Posterior iliac offset: description of a new radiological measurement of sacroiliac joint instability.

The purpose of this study was to describe the radiological characteristics of a previously unreported finding: posterior iliac offset at the sacroiliac joint and to assess its association with pelvic instability as measured by initial displacement and early implant loosening or failure. Radiographs from 42 consecutive patients with a mean age of 42 years (18 to 77; 38 men, four women) and mean follow-up of 38 months (3 to 96) with Anteroposterior Compression II injuries, were retrospectively reviewed. Standardised measurements were recorded for the extent of any diastasis of the pubic symphysis, widening of the sacroiliac joint, static vertical ramus offset and a novel measurement (posterior offset of the ilium at the sacroiliac joint identified on axial CT scan). Pelvic fractures with posterior iliac offset exhibited greater levels of initial displacement of the anterior pelvis (anterior sacroiliac widening, pubic symphysis diastasis and static vertical ramus offset, p < 0.001,0.034 and 0.028, respectively). Pelvic fractures with posterior ilium offset also demonstrated higher rates of implant loosening regardless of fixation method (p = 0.05). Posterior offset of the ilium was found to be a reliable and reproducible measurement with substantial inter-observer agreement (kappa = 0.70). Posterior offset of the ilium on axial CT scan is associated with greater levels of initial pelvic displacement and early implant loosening.

Melatonin and adolescent idiopathic scoliosis.

Scoliosis seen in the chicken after pinealectomy resembles adolescent idiopathic scoliosis in man. It has been suggested that in both species, deficiency of the pineal hormone, melatonin, is responsible for this phenomenon. In nine patients with adolescent idiopathic scoliosis and in ten age- and gender-matched controls, the circadian levels of serum melatonin and the excretion of urinary 6-hydroxy-melatonin-sulphate, the principal metabolite of melatonin, were determined. There were no statistically significant differences in the secretion of serum melatonin or the excretion of urinary 6-hydroxy-melatonin-sulphate between the patients and the control group. The hypothesis of melatonin deficiency as a causative factor in the aetiology of adolescent idiopathic scoliosis cannot be supported by our data.

[Minimally invasive distraction arthrodesis of the ankle joint using threaded titanium cages]. / Die minimalinvasive Arthrodese des oberen Sprunggelenks mittels spongiosagefüllter Titanschraubzylinder.

OBJECTIVE: We present the theoretical principles and the results of a new kind of minimal invasive distraction arthrodesis of the ankle joint using threaded titanium cages. METHOD: Experimental operation was done on eight cadavers using a anterio-medial and lateral approach. Threaded titanium cages (12 mm diameter), known from spine surgery, were implanted under distraction. Four operations were done without and four with radiologic control. RESULTS: The samples demonstrated a high primary stability. After dissection of the ligaments a good position of the implants, with one exception, which was implanted without radiological control, was found. Cages, which were implanted under radiological control, were nearly parallel in sagittal direction, divergence ranged from 1 degree to 3 degrees (mean 2 degrees). Operation time was always shorter than 20 minutes. CONCLUSION: As indication for using this experimental operation in patients a primary osteoarthritis with intact ligaments and without severe malposition can be regarded. From the theoretical view advantages of this technique can be seen in the minimal invasive approach, the short duration of the operation and the high primary stability.

Comparative study of surface displacement in discs following chemonucleolysis and lasernucleotomy.

BACKGROUND AND OBJECTIVE: Dynamic changes of the dorsolateral protrusion site have been postulated to play an important role in the therapeutic effect of lasernucleotomy and chemonucleolysis. Basic biomechanical effects of the anulus after lasernucleotomy and chemonucleolysis are investigated. STUDY DESIGN/MATERIALS AND METHODS: This study evaluates the in vitro bulging of lumbar discs comparing lasernucleotomy and chemonucleolysis. The horizontal displacement at the ventral and dorsolateral surface of 20 cadaver discs were tested by application of a continuously increasing axial deformation before and after therapy. The increase in horizontal displacement due to this longitudinal deformation was measured. RESULTS: Bulging was significantly lower at the puncture site of the chemonucleolysis needle as well as at that of the laser trocar. Significantly reduced bulging of the anulus was observed after chemonucleolysis. Slightly increased bulging was observed after lasernucleotomy in the total posterior region. There was a tendency to decreased stiffness after chemonucleolysis and a significantly decreased stiffness after lasernucleotomy. CONCLUSIONS: The in vitro effect of lasernucleotomy seems to be based on reduction of the stiffness by distributing the load all over the anulus, whereas chemonucleolysis reduces bulging.

[Position of the patella after knee endoprosthesis. A by radiology and computerized tomography controlled study]. / Die Patellaposition nach Knieendoprothese. Eine mittels Radiologie und Computertomographie kontrollierte Studie.

