[Spinal injuries in children and adolescents]. / Halswirbelsäulenverletzungen im Kindes- und Jugendalter.

Pediatric cervical spine injuries are rare. Knowledge of possible types of injury, physiological development and anomalies is necessary in order to not overlook the injury and to initiate suitable therapy. Description of the clinical assessment, Management of diagnostics and therapy of specific injuries. Based on a selective literature search and taking into consideration our own experience, typical injuries at the upper and lower cervical spine in pediatric patients are depicted. In the presence of neurological deficits, identification of the cause is crucial. Odontoid fractures and injuries to the second cervical vertebra are common in upper cervical spine injuries, compression fractures and facet joint dislocation injuries are common in lower cervical spine injuries. Depending on the location of the injury and on the grade of instability, specific therapy, including conservative treatment (orthosis, halo fixation) and operative treatment (internal fixation, fusion) might be necessary.

[Clinical experience and results of using the V.A.C. instill therapy in infected hip- and knee prosthetics]. / Klinische Erfahrungen und Ergebnisse über die Anwendung der V.A.C.-Instill bei infizierten Hüft- und Kniegelenksprothesen.

Since September 2005 our patients with acute endoprosthetic infection are treated, next to the normal wound debridement, with a full automatic vacuum drain system (V.A.C. instill system). This therapy unit entail a three step program. Based on the well known vacuum therapy, the new system contains an additional fluid drain and affecting period with an antibiotic or antiseptic instillation therapy. In the last half year we were able to treat five patients with endoprosthetic infection by using this therapy unit. In our opinion, we have a successfull method of treating patients with acute, infected big joints after endoprosthetic implantation. The therapy unit of V.A.C. instill is quickly available and easy to learn. Next to much better comfort for the patients the most advantage is to leave the prosthetic inside during the infection management with the new therapy unit. Further results in treating acute joint infections after endoprosthetic implantation must been shown, if this new method is to be the new standard in daily clinical routine.

Coincidental deficiency of the posterior arch of the atlas and thalassaemia minor: possible pitfalls in a trauma victim.

Congenital abnormalities of the cervical spine are rare findings in trauma victims. Deficiency of the posterior arch of the atlas and coincidental thalassaemia minor are even more unusual. This case report is about a young female trauma victim with both abnormalities, a combination that has previously not been described in literature. The classification, as proposed by Currarino et al in 1994, and the importance of being aware of these abnormalities are discussed.

Long-term results after posterior fixation of thoraco-lumbar burst fractures.

Current concepts of treating thoraco-lumbar burst-compression injuries are based on posterior transpedicular fixation techniques which are angular stable. However, the long-term results of this approach are controversial due to inconsistent reports and due to a paucity of data on late outcome. In the present study we analyzed 50 patients retrospectively who had an unstable burst-compression injury at T 11-L 2 (type A 3 according to Magerl) without a neurological deficit. All fractures were stabilized by an internal fixator either with or without transpedicular spongiosa grafting. Patients were treated between 1991 and 1997. Follow-up times ranged from 36 to 103 months. Follow-up examinations collected occupational, subjective and clinical data (activity score, Hannover spine score) and included radiographic measurements. The latter were used to calculate the sagittal index (SI) which measures deformities of the fractured vertebral body, and the sagittal plane kyphosis (SPK) which additionally describes an eventual destruction of the affected intervertebral disc. Compared with the preinjury status, the percentage of subjects who were able to do physical labor was reduced by half at follow-up, and four times as many patients had a permanent disability. Correspondingly, activity scores and Hannover spine scores declined significantly. After the initial surgical correction SI remained stable until follow-up, whereas SPK decreased again towards pre-operative values indicating a progressive deformity of the intervertebral disc space. Clinical results did not correlate with radiographic results, and neither the time until follow-up nor the type of fracture n or the use of transpedicular bone grafting affected clinical or radiographic results significantly.

Metastatic lesions of the humerus treated with the isoelastic diaphysis prosthesis.

