Complications and patient satisfaction after periacetabular pelvic osteotomy.

Periacetabular osteotomy (PAO) is a well established method to treat hip dysplasia in the adult. There is, however, a lack of information on the subjective outcome of patients with complications after PAO. The purpose of this study was therefore to assess the influence of complications on the patients' post-operative wellbeing and function: 60 PAOs on 50 patients were investigated retrospectively after a mean follow-up of 7.4 years. The patients' self-reported assessment of health and function was evaluated by the Medical Outcomes Short Form-36 (SF-36) and the Western Ontario and McMaster Universities (WOMAC) questionnaires at last follow-up. Forty healthy persons served as a control group. Of the 60 interventions 13 had no complications. Minor complications occurred in 25 (41%) and in 22 (37%) at least one major complication occurred. SF-36 summary measure was 76.4 for PAO patients and 90.3 for the control group. Mean WOMAC score was 25.1. Patients with major complications had a similar subjective outcome as patients with minor or without complications, but persistent dysaesthesia due to lateral femoral cutaneous nerve dysfunction led to a worse subjective function. Lesions of the lateral femoral cutaneous nerve have much greater influence on patients' self-assessed functional outcome after PAO than previously reported and greater attention has to be given to this supposedly minor complication.

[Surgical treatment of idiopathic scoliosis and juvenile kyphosis]. / Operative Therapie von idiopathischen Skoliosen und juvenilen Kyphosen.

Indication for operative treatment of idiopathic scoliosis and juvenile kyphosis is mainly cosmetic. There is also a higher incidence of pain in scoliosis patients, and reduced pulmonary function in severe deformity, especially in severe deformities present at the age of 5 years (early onset). Scoliotic curves of less than 30 degrees will not progress in adults, whereas curves of 50-75 degrees will further progress a mean of 25 degrees during 40 years. Progression in adults with juvenile kyphosis is not well documented. Operative treatment aims to stop progression, to control spinal growth, or to perform correction and fusion by spinal instrumentation and bone grafts. These goals can be achieved either by an anterior, a posterior, or a combined approach. Correction principles are compression, distraction, derotation and translation. The forces applied by correction are transferred by fixation devices (pedicle screws, anterior screws, hooks, sublaminar wires) to the spine. The higher correction forces are, the higher is the correction achieved, but also the risk of fracture and torn out implants. Mobilisation reduces rigidity and allows to achieve a better correction with equal forces. The best mobilisation techniques are disc excision, facet joint removal, and techniques to mobilise the thorax.

[Videotape preparation of patients before hip replacement surgery improves mobility after three months]. / Video-Vorbereitung bei Hüftgelenkersatz-Operation verbessert die Mobilität nach drei Monaten.

Long-term follow-up investigations of the effect of psychological preparation on postoperative physical outcome measures have very rarely been done. In this study a three-month follow-up of a previous investigation of videotape preparation before hip replacement surgery is reported. 100 patients who previously participated in a randomized controlled study received physical examination and x-ray of the hip joint three months after the operation. The mobility of the replaced hip joint was recorded as well as ossifications of the joint. Prepared patients showed a significantly higher improvement of internal rotation, rotational range of motion, and abduction, compared to the controls. The effect sizes ranged between 21% and 32% and, thus, were of clinical relevance. Prepared patients showed less ossifications (15%) that controls (22%), this difference was not significant. For the first time it could be demonstrated that psychological preparation before surgery can not only improve short-term and psychosocial outcome parameters, but also long-term physical measures. The reason for this effect remains to be investigated.

Can the dimensions of artificial tendon lesions be predicted ultrasonographically? A cadaveric study.

OBJECTIVE: To prove the reliable assessment of artificial partial tendon lesions in cadavers. METHODS: The tendon of the tibialis anterior muscle was cut twice (transversely, not standardized depths) along its dorsal surface. The dimensions were measured by using a 10-MHz linear probe and a gliding caliper. The lesions were classified as type A tears (<60%; n = 15) and type B tears (>60%; n = 28). RESULTS: The depths of type A tears had high correlation (r = 0.827), and those of type B tears had low correlation (r = 0.415). This low correlation was due to subtotal lesions (50%-70%; r = 0.699). High-resolution ultrasonography allowed the correct detection of 14 type A tears and 21 type B tears (kappa = 0.63; accuracy, 81%; type B tears: sensitivity, 75%; specificity, 93%). CONCLUSIONS: High-resolution ultrasonography is able to assess the dimensions of artificial partial tendon lesions in cadavers and would be an accurate tool for determining the lesion percentages in patients with partial tendon tears.

Motion in lumbar functional spine units during side bending and axial rotation moments depending on the degree of degeneration.

