[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.

Foot deformities in adolescents and young adults with spina bifida.

Spina bifida is generally accompanied by a high incidence of foot deformities. The goal of management is to achieve a plantigrade foot. Deformities are related to the level of the lesion. With thoracic lesions, the most frequent deformity is an equinus lesion (55%), a club foot with mid-lumbar lesion (87%) and a calcaneal foot with sacral lesions (34%). No deformity was present in 56% of feet in sacral lesion children. Club foot surgery before the age of 2 years entails a high rate of recurrence (78%), necessitating redo surgery. A calcaneo-valgus deformity developed in 45% of ambulating patients with sacral lesions requiring operative stabilization of the foot. Patients with sacral lesions were almost the only ones who remained ambulators. Ambulation was not seen to be related to foot deformities in adolescents and young adults.

False aneurysm 14 years after total hip arthroplasty.

Many reports of complications after total hip arthroplasty have been published concerning typical orthopaedic problems. Relatively little attention has been paid to serious vascular injuries, such as the development of a false aneurysm. To our knowledge, 10 cases have been described in the English literature. The mean time interval between surgery and initial manifestation of the aneurysm was 9 months in these cases. Our patient developed first symptoms of a false aneurysm 14 years after surgery. A minimally invasive technique was used to cut the aneurysm from perfusion. Removal of the total hip arthroplasty was performed through a retroperitoneal and lateral approach.

Pelvic tilt in neuromuscular disorders.

The pelvic tilt is part of a complex deformity in which both the spine and the hip are involved. By viewing the different planes and analyzing the deforming forces, four different types of pelvic tilt in combination with spinal and hip deformities can be identified. In spina bifida patients congenital deformities of the spine may add to the progression of scoliosis. Analyzing our own patients we found that certain types of pelvic tilt can be related to certain neuromuscular diseases. Moreover our results show that the pelvic tilt can be effectively corrected by spinal surgery, whereas no effect of hip surgery could be demonstrated.

Consequences of acute normovolaemic haemodilution on haemostasis during major orthopaedic surgery.

Acute preoperative normovolaemic haemodilution (NHD) is an accepted tool for reducing allogeneic blood transfusion requirements during surgery. At present, little is known of its impact on haemostasis. We have investigated the consequences of NHD on haemostasis by comparing conventional global tests (prothrombin time (PT), activated partial thromboplastin time (aPTT) with more specific measures of coagulation (prothrombin fragment 1 + 2 (F 1 + 2), thrombin-antithrombin III complex (TAT) and fibrinolysis (D-dimer (DD), plasmin-alpha 2-antiplasmin complex (PAP)). Blood samples were collected from two groups (NHD and controls) undergoing elective spinal surgery or pelvic osteotomy until day 3 after operation. The conventional global tests remained within normal limits: there were no significant differences between groups. Although surgery induced significant increases in the more specific measures of coagulation and fibrinolysis, there were no differences between NHD and control patients. Major orthopaedic surgery strongly activates coagulation and fibrinolysis. As the degree of these alterations was similar in haemodiluted and control patients, we suggest that acute preoperative normovolaemic haemodilution itself does not appear to be associated with greater perioperative disturbances in haemostasis.

Migration of the Duraloc cup at two years.

We carried out 71 primary total hip arthroplasties using porous-coated, hemispherical press-fit Duraloc '100 Series' cups in 68 consecutive patients; 61 were combined with the cementless Spotorno stem and ten with the cemented Lubinus SP II stem. Under-reaming of 2 mm achieved a press-fit. Of the 71 hips, 69 (97.1%) were followed up after a mean of 2.4 years. Migration analysis was performed by the Ein Bild Rontgen Analyse method, with an accuracy of 1 mm. The mean total migration after 24 months was 1.13 mm. Using the definition of loosening as a total migration of 1 mm, it follows that 30 out of 63 cups (48%) were loose at 24 months.

Free and total bupivacaine plasma concentrations after continuous epidural anaesthesia in infants and children.

We measured free and total venous bupivacaine plasma concentrations in fourteen infants and children aged 6 days (2800 g) to 9 years (27 kg) undergoing epidural anaesthesia. An initial bolus of 0.5 ml.kg-1 bupivacaine 0.25% was followed by a continuous infusion administered one h after bolus over a period of seven h (first hour 0.25 ml.kg-1.h-1 0.25%; then reduced to 0.125%). Although total bupivacaine plasma concentrations were within acceptable limits (< 1.5 micrograms.ml-1), four of the seven infants showed adverse reactions. Maximum plasma concentrations of free bupivacaine were significantly higher in infants (P < 0.05) than in older children. We conclude that toxicity may be underestimated when only measuring total bupivacaine concentrations. In young infants the bupivacaine dose administered for continuous epidural anaesthesia should be further lowered below recommended concentrations and the patients closely observed for possible adverse reactions.