Between January 1, 1987, and December 31, 1997, an isoelastic polyacetal resin prosthesis was used in 50 patients with metastatic bone disease to reconstruct pathologic or impending fractures of the humeral diaphysis. Fifty-seven operations were performed, including seven revision surgeries. The patients were assessed before and after surgery for limb function and quality of life using a modified Karnofsky scale. The mean survival time was 440 days. Ninety-one percent of the operations resulted in restoration or improvement of quality of life. Limb function was good or excellent in more than 80% of the patients after surgery. Breaking of the implant (n = 3), loosening of the implant (n = 2), periprosthetic fracture (n = 1), hematoma (n = 2), infection (n = 1), and one radial nerve paralysis were the main complications. In the cases of implant failure, the prosthesis broke at the site of a locking screw that was inserted across the prosthetic shaft in the cementless implantation technique. This kind of complication could be avoided by using bone cement for implantation or additional plate osteosynthesis between the prosthesis and humeral shaft. The isoelastic diaphyseal prosthesis offers a promising method of treating patients with metastatic lesions of the humeral shaft.

Use of human GH in elderly patients with accidental hip fracture.

OBJECTIVE: To investigate whether early intervention with recombinant human growth hormone (hGH) after hip fracture improves functional recovery and long-term outcome. SUBJECTS AND METHODS: Functional recovery after hip fracture is often incomplete. The catabolic situation that develops after the hip fracture accident, and a state of malnutrition either pre-existing or developing after surgery, are main contributing factors for the poor clinical outcome. hGH has been used to promote anabolism in a variety of clinical catabolic situations. The study design was randomized, double-blind and placebo-controlled. A total of 111 patients older than 60 years with an accidental hip fracture (mean age 78.5+/-9.1 (s.d.) years) were randomized to receive either hGH (20 microg/kg per day) or placebo for a period of 6 weeks, starting within 24 h after the hip fracture accident. Thereafter patients were followed up for an additional period of 18 weeks. Efficacy was assessed by comparing the changes in the Barthel Index score of activities of daily living and in a patient's living situation between the hGH- and the placebo-treated subjects. RESULTS: Eighty-five (78.5%) patients completed the first 8 weeks of the study and 76 (68.5%) the entire study period of 24 weeks. When split according to age, a trend was found that for patients older than 75 years the changes in Barthel Index score from baseline were less in the hGH group than in the placebo group (-18.6+/-18 vs -28.1+/-26) at 6 weeks after surgery (P<0.075). There was an overall trend to a higher rate of return to the pre-fracture independent living situation in the hGH group than in the placebo group. Analysis by age revealed a significantly higher proportion of hGH- than placebo-treated patients returning to the pre-fracture living situation for subjects older than 75 years (93.8 vs 75.0%, P=0.034). hGH treatment increased IGF-I values to levels in the range of those of normal subjects of 50-60 years of age. CONCLUSIONS: A 6 week treatment with hGH (20 microg/kg per day) of otherwise healthy patients after an accidental hip fracture may be of benefit if given to subjects older than 75 years of age. The rate of return to the pre-fracture living situation in subjects of this age treated with hGH was significantly increased when compared with the placebo-treated group. The treatment intervention was well tolerated and no safety issues were recorded.

[Unstable pediatric femoral and forearm shaft fractures. Comparison between conservative treatment and stable intramedullary nailing]. / Instabile kindliche Femur- und Unterarmschaftfrakturen. Vergleich zwischen konservativer Behandlung und stabiler intramedullärer Schienung.

Elastic intramedullary nailing represents a new surgical concept in the treatment of unstable shaft fractures in children. The present case control study wanted to examine the superiority of intramedullary nailing in comparison to conservative therapeutic concepts which had been applied so far. 13 children with forearm fractures who were treated initially by conservative measures were compared to 13 other children who received a primary intramedullary nailing. With femoral fractures, 12 children were included in each group. In each patient pair age, type and localisation of the fracture were comparable. During the observation period (until the termination of final therapeutic measures or until the third year after injury) we examined clinical variables and subjective findings. Both therapeutic concepts led to comparably good functional results. Also subjective judgement of the therapeutic success did not differ between groups. However, with intramedullary nailing of shaft fractures of the femur the mean hospital length of stay (7.0 +/- 3.5 days) was significantly shorter than with initial conservative treatment (36.5 +/- 2.2 days, P < 0.05). Irrespective of the localisation of the fracture intramedullary nailing required significantly less x-ray examinations during the observation period. These results suggest intramedullary nailing to be the procedure of choice to treat unstable forearm and femoral fractures in children.