The position of the Patellaimplant of 35 total knee arthroplasties (PCA) in regard to the other components, to patellar ligament and to correction of axis was analysed. The position of the patella was investigated with an average follow up of 38 months both radiologically and by computed tomography. A lateralisation of 4 mm on average and a lateral tilting of 4 degrees on average were found. The lateralisation of the patella in 30 and 60 degrees defilee radiographs demonstrated a significant dependence on the correction angle into valgus position. In lateral view and computed tomography the tilting of the patella is also dependent on the length of the ligamentum patellae. To avoid lateralisation and tilting of the patella in case of caudal position of the patella and a high intraoperative degree of correction into valgus position, careful check of the patella position is recommended in order to lateral release or medial capsular shift.

Circumferential measurement of anulus deviation after laser nucleotomy.

BACKGROUND AND OBJECTIVE: Former studies investigated only the intradiscal pressure after laser nucleotomy. As the outer anulus causes compression of neural structures, the present in vitro study was performed to investigate the circumferential pressure conditions of the outer posterolateral anulus following laser nucleotomy. STUDY DESIGN, MATERIALS AND METHODS: Laser nucleotomy was performed using a Hol:YAG laser (14 Watt, total energy applied 10kJ). Stiffness of the intervertebral disc and deviation of the posteriolateral portion of the disc under axial pressure were investigated. The forces observed during external deformation of the anulus were measured by stain gauges and recorded by a data logger. Measurements were taken at 4.8 and 10 kJ. The maximum axial load was 400 Newton. RESULTS: We found a preoperatively reduced external deviation within the punctured area after positioning the laser probe. Postoperatively, the posteriolateral parts of the disc showed a relatively increased external deviation due to reduced stiffness whereas the anterior parts remained unchanged. Stiffness of the disc decreased with increasing total energy applied. CONCLUSIONS: Puncture of the intervertebral disc for laser nucleotomy should be performed on the side of the prolapse. Due to the reduced stiffness peak pressure loads on the protrusion site might be distributed over the whole disc. The linear negative correlation observed between energy and stiffness suggests a good therapeutic correlation with laser treatment.

Hodgkin's disease in association with hexavalent chromium exposure.

During an epidemiological study assessing cancer risk in a small isolated population exposed to excessive amounts of hexavalent chromium, we noted two patients with Hodgkin's disease after exposure for many years and after a long latency period. The study population demonstrated an observed risk between 65 and 92 times that of reported risks for non-exposed US populations. Although malignant lymphoma, as well as many other malignancies, has clearly been associated with hexavalent chromium exposure, no reports have yet specifically mentioned Hodgkin's disease. We herein report Hodgkin's disease specifically in two individuals so exposed. Although this may be a chance occurrence, clinicians should be aware of the potential association between hexavalent chromium exposure and Hodgkin's lymphoma.

[MRI and ultrasound in rheumatology]. / MRT und Sonographie in der Rheumatologie.

Technical innovations and software improvements in magnetic resonance imaging (MRI) and high-resolution sonography (US) have definitely influenced the diagnostic imaging of rheumatic diseases. For MRI, improvements in surface coils, dedicated low-field systems (0.2 T), and software improvements (shorter acquisition times and refinements of fat suppressing techniques) must be mentioned. For sonography, the main innovations concern the development of higher transducer frequencies (7-15 Mhz) and power Doppler imaging. Clinical evaluations have shown that MRI and US are most useful in cases of suspected rheumatic disease with negative plain film radiographs and for documenting the course of the disease, diagnosing of early rheumatoid arthritis, making a differential diagnosis in clinically unclear rheumatic diseases, investigating vascularization, and quantifying pannus formation. In order to improve diagnostic efficacy the role of MRI and US in the management of patients with rheumatic disease should be reconsidered.

[Surgical treatment of spinal metastases]. / Chirurgische Behandlung von Metastasen der Wirbelsäule.

87 patients were treated for metastatic disease of the spine between 1970 and 1992. In the majority of the patients anterior decompression and stabilization was performed. The posterior approach was chosen only in case of predominant infiltration of the dorsal parts of the vertebra or in case of inaccessibility of the tumor via an anterior approach. The most common primary tumors were cancer of the breast, kidney and thyroid. Overall survival was 15.1 months. Only patients with metastases of thyroid cancer showed a statistically significant longer survival. Clinical results showed an improvement of pain in 83% and preoperative neurologic dysfunction could be improved in 53% of the patients. Our results suggest that surgical treatment improves life quality also in patients with short life expectancy. Patients who are expected to have longer survival times should be treated according to the general principles of stabilizing spine surgery.

[Total spondylectomy in metastasizing osteosarcoma of the spine--case report]. / Totale Spondylektomie bei metastasierendem Osteosarkom der Wirbelsäule--ein Fallbericht.

