These poor results were mainly due to persistent symptoms (pain, swelling, giving-way) (30/30), limited range of motion (27/30) as well as impairment of joint-stability (25/30). Our results stress the need for sophisticated operative and p.op. therapy of these complex injuries.

[Proteases and their inhibitors in posttraumatic knee joint effusion]. / Proteasen und deren Inhibitoren im posttraumatischen Kniegelenkserguss.

Humoral aspects are being discussed in development of arthrosis. Punctuate of 144 traumatized knee joints has been investigated. Proteolytic enzymes elastase and cathepsin D were assessed. Furthermore, protease inhibitors alpha 1-antitrypsin and alpha 2-macroglobulin were determined. Activity of chondrolytic enzymes elastase and cathepsin D clearly correlates with the clinical severity of injuries. At the same time, primary inhibitory mechanisms for compensation seem to be non-sufficient, however.

[Differential indications for intramedullary nailing of the tibia with the reamed and unreamed technique]. / Differentialindikation zur Marknagelung der Tibia in aufgebohrter und nicht aufgebohrter Technik.

The principle of unreamed intramedullary nailing in tibial fractures is theoretically convincing: regarding the almost fully maintained endosteal blood supply, this concept of biological osteosynthesis implies a lower rate of postoperative complications such as non- or malunion and infection. In our clinic, 89 patients underwent intramedullary nailing of the tibia since August 1988 using the "AO-Universal-Nagel" in 63 and the Russell-Taylor unreamed nail in 26 cases. With primary data (type of fracture and grade of soft tissue injury) being comparable, we found an almost identical rate of infection for both techniques. In RT nailing, however, rates were significantly higher for non- or malunion (AO 10.3%, RT 27.6%) and implant complications such as interlocking screw or nail breakage (AO 6.2%, RT 17.2%). Thus indicating less mechanical stability, for RT- nail we allowed full weight bearing after 6-8 weeks only, whereas for AO-nail this was performed approximately 14 days p. op. after satisfying soft tissue conditions had occurred. Subsequently, this worse mechanical properties of an unreamed nail mean loss of comfort for patients, which is not fully equalized by biological advantages in all cases. We therefore champion a differentiated indication for the unreamed technique, determined by the grade of soft tissue injury: treatment of Gustilo type II and III a and b open tibial fractures by either primarily performing biological osteosynthesis or early changing from external fixation. Finally, unreamed nailing has been established as monorail procedure treating defect fractures by means of segmental transport.

[Tumorous calcinosis (Teutschländer disease)]. / Tumoröse Calcinose (Morbus Teutschländer).

A case report on tumoral calcinosis (Teutschländer disease), a comparatively rare clinical entity, is presented. The localization of these painful, mostly periarticular soft tissue calcifications as well as their aetiology in connection with chronic renal failure, longstanding hemodialysis or secondary hyperparathyroidism are stressed. The surgical approach as the primary therapeutic option is compared with the more traditional conservative management.

Occupational hand cramps: professional disorders of motor control.

Occupational cramps affecting the upper extremities have been described for centuries, though only recently is light being shed on their pathogenesis, pathophysiology, and improved strategies for diagnosis and treatment. These dystonias represent localized stereotyped painless movement disorders affecting certain occupational groups in characteristic ways. We retrospectively reviewed 65 patients given a diagnosis of focal dystonias of the upper extremity and describe painless manual incoordination syndromes, insidious in onset, without objective sensory abnormalities, precipitated by certain repetitive actions of the upper extremity. This confirms previous clinical reports. Pathogenesis and pathophysiology are still uncertain, but evidence for altered higher order (basal ganglia and cortical) influences on spinal interneurons leading to ill-directed motor output is hypothesized. Therapeutic options are reviewed stressing the inadequacy of any one mode discovered to date.