No release of cardiac troponin I during major orthopedic surgery after acute normovolemic hemodilution.

BACKGROUND: Normovolemic hemodilution is a well-accepted method for intraoperative blood salvage. However, some controversy exists concerning the possible risk of myocardial fiber injury as consequence of the reduced oxygen content. Laboratory diagnosis of perioperative myocardial fiber injury is difficult, since biochemical markers are elevated postoperatively due to the surgical trauma. Cardiac troponin I (cTnI) is a new, highly sensitive and specific marker for the detection of myocardial injury. The aim of our study was to investigate whether normovolemic hemodilution in patients with major orthopedic surgery (13 hemodiluted patients, 15 control) induces a release of cTnI. METHODS: cTnI as a highly specific and sensitive cardiac parameter, as well as total creatine kinase (CK), creatine kinase isoenzyme MB mass (CKMB mass) and myoglobin were measured after induction of anesthesia, after normovolemic hemodilution, prior to retransfusion of blood components, 3 h after surgery, and on the first and third postoperative days. RESULTS: Prior to retransfusion of blood components the hematocrit was decreased to 25.4 +/- 1.2% (mean +/- SEM; range: 18%-34%) in the control group and to 20.2 +/- 0.8% (mean +/- SEM; range: 17%-24%) in the hemodilution group. Total CK, CKMB mass as well as myoglobin concentration increased significantly in both groups, reaching their maxima within the first day of surgery. In contrast, cTnI was below the detection limit of assay (< 0.5 micrograms/L) at any time. CONCLUSIONS: We suggest that pre- and intraoperative hemodilution to a hematocrit of approximately 20% by maintaining normovolemia does not induce myocardial fiber injury in patients without preexisting cardiac diseases.

Influence of antibiotics on infection in spinal surgery: a prospective study of 110 patients.

The purpose of this prospective study was to evaluate the effect of prophylactic antibiotic treatment on postoperative antibiotic spinal wound infection after spinal surgery with instrumentation. Subjects consisted of 110 successive patients that underwent instrumented fusion with Cotrel-Dubousset (CD) or Miami Moss instrumentation. In 56 cases, the indication for surgery was painful spondylolisthesis. The remaining 54 patients were treated for idiopathic scoliosis. In total, 172 spinal procedures were performed and included in the study. Preoperative infection prophylaxis consisting of 2 g cefamandole was administered to all patients. Patients received three doses of 2 g/day cefamandole after surgery for 3 days. Follow-up ranged from 1 to 4 years. The study revealed an early infection in one (0.6%) of the 172 procedures in a patient with spondylolisthesis. A late infection occurred in one (0.6%) patient with the diagnosis of idiopathic scoliosis. In both cases, cultures were positive for Staphylococcus aureus.

Surgical treatment of neuropathic scoliosis: morphologic and functional outcome.

We evaluated the morphologic and functional outcome as well as the extent of satisfaction following surgical treatment in 41 patients with progressive neuropathic scoliosis. The mean follow-up time was 5.6 years (range 2.5-20 years), and follow-up rate was 97.6%. Posterior spine fusion was performed with new instrumentation techniques (Luque/Luque-Galveston, CD, ISOLA) in 29 patients, with extension onto the sacrum in 16 patients, and Harrington instrumentation in 12. In 20 patients we did an additional intervertebral disc excision and fusion. Mean correction of the thoracic spine deformity, as assessed by comparing the Cobb angles on pre- and postoperative X-rays, was 53%, and of the lumbar spine 55.2%, in patients classified as Lonstein I. Scolioses classified as Lonstein II evidenced an average correction of 46.2%. Functional improvement according to the Rancho-Los Amigos scheme could be demonstrated in 20 patients. Seventeen patients remained unchanged, whereas 4 patients showed deterioration. Cosmetic results were rated as excellent by 25 patients, good by 7, and poor by 1. For 8 patients the appearance was unimportant. Pain relief was experienced in all cases (n = 4) of the preoperative low-back or abdominal pain. The major complications were deep wound infection in 3 patients which led to revision surgery, and removal of instrumentation in 1 patient.

[Magerl's subcapital osteotomy in the treatment of hallux valgus]. / Die subkapitale Osteotomie nach Magerl zur Behandlung des Hallux valgus.

The distal metatarsal osteotomy according to Magerl allows correction of a hallux valgus deformity by lateral and plantar displacement as well as by pronation and variasation. The length of the first metatarsal can be adjusted by the depth of the cut at the resection or by a slightly oblique osteotomy. If necessary, soft tissue release and/or a osteotomy of the first proximal phalanx can be done to relocate the sesamoids under the head of the first metatarsal. A review of 118 foot operations in 75 patients demonstrated a very good or good result in about 75%. Radiological examination showed sufficient lateralisation of the metatarsal head. Evaluating the length of the first metatarsal and the amount of variation, the results were less satisfying. The metatarsophalangeal angles could be corrected by 14 degrees and the intermetatarsal angles by 7 degrees on average. The sophisticated operative procedure limits the use of this technique as a standard procedure.