We report on a case of a 28 year old male patient, on whom in 1984 a rotation plasty was performed, due to an osteogenic sarcoma of the left distal femur. Eight years after the incidence of the primary tumor, a metastasis of the osteogenic sarcoma in the twelfth thoracic vertebra occurred. The tumor extended from the vertebral body to one pedicle and did not pass over the bony limits. After neoadjuvant chemotherapy an total spondylectomy was performed. Due to this method wide surgical margins could be achieved. Up to now these margins could only be executed with malignant bone tumors located in the extremities, whereas they could not be realized with the methods of spondylectomy, that were already introduced. By this case we want to present an innovative operation method for the treatment of primary malignant tumors or solitary metastasis of the spine, with the help of which we could give these patients a promising life expectancy.

Necrotizing effect of phenol on normal tissues and on tumors. A study on postoperative and cadaver specimens.

We investigated the necrotizing effect of a 75% alcoholic solution of phenol on normal tissue harvested during surgery (muscles, fatty or connective tissue) or post mortem (peripheral nerves, arteries, epidermal tissue, joint and epiphyseal cartilage) and on tumor tissue (60 samples freshly harvested from patients suffering from bone tumors). The necrotizing effect was measured by determining the thickness of the cell layers demonstrating nuclear pyknosis or necrosis after 2 min of phenolization in a light microscope by ocular measurements in microns. No effect could be seen in epidermal tissue and in cartilage, whereas all other normal tissues exhibited necrotic zones between 40 and 500 microns. In all the tumors except those with chondromatous tissue, necrotic zones between 40 and 1000 microns were found. No difference in extension of the necrotic zone was seen between specimens from benign and malignant tumors and tumor-simulating processes. Phenolization cannot be recommended for the treatment of chondromatous tumors.

[Postural disorders in children and adolescents]. / Haltungsstörungen bei Kindern und Jugendlichen.

Posture is defined as the upright well balanced position of an individual person. A postural fault is a posture that deviates from normal alignment without structural limitations. Postural faults are established in adolescence causing pain syndromes in adulthood. Major components of spinal structure and function are reviewed. The dynamics of posture are described. Characteristics and etiology of common postural faults in childhood and adolescence are characterised. Based on standardised diagnostic techniques, principles of how to manage posture and treatment of postural dysfunctions are discussed.

[Scoliosis and its conservative treatment possibilities]. / Die Skoliose und ihre konservativen Behandlungsmöglichkeiten.

Idiopathic scoliosis (IS) is the most common spinal deformity. Prevalence rates are reported between 0.3% and 13.3% respectively and depend on the screening methods being used. Girls are more likely to be affected than boys. The etiology of IS remains unknown, and its prognosis depends on various factors including age of onset, skeletal and sexual maturity, type and severity of the curve. Non-operative treatments are observation, bracing, physical exercise and electrical muscle-stimulation. Bracing of the adolescent idiopathic scoliosis has been proven to be effective and is indicated in curves between 25 degrees and 45 degrees Cobb and rapidly progredient curves under 25 degrees Cobb. Electrotherapy was promising, but failed to alter natural history of IS. Efficacy of physical exercise training in patients suffering from IS has not been evaluated.

Comparison of tuberculous and pyogenic spondylitis. An analysis of 122 cases.

One hundred twenty-two patients with tuberculous or pyogenic spondylitis were investigated retrospectively. Patient histories, laboratory tests, and radiographic findings were compared statistically between the two groups. Significant differences were calculated for the interval between onset of symptoms and diagnosis, erythrocyte sedimentation rate, mean vertebral loss at discharge, and sclerosis of the vertebral bodies involved. Open or closed biopsy was performed in 91 patients. The result provided a clear distinction between tuberculous and pyogenic spondylitis in 62.2%, either by means of histology or by culture growth. In pyogenic spondylitis, staphylococci were the most predominant bacteria isolated. Neurologic deficits were demonstrated in 17.8% of patients with tuberculous spondylitis and 22.7% with pyogenic spondylitis. At follow-up examinations, only two patients still had a motor deficit. Additionally, pain, gibbus formation, and bony fusion were evaluated, but no significant differences were found. The combination of several unspecific findings such as patient history, erythrocyte sedimentation rate, and radiographic assessment can lead to the correct diagnosis. A definitive diagnosis is established by means of biopsy, histologic evidence, and bacterial culture.

[Effects of inflammation-induced spinal fusion of the lumbar area on movement of the lumbar spine]. / Die Auswirkungen der entzündungsbedingten Blockwirbelbildung im Lumbalbereich auf das Bewegungsverhalten der LWS.

