Kümmell's Disease: Clarifying the Mechanisms and Patients' Inclusion Criteria.

The three major causes of vertebral body collapse include infection, malignant neoplasia, and trauma and it may be difficult to distinguish between them, particularly in the presence of severe osteoporosis. In 1891, however, Dr Hermann Kümmell, further added another possibility of vertebral body crush; the delayed posttraumatic collapse. As originally described, this rare clinical entity includes patients, who after a trivial trauma and an asymptomatic clinical course they develop a progressive vertebral body collapse and a painful kyphosis. Although more than a century has passed from its initial description, only few cases have been reported in the literature, whereas the main pathologic eliciting event is still under investigation. As a consequence, great controversy exists regarding the discrete features of the clinical course, its radiographic appearance and the histopathological findings. To explain the time lag between the initial trauma and the occurrence of the vertebral collapse, the hypothesis of ischemic necrosis was advanced. Equation of Kümmell's disease with vertebral osteonecrosis, however, has wrongly led many authors to report cases of Kümmell's disease, even in the absence of history of spinal trauma. On the other hand, high coincidence of vertebral osteonecrosis and the pathognomonic radiographic finding of intravertebral vacuum cleft, has further added to the confusion. In this review we present an overview of the literature on Kümmell's disease, focusing on the different proposed eliciting mechanisms. We also highlight controversial subjects on clinical course, diagnosis and treatment of this entity, in an attempt to further clarify patients' inclusion criteria.

Operations in spinal surgery are not always needed. Do we operate more than we should?

Lumbar disc herniation and low back pain are the main cause of sickness during labor life. The decision for operation is thought to be taken easily and as a result a lot of money is being spent for treatment and rehabilitation. The aim of this study was to evaluate whether conservative treatment is sufficient for treatment of lumbar disc herniation and low back pain and what percentage of the patients operated are satisfied with social and everyday life two years after operation. One hundred and twenty seven patients (67 male and 60 female) were treated because of lumbar disc herniation. No neurological deficiency or muscle weakness was observed. Seventy two patients underwent conservative treatment. Fifty five patients underwent microsurgical discectomy. Back and leg pain are reported on a visual analog scale (VAS) and with the Oswestry disability index (ODI). The Short Form-36 health survey (SF-36) and the European Quality of Life questionnaire (EQ-5D) should also be completed. Surgical data, including diagnosis, are recorded by the surgeon without access to the patient's questionnaires. Both groups (conservative and operative) improved from baseline with regard to SF-36 and ODI (all P<0.01). The results 2 years after surgery were similar for both groups, as measured with the SF-36 and the ODI. Both groups improved from baseline to follow-up with regard to both back pain and leg pain (all P<0.01). The frequency of returning to work was analyzed for those patients who were less than 65 years of age at the time of follow up, and who had been working before surgery. Statistical analysis indicates that there are no significant differences between the groups. The decision for operation is thought to be taken easily and as a result a lot of money is being spent for treatment and rehabilitation. In conclusion, this study shows that operative treatment is equal in outcome to conservative treatment and should follow, seen from an economic perspective, the conservative treatment.

Strontium ranelate enhances callus strength more than PTH 1-34 in an osteoporotic rat model of fracture healing.

Treatment of an underlying disease is often initiated after the occurrence of an osteoporotic fracture. Our aim was to investigate whether teriparatide (PTH 1-34) and strontium ranelate affect fracture healing in ovariectomized (OVX) rats when provided for the first time after the occurrence of an osteoporotic fracture. We combined the model of an OVX rat with a closed diaphyseal fracture. Sixty Sprague Dawley rats were randomly assigned to four groups. Fracture healing in OVX rats after treatment with pharmacological doses of strontium ranelate and PTH 1-34 was compared with OVX and sham-treated control groups. After 28 days, the femur was excised and scanned by micro computed tomography and the callus evaluated, after which biomechanical torsional testing was performed and torque and toughness until reaching the yield point were analyzed. Only treatment with strontium ranelate led to a significant increase in callus resistance compared to the OVX control rats, whereas both PTH 1-34 and strontium ranelate increased the bone volume/tissue volume ratio of the callus. The PTH 1-34-increased trabecular bone volume within the callus was even higher compared to sham. As for the callus tissue volume, the increase induced by strontium ranelate was significant, contrary to the changes induced by PTH. Callus in strontium ranelate-treated animals is more resistant to torsion compared with OVX control rats. To our knowledge, this is the first report of the enhancement of fracture healing by strontium ranelate. Because both treatments enhance bone and tissue volume within the callus, there may be a qualitative difference between the calluses of PTH 1-34- and strontium ranelate-treated OVX rats. The superior results obtained with strontium ranelate compared to PTH in terms of callus resistance could be the consequence of a better quality of the new bone formed within the callus.

Total joint replacement in HIV positive patients.

BACKGROUND: Recent HIV therapies have improved life expectancy in HIV positive patients. For the purpose of the following retrospective investigation, we analyzed the results of total joint replacement in HIV positive patients. This study exemplifies orthopaedic treatment options and perioperative problems in HIV positive patients. Our population included a high proportion of hemophilic patients. DESIGN AND METHODS: Between 1988 and 2000, we performed 55 endoprosthetic procedures (20 total hip replacements (THR), 33 total knee replacements (TKR), two shoulder replacements) in 41 patients suffering form HIV. Thirty patients are afflicted with hemophilia, seven patients were intravenous drug addicts. The mean follow-up was 81 months (2-14) years. Patients were seen annually; either the Harris Hip Score or the Knee Society Rating System was applied. RESULTS: The following septic complications were observed: a mycotic abscess of both hips 5/10 months after bilateral THR, two early infections following coxitis in patients with intravenous drug abuse, and one further case of septic loosening after 15 months in one patient after THR. Furthermore, one aseptic loosening of a THR after 14 months in a hemophilic patient was seen. After TKR, two early infections in patients with intravenous drug addiction were seen. The total complication rate was 12.7%. A coherency between the infection rate and the CD4+ count was not seen. DISCUSSION: An analysis of the results shows that the complications occurred in patients living under difficult social circumstances. Whereas total joint replacement in hemophilic patients with or without HIV seems to be a fairly safe procedure concerning the postoperative infection rate, intravenous drug abuse increases the risk. Functional outcome does not differ from an HIV negative population both in the TKR and THR groups.

Tartrate-resistant acid phosphatase 5b (TRAP 5b) as a marker of osteoclast activity in the early phase after cementless total hip replacement.

BACKGROUND: After total hip replacement, increased bone metabolism is seen. A local periprosthetic osteopenia can be measured by dual-energy X-ray absorptiometry (DXA), but it is still unkown whether biochemical markers can be used to monitor the local remodeling at an earlier stage. PATIENTS AND METHODS: In this prospective study we compared the biochemical markers tartrate-resistant acid phosphatase 5b (TRAP 5b), bone ALP, osteocalcin and CrossLaps with periprosthetic DXA in 17 consecutive patients after uncemented total hip replacement. RESULTS: We found a highly significant early increase in TRAP 5b after 2 weeks and 6 weeks, which was followed by a densitometrically detectable decrease in bone mineral density after 26 weeks, especially in periprosthetic section Gruen zone 7. Bone ALP and osteocalcin levels as markers of osteoblast activity, and also Cross-Laps as a further marker of osteoclast activity, did not appear to allow any significant prediction of local bone remodeling. DISCUSSION: Our findings show that TRAP 5b is a sensitive parameter for monitoring of osteoclast activity after cementless total hip replacement, and may predict local osteopenia.