Axial rotation measurement of scoliotic vertebrae by means of computed tomography scans.

STUDY DESIGN: This study evaluated the preconditions for exact axial rotation measurement and the possibility for other parameters to measure axial rotation and mechanical torsion. OBJECTIVES: Quality criteria for axial rotation measurement in computed tomography scans are not established yet. Criteria should be found to improve axial rotation measurement. SUMMARY OF BACKGROUND DATA: To the authors' knowledge, no systematic analysis of the errors of axial rotation measurement based on computed tomography scans has been performed. METHODS: Axial rotation was measured in 259 computed tomography scans of 11 cadaveric vertebrae from scoliotic specimens. The sagittal axial rotation measurement angle of Aaro and Dahlborn and a new rotation parameter were measured with a pencil and ruler. Five landmarks were digitized and consequently five axial rotation parameters were computed. The influence of insufficient visualization of bony landmarks, mechanical torsion of the vertebra itself, and oblique position of the vertebra was evaluated. RESULTS: Accuracy is considerably improved in central computed tomography scans (same distance to the top and bottom of the vertebral body) due to good visualization of landmarks and reduction of effects of mechanical torsion. The oblique vertebral position causes more errors. One mechanical torsion parameter with sufficient reliability is identified. CONCLUSION: The sagittal axial rotation measurement method of Aaro and Dahlborn is superior to other techniques of measurement. It can be improved considerably if computed tomography scans fulfill certain quality criteria.

Suprascapular nerve entrapment at the spinoglenoid notch caused by a ganglion cyst.

A 34-year-old man had right infraspinatus muscle palsy and posterior aching of the shoulder caused by electromyographically confirmed suprascapular nerve entrapment. Sonography and magnetic resonance imaging revealed a cystic lesion at the spinoglenoid notch; this lesion was diagnosed as a ganglion. Operative removal led to immediate pain relief and incomplete recovery of the compressed branches of the suprascapular nerve.

Bupivacaine plasma concentrations during continuous epidural anesthesia in infants and children.

Venous bupivacaine plasma concentrations were measured in six neonates and infants aged 4 days to 3.9 mo (mean, 2.1 mo) and 10 infants and children aged 9 mo to 6 yr (mean, 3.1 yr) after administration of an initial bolus of 0.5 mL/kg bupivacaine 0.25%, followed by a continuous infusion of local anesthetic (0.25 mL.kg-1.h-1) over a period of 4 h (first hour: bupivacaine 0.25%, then reduced to 0.125%). Plasma concentrations of local anesthetic measured at 180 min and 300 min after beginning of bupivacaine administration were significantly higher in younger infants when compared to older infants and children (180 min: 0.67 +/- 0.24 micrograms/mL [0.25-0.97] vs 0.27 +/- 0.11 micrograms/mL [0.19-0.55], P < 0.01; 300 min: 0.86 +/- 0.36 micrograms/mL [0.35-1.25] vs 0.34 +/- 0.12 micrograms/mL [0.18-0.57], P < 0.01). The results of our study show that despite applying the same dosage of epidural bupivacaine significantly higher plasma concentrations were seen after short periods of continuous infusion in infants up to 4 mo than in children older than 9 mo.

Recurrence of infection after revision of infected hip arthroplasties.

We performed revision surgery for infected arthroplasty in 98 hips (96 patients). In 28 hips infection persisted. Of the remaining 70 hips, 61 (87%) were reviewed after a mean interval of 5.9 years (1 to 17). Infection occurred in 10% of these after three years and in 26% after ten years. The infection rate after initially successful revision for septic arthroplasty is higher than after revision for aseptic loosening and the risk of developing infection continues for many years.

Acetabular development following early treatment of hip dysplasia by Pavlik harness.

One hundred sixty-two neonates with sonographically diagnosed developmental dysplasia of the hip (200 hips) according to the method of Graf were treated with a Pavlik harness until sonographic maturation was reached. Eight patients (12 hips) treated with closed reduction and retention in a bilateral hip spica cast were included. When the children started to walk their acetabular indices were assessed and demonstrated low-grade dysplasia in 26% and high-grade dysplasia in 6% according to the criteria of Tönnis and Brunken. We discuss the current sonographic criteria defining treatment-induced normalization and the adequacy of the length of treatment. We conclude that despite normal values at the end of treatment dysplasia may develop, which necessitates further radiological monitoring of all hips initially rated at risk on sonography. When to end monitoring, however, remains to be determined.