[Treatment of per- and subtrochanteric femoral fractures by gamma nails and modular hip prostheses. Differential indications and results]. / Versorgung der per- bis subtrochantären Femurfraktur durch Gammanagel und modulare Hüftprothese. Differentialindikation und Ergebnisse.

From January 1997 to August 1998 all stable and nonstable trochanteric femoral fractures (n = 72) were treated routinely by gamma nail using the correct operative technique. Patients showing additional osteoarthritis of the hip in radiographs hip replacement was performed by a cementless modular femoral hip prostheses from January 1996 to August 1998 (n = 28). Follow up period was 6 to 18 months. Operation time and blood loss were higher using the prostheses. However complications and lethality (< 5%) were not different during postoperative course. In each group three operative technical complications occurred. Using a modified Harris Hip Score (without range of motion, contractions) the score was decreased non significant comparing both groups first of all in unstable fractures until follow up. In each group one revision (loosening of prostheses, excessive shortening of femoral neck) was necessary. Using the correct operative technique, the gamma nail proved to be a save device with good outcome. Outcome using modular prostheses is comparable to gamma nail. Therefore the use of modular prostheses is justified in case of osteoarthrosis and in some cases of very unstable fracture.

Endoscopic osteosynthesis after thoracic spine trauma: a report of two cases.

Modern concepts of treating thoracic diseases suggest more and more the use of minimally invasive thoracoscopic techniques to reduce morbidity and save costs. For treatment of specific lesions at the thoracic spine, several thoracoscopic procedures have been performed successfully. The present report examines the feasibility of thoracoscopic osteosynthesis in two patients with ventral hyperextension injuries and anterior instability of the thoracic spine. After initial correction of the anatomical deformity, autologous bone was harvested from the anterior iliac crest. Using a ventral, thoracoscopic approach, the main location of the ventral, damaged spinal segment was identified by the covering pleural haematoma. After endoscopic ventral bone grafting, osteosynthesis was performed, using dynamic compression plates, cardan drills and screw drivers. The perioperative course was uneventful, and follow up examinations after 3 years and 9 months, respectively, revealed an unchanged stable spinal segment. Our results show thoracoscopic osteosynthesis to be technically possible, with a potential for yielding satisfying long-term results.

[Spontaneous hemothorax in dermatomyositis and long-term glucocorticoid treatment]. / Spontaner Hämatothorax bei Dermatomyositis und langjähriger Glucocorticoidtherapie.

A 65-year-old woman with dermatomyositis for which she had been treated for ten years with prednisone (latterly 15 mg daily) suddenly experienced severe pain in the left thoracolumbar region. Cardiovascular, pulmonary and vertebral causes of the pain were excluded. But serological tests indicated inflammatory disease and the haemoglobin concentration was low (10.4 g/dl). Left pleural effusions were repeatedly aspirated and some haemorrhagic fluid obtained (haematocrit 0.31 in blood, 0.28 in the pleural effusion). Five days after admission her cardiovascular status became unstable and she developed respiratory failure (haemoglobin 7.6 g/dl). Chest radiograph showed increased pleural effusion. Subsequent thoracotomy revealed a left coagulothorax which was removed and flushed. During this procedure severe bleeding occurred from a covered perforation of the descending aorta, 1.5 x 1.5 cm in size. Although the aortic wall was thin, there was no aneurysm but arteriosclerotic changes and an external erosion near an abscessing mediastinitis, originating from a chronic purulent pleuritis and bronchopneumonia. The severe blood loss caused circulatory failure from which the patient could not be resuscitated.

Thoracoscopic repair of thoracic spine trauma.