Lateral x-rays of the lumbar spine in standing position and functional flexion-extension roentgenograms of 21 patients with spontaneous fusion within the lumbar area after spondylitis were checked related to kyphosis of the block, lordosis and mobility of the lumbar spine and the single discs, and the appearance of degenerative spondylolisthesis. 76% demonstrated degenerative spondylolisthesis of the neighbouring discs, the half of them more than 5 mm with a significant higher number of segmental loosening of the disc caudal to the fusion. The kind of instability is a pseudo-spondylolisthesis (Junghans 1930) above and a retrolisthesis below the fused area. No higher mobility (no significant difference of mobility between the two cranial and the two caudal discs) can be seen as cause of this behaviour. The increased lordosis of the caudal segments is discussed to be the cause of the retrolisthesis distal the fusion. Altogether, kyphosis of the fused area leeds compensatory to a higher grade of lordosis in the mobile part of the lumbar spine without reaching the physiological lordosis of total lumbar spine. Kyphosis of the block does not influence mobility of the discs or the total lumbar spine, but increases significantly the rate of degenerative spondylolisthesis in the vicinal segments. These results suggest the operative reduction of lumbar lordosis in cases of kyphotic spondylitic destruction within the lumbar or thoracolumbar region in younger patients.

[The spine in adulthood]. / Die Wirbelsäule im Erwachsenenalter.

Back pain and low back pain can be caused by extravertebral diseases, functional disorders or morphologic changes of the spine. Diagnosis of back pain is mainly done by clinical examination. The examination of segmental mobility is necessary to make the diagnosis of functional disorders. X-ray and laboratory are mainly used to exclude morphologic changes of the spine. Functional disorders are best treated by chirotherapy completed by rehabilitation of the active motion apparatus. The most important morphologic diseases of the spine causing back pains are deformities, especially lumbar scoliosis, infectious diseases as pyogenous or specific spondylitis, rheumatic diseases as rheumatoid arthritis, mostly at the occipitocervical region, and Bechterew's disease, furthermore instability caused by spondylolisthesis or iatrogenic low back pain as the failed-backsyndrome and tumors, which are in the majority metastases. The role of degenerative changes as a cause of back pain is difficult to estimate. The operative treatment of spinal instability, which has changed in the last years is described, as modern treatment facilities of lumbar disc herniation as chemonucleolysis or percutaneous nucleotomy.

Devitalizing effects of phenol on bone marrow cells. Histologic study on cadaveric animal vertebrae.

The devitalizing effects of 5-90 percent phenol for 30 seconds on bone marrow cells were examined on vertebral bodies of fresh animal cadavers. Evaluation was made by measuring the width of the zone of necrotic cells. The zone increased with rising phenol concentration up to 75 percent, reaching an average width of 0.75 mm. However, when protected by bone trabeculae, the cells escaped devitalization.

[Widening of the sub-acromial space using a wedge osteotomy of the scapular spine. Anatomical bases, measurements on the preparation, studies of the kinematics of the acromion movements on a computer model]. / Erweiterung des subacromialen Raumes durch Keilosteotomie der Spina scapulae. Anatomische Grundlagen, Messungen am Präparat, Untersuchungen zur Kinematik der Acromionbewegung am Computermodell.

We describe the theoretical principles of a new kind of decompression of subacromial impingement syndrome by means of a wedge osteotomy at the transition between acromion and spine of the scapula. The operation on cadaver bone and the simulation of acromion movement in a computer model demonstrate an increase of subacromial space more than 1 cm after wedge excision with cranial base of 5 mm and ventral base of 3 mm. After the excision of an anterior based wedge the resection of the coracoacromial ligament is not necessary. An angle between 50 and 60 degrees from mediocranial to laterocaudal referred to the transverse plane has been calculated as optimal. We regard the sparing of the abducting parts of deltoid muscle, the better approach to the cuff with the possibility to mobilize the supraspinate muscle in cases of greater cuff-tears and the possibility to obtain a smooth undersurface of the acromion as further advantages of this procedure. Further biomechanic experiments will be necessary to optimize osteosynthesis.

Chiari pelvic osteotomy for osteoarthritis secondary to hip dysplasia. Indications and long-term results.

Of 142 Chiari pelvic osteotomies for osteoarthritis in dysplastic hips, most performed by Chiari himself, we were able to review 82 and obtain information about 18 by questionnaire. All patients were over 30 years of age at operation; follow-up averaged 15.5 years. Twenty hips had undergone secondary total hip replacement. The outcome was good in 75%, fair in 9% and poor in 16%. High osteotomies all gave good results, and the result also depended on adequate medialisation. Statistics were worse for patients over 44 years of age at the time of operation. For osteoarthritis secondary to hip dysplasia, the Chiari pelvic osteotomy is an alternative procedure to early hip replacement. In contrast to intertrochanteric osteotomy, it has the advantage of facilitating the implantation of an acetabular prosthesis should arthroplasty become necessary at a later stage.