STUDY DESIGN: Human lumbar spine specimens were tested in axial rotation and side bending. Motion was related to the grade of degeneration. OBJECTIVES: To determine the degree to which degeneration with fissure formation in the disc affects axial rotation of the lumbar functional spine unit. SUMMARY OF BACKGROUND DATA: There is controversy in the literature regarding the influence of severe degeneration and fissures of the disc on the range of axial rotation. METHODS: Thirty-six lumbar spine specimens were tested in axial rotation and side bending, by applying pure moments in an unconstrained setting. The motion in 6 df was recorded by dial gauges. The grade of degeneration was established by the grading schemes of Nachemson, Thompson, Adams, and Mimura. RESULTS: A significant increase of axial rotation and lateral translation under torque was found. This increase mainly took place between Grade 3 according to the schemes of Nachemson, Thompson, and Adams (no fissure formation) and the higher grades of degeneration (defined by fissure formation). Reduced disc height was always associated with fissures. CONCLUSIONS: A reduced lumbar disc height in radiographs seems to be associated with fissure formation in the disc. In this case, the range axial rotation after torque is increased in comparison with cases with less degeneration.

Videotape preparation of patients before hip replacement surgery reduces stress.

OBJECTIVE: Elective surgery represents a considerable source of stress for the patient. Many attempts have been made to prepare patients before surgery with the aim of reducing stress and improving outcome. This study used a novel approach to fulfill this aim by showing a videotape of a patient undergoing total hip replacement surgery, covering the time period from hospital admission to discharge, that strictly keeps to the patient's perspective. METHODS: Before elective total hip replacement surgery, 100 patients were randomly assigned to a control group or a preparation group; the latter group was shown the videotape on the evening before surgery. Anxiety and pain were evaluated daily for 5 days, beginning with the preoperative day, by means of the State-Trait Anxiety Inventory and a visual analog scale. Intraoperative heart rate and blood pressure, as well as postoperative intake of analgesics and sedatives, were recorded. Urinary levels of cortisol, epinephrine, and norepinephrine were determined in 12-hour samples collected at night for 5 nights, beginning with the preoperative night. RESULTS: Compared with the control group, the preparation group showed significantly less anxiety on the morning before surgery and the mornings of the first 2 postoperative days, and significantly fewer of them had an intraoperative systolic blood pressure increase of more than 15%. The pain ratings did not differ significantly between the two groups, but the prepared patients needed less analgesic medication after surgery. Prepared patients had significantly lower cortisol excretion during the preoperative night and the first 2 postoperative nights. Excretion of catecholamines did not differ significantly between groups. CONCLUSIONS: We conclude that use of the videotape decreased anxiety and stress, measured in terms of urinary cortisol excretion and intraoperative systolic blood pressure increase, in patients undergoing hip replacement surgery and prepared them to cope better with postoperative pain.

Comparison of spinal mobility after Harrington and CD instrumentation.

Of 229 patients, 15 pairs of patients with right thoracic idiopathic scoliosis (King III) and 15 pairs with combined thoracic and lumbar scoliosis (King II) were identified. Each pair consisted of one patient with Harrington and the other with Cotrel-Dubousset instrumentation. Pairs were comparable with regard to thoracic curve magnitude, and level of end and stable vertebrae. Minimum follow-up was 4 years postoperatively. Spinal mobility of patients in the coronal and sagittal plane, and axial rotation was measured with inclinometers. The differences between operatively treated groups are not significant. The more caudal instrumentation ends, the more reduced is spinal mobility in the coronal plane. Motion in operated patients is significantly reduced in comparison to a healthy reference group.

[Biomechanics of lumbar instability]. / Biomechanik der lumbalen Instabilität.

Several authors have tried to define segmental lumbar instability. Their definitions: increased antero-posterior translation, pathologic coupled motion, increased neutral zone, pathologic instantaneous center of rotation describe some mechanic findings occurring in the aging spine. However, there is no evidence that they help to differentiate the pathologic entity of segmental lumbar instability from the normal aging process. Dynamic explanation models are promising but at the moment they cannot be used clinically for diagnosis of instability as well. The most important structure to maintain lumbar stability is the intervertebral disc. In the third and fourth decade, more than 50 percent of specimen show peripheral tears of the anulus. It was shown in animal experiments that these tears develop to radial tears, which are accompanied by nuclear volume loss and decreased height. The facets degenerate one or two decades later. Corresponding with the loss of discal function, they increasingly contribute to spinal stability. In conclusion, the concept of lumbar segmental instability is not very helpful in clinical practise. It is recommended to base the decision of lumbar fusion on a painful degenerated disc, and additional findings promising a good result.