Modern concepts of treating thoracic and lumbar spinal trauma are based on posterior transpedicular fixation techniques which confer angular stability and instrument only a few levels of the spine. In addition, to prevent secondary losses in postoperative reduction of kyphotic deformities, transpedicular resection of torn discs, and inter- and intracorporeal bone grafting are included in the repair procedures for the entire damaged motion segment. However, due to the small size of the pedicles, a transpedicular approach to the injured vertebral body is not possible in the upper thoracic spine. Patients whose thoracic spine trauma is not serious enough to require ventral instrumentation through open thoracotomy, but who present with an unstable vertebral fracture, may profit from additional ventral bone grafting to stabilize the fracture. The present study examined the feasibility of thoracoscopic ventral bone grafting in seven patients with unstable fractures of the upper thoracic spine. For primary repair, we stabilized the fracture by using posterior transpedicular screw systems (rods or plates). Simultaneously, spongiosa was harvested from the posterior iliac crest and deepfrozen. Repair was completed a few days later via a ventral thoracoscopic approach. The main location of the ventral osseous defect was identified by intraoperative radiology. After mechanical removal of destroyed connective tissue and disc material, fusion was performed using the previously harvested spongiosa, which was placed into the intervertebral disc space and the anterior osseous defect. Our results show thoracoscopic bone grafting to be technically possible and associated with low morbidity, with a potential of yielding satisfactory long-term results.

Posterior stabilization of C2 metastases by combination of atlantoaxial screw fixation and hook plate.

A new technique for the stabilization of metastatic cervical instability of the axis and/or neighboring vertebrae at lower levels is described. By a combination of the transarticular screw fixation C1/2 (Magerl) with the hook plate technique (Magerl) (or facultatively with a 1/3 tubular or 3.5 mm dynamic compression plate) from a posterior approach, the risks and stresses on the patient of a transoral or a combined extended technique are avoided, creating a proven biomechanically stable situation. The new technique is particularly helpful in those patients with a rapid progression of their malignant disease in whom local tumor growth is not expected to compress the spinal cord, and palliative stabilization of the unstable upper cervical spine can avoid neurological deficits or alleviate pain syndromes at a minimized morbidity due to surgery. The new technique has been successfully applied in a limited clinical series of four patients with metastasis of the cervical spine, resulting in substantial improvement of the general condition and cervical pain syndrome and stability of the assemblage during the observation period (4-9 months).

[Surgical treatment strategies in femoral metastases]. / Operative Behandlungsstrategien bei Femurmetastasen.

Because of the increasing survival-time of tumor-patients bone metastasis is becoming an important subject in surgery. In the case of osteolysis of the femur a concept of treatment in consideration of various localisations is presented. In 81 patients with pathological fractures of the femur or osteolysis in this region from January 1987 to June 1992 96 stabilizing operations were performed. Almost one half of the patients suffered from breast carcinoma followed by hypernephroma, Plasmocytoma, bronchial-carcinoma and prostate-carcinoma. The average survival time after stabilization of the femur was 8.3 months. After the operation the condition of the patients improved on an average by 0.64 units of the modificated Karnowsky-Index. Surgical treatment of osteolysis in the femur is indicated either in pathological fractures or if instability is imminent. Moreover patients who suffer from severe pain should also receive palliative surgery. With regard to the site of the lesion various types of endoprostheses and osteosynthesic devices can be used. If the femoral neck or the intertrochanteric region is affected arthroplasty with cemented endoprosthesis may be performed. In subtrochanteric osteolysis long and thin endoprosthesis can be used as well as Gamma-nails. Pathological fractures in the shaft of the femur should be treated with intramedullary static locked nails, which can be strengthened by supplementary lateral plates. If the distal metaphysis of the femur is involved compound osteosynthesis with methylmethacrylate and dynamic condylar screws or angle plates can be used.

Analysis of morphology and gait function after intraarticular calcaneal fracture.

Open reduction and internal fixation is suggested by an increasing number of investigators as preferable treatment of displaced intraarticular calcaneal fractures. Assuming that quasianatomical reduction coincides with adequate function, many surgeons rely on morphological parameters (standard radiography, computed tomography) to demonstrate the effectiveness of surgery by achieving an optimum restoration of calcaneal geometry and joint surfaces. In order to correlate morphologic parameters and functional assessment, a prospective study was performed on 45 patients after surgical treatment of intraarticular calcaneal fractures using standard radiographic and computed tomographic scores, clinical evaluation, and gait analysis (dynamic pedography). Mean follow-up time after reconstruction was 23 months (range 18-50). Although clinical evaluation and assessment of gait function corresponded well with each other, radiographic scores showed a poor to moderate correlation with functional evaluation (r = 0.29-0.62); this was probably due to the missing analysis of soft tissue parameters. The comparison of clinical results and gait parameters with the individual radiographical parameters allowed us to identify those factors, with the greatest influence seen on the functional prognosis (i.e., calcaneal width, arthrosis in the neighboring joints). Morphologic analysis after calcaneal reconstruction based on radiographic techniques cannot predict subsequent function or substitute for functional assessment. However, it does allow for practical conclusions for surgical strategy in primary osseous reconstruction or secondary corrections.

[Surgery of metastases--can surgery of metastases be radical?]. / Metastasenchirurgie--Kann Metastasenchirurgie radikal sein?

Resection of metastases gains more and more importance in day to day surgical work task. Mainly only liver- and pulmonary metastases can be resected with a curative aim, depending on the primary tumor and the metastasing cascade. According to tumor surgery a R0-resection is warranted. Whether a multimodal approach may improve long-term results by eliminating occult micrometastases should be answered by ongoing studies. Even in palliative situations complete resections of metastasis are preferred and in selected situations a multimodal approach may be chosen.

[Experiences with the isoelastic prosthesis in treatment of humerus metastases]. / Erfahrungen mit der isoelastischen Prothese bei der Behandlung von Humerusmetastasen.

39 patients with pathological fractures of the humerus were treated by isoelastic polyacetal endoprosthesis. Ten patients received a humeral-head-prosthesis and 32 a prosthesis of the humeral-shaft. The average survival time was nine months. Three times within the first group of twelve patients fracture of the cone of the prosthesis occurred. Therefore an additional stabilization of the contact zone between bone and prosthesis by plate-osteosynthesis was performed in the following 20 operations, preventing breakage of the material. In contrast to the conventional posterior approach to the humeral-shaft we chose a ventrolateral approach between the biceps and triceps muscle. This technique is less traumatic and leads to a shorter operation time. In patients with pathological humeral fractures a conception of treatment is demonstrated which provides an immediate stability by using endoprostheses to preserve the quality of life of oncological patients.

Anterior transpedicular instrumentation of the lumbar spine: an anatomical study.

Lumbar burst fractures or massive tumorous destruction of the lumbar spine generally require a combined anterior-posterior surgical approach for adequate decompression and stabilization. Anatomical studies in 10 adult cadavers with 100 pedicle screw placements from a single strictly anterior approach showed that this new method represents a safe and promising way for stable lumbar spine instrumentation, avoiding the risks of a bilateral approach. The technique provides a stability comparable with bilateral instrumentation. Exact knowledge of the geometry of the corresponding vertebral bodies and the spinal canal by computed tomography scanning is a prerequisite for this surgical technique. First clinical applications using this technique reconfirm the experiences of the anatomical study.

Spinal stabilization for patients with metastatic lesions of the spine using a titanium spacer.

Anterior decompression in spinal metastases of the corporal type with impending (n = 5) or present (n = 36) neurological complications was performed in 41 patients. For reconstruction, a titanium cylinder was inserted after spondylectomy and augmented with an anterior plate. The titanium implant can easily be adjusted to the length needed without necessitating expensive additional equipment. Outside the patient the implant is filled with polymethylmetacrylate, facilitating plate transfixation for rotational locking. There was a 30-day mortality of 9.7%. Pain relief was apparent in 38 of 41 patients (92.7%), and motor improvement was manifest in 31 of 35 cases (88.6%). Six patients did not present with any neurological symptoms pre- or postoperatively. Neurological deterioration was registered in only 1 case (2.4%). Surgical efficacy was maintained until the death of the patients. Though tumor recurrence at a different spinal level led to consecutive surgery in 5 patients, no implant dislocation occurred during the observation period (maximum 44 months), characterizing the procedure as a mechanically reliable and safe technique.

[Extension-distraction injury of the lumbar spine in Bechterew's disease]. / Extensions-/Distraktionsverletzung der lumbalen Wirbelsäule bei Morbus Bechterew.

Back-pain following trauma of the vertebral column in patients suffering from Bechterew's disease should be examined carefully. Instable spine fractures in those patients are recommended to be treated surgically to avoid the specific risks of long-time immobilisation. Further on surgical therapy eventually allows an intraoperative correction of the kyphosis angle. Due to the particular pathological alterations of the spine in Bechterew's disease a long-distance intervertebral fusion will usually be necessary. Therefore, internal stabilisation is proposed as therapy of choice.