Approaches to optimize focused extracorporeal shockwave therapy (ESWT) based on an observational study of 363 feet with recalcitrant plantar fasciitis.

INTRODUCTION: Extracorporeal shockwave therapy (ESWT) is an established second-line treatment option for plantar fasciitis. Longer term results of focused ESWT are rare in literature. This study assessed the treatment success-rates of single session ESWT compared to repetitive ESWT treatment sessions, the mid-term results as well as treatment- or patient-related factors influencing the outcome of focused ESWT for plantar fasciitis. METHODS: 284 patients (363 feet) received ESWT for plantar fasciitis and answered a questionnaire on socio-demographic and anamnestic data immediately before as well as 19-77 weeks after the first application of ESWT. RESULTS: 76 percent of patients treated only once and 74 percent of all patients reported satisfying pain relief (with up to three treatment sessions). This was consistent in the mid-term and over different physicians as well as independent of assessed patient- or treatment-related factors. DISCUSSION: Applying repeated ESWT in weekly intervals by default may be helpful in reducing healing time for those patients requiring more than one treatment session. Prospective research is needed to find out whether further treatment sessions are justifiable in patients who indicate no improvement after two or three treatment sessions. CONCLUSIONS: In many cases, focused ESWT needs to be applied only once. Further research should focus on the number of treatment sessions as well as the minimum energy flux density needed.

Analysis of a ß-TCP bone graft extender explanted during revision surgery after 28 months in vivo.

PURPOSE: Analysis of a ß-tricalcium phosphate (ß-TCP) bone graft soaked with bone marrow aspirate explanted during revision surgery after 28 months. METHODS: A 41-year-old female patient undergoing scoliosis correction Th4-L5 in 2007 was revised due to screw loosening in 2008. During revision surgery, a ß-TCP bone graft (chronOS(®) chips) soaked with bone marrow aspirate was applied. Due to implant failure, the patient was revised again 2011. The bone graft was removed and taken to the laboratory for histological analysis. The biomaterial samples were stained with DAPI and analyzed under a fluorescence microscope. Five biomaterial chips were maintained in tissue culture to evaluate outgrowing cells. The remaining samples were embedded in paraffin, sectioned into 7 µm sections and stained with Hemalaun/eosin. RESULTS: The morphology and rigidity of the ß-TCP bone graft were comparable to the original. The pores were not filled with tissue and could be clearly identified. Only single vital cells were detected on the graft. The outgrowth culture yielded only erythrocytes-no cells of the osteoblastic lineage cells could be harvested. Histological analysis demonstrated a failure of resorption and the absence of new bone formation. CONCLUSION: Histological analysis of bone grafts is rare after implantation in humans due to ethical and clinical limitations of sample harvest. In this study, implantation of a ß-TCP bone graft did not result in bone formation after 28 months in vivo.

Comparison of inpatient treatment costs after balloon kyphoplasty and non-surgical treatment of vertebral body compression fractures.

We performed an analysis of following costs after primary conservative or operative treatment with balloon kyphoplasty (BKP) in osteoporotic vertebral fractures. Patients with primary osteoporotic vertebral fractures treated with BKP or conservatively from discharge year 2002-2005 were retrospectively assessed regarding the following hospital treatment in any hospital in Austria from 2002 to 2006. A statistical record linkage between the hospital data and the mortality registry of Statistic Austria was performed. The data search was restricted to ICD-10 and procedures according to the Austrian catalogue of procedures defined as "spine relevant". Number of readmissions, length of hospital stay and DRG related costs were calculated for the surgical and conservative group separately. 324.5 years (mean 2.93 ± 1.40, conservative group) and 343.6 (mean 2.56 ± 0.96, BKP group) of 110 conservative patients and 134 BKP patients were analyzed. There was no statistical difference of the mortality rate with 9 patients (6.7%, BKP) and 11 patients (9.9%, conservative). The number of readmissions was 1.62 times higher (P = 0.039), the length of stay 1.09 times higher (P = 0.046) in the conservative group. No difference in the DRG scores were found (P = 0.11). In conclusion, patients with osteoporotic vertebral fractures showed in the following years after BKP fewer hospital readmissions and shorter hospital stays but no difference in DRG scores in comparison to conservatively treated patients.

Assessment of different screw augmentation techniques and screw designs in osteoporotic spines.

This is an experimental study on human cadaver spines. The objective of this study is to compare the pullout forces between three screw augmentation methods and two different screw designs. Surgical interventions of patients with osteoporosis increase following the epidemiological development. Biomechanically the pedicle provides the strongest screw fixation in healthy bone, whereas in osteoporosis all areas of the vertebra are affected by the disease. This explains the high screw failure rates in those patients. Therefore PMMA augmentation of screws is often mandatory. This study involved investigation of the pullout forces of augmented transpedicular screws in five human lumbar spines (L1-L4). Each spine was treated with four different methods: non-augmented unperforated (solid) screw, perforated screw with vertebroplasty augmentation, solid screw with vertebroplasty augmentation and solid screw with balloon kyphoplasty augmentation. Screws were augmented with Polymethylmethacrylate (PMMA). The pullout forces were measured for each treatment with an Instron testing device. The bone mineral density was measured for each vertebra with Micro-CT. The statistical analysis was performed with a two-sided independent student t test. Forty screws (10 per group and level) were inserted. The vertebroplasty-augmented screws showed a significant higher pullout force (mean 918.5 N, P = 0.001) than control (mean 51 N), the balloon kyphoplasty group did not improve the pullout force significantly (mean 781 N, P > 0.05). However, leakage occurred in some cases treated with perforated screws. All spines showed osteoporosis on Micro-CT. Vertebroplasty-augmented screws, augmentation of perforated screws and balloon kyphoplasty augmented screws show higher pullout resistance than non-augmented screws. Significant higher pullout forces were only reached in the vertebroplasty augmented vertebra. The perforated screw design led to epidural leakage due to the position of the perforation in the screw. The position of the most proximal perforation is critical, depending on screw design and proper insertion depth. Nevertheless, using a properly designed perforated screw will facilitate augmentation and instrumentation in osteoporotic spines.

Balloon kyphoplasty for vertebra plana with or without osteonecrosis.

PURPOSE: To compare efficacy of balloon kyphoplasty in restoring vertebral height and correcting kyphosis in patients having vertebra plana with or without osteonecrosis. METHODS: 12 women and 3 men (mean age, 76 years), who had a complete vertebra plana with or without osteonecrosis (n=8 vs n=7), underwent balloon kyphoplasty. No external manoeuvres were performed before or during balloon kyphoplasty, except for positioning the patients in a prone posture on the operating table. The anterior, middle, and posterior vertebral height and the kyphotic angle were measured pre- and post-operatively with a digital imaging system. The vertebral height was measured as a percentage of the adjacent normal vertebral height. RESULTS: Respectively in vertebra plana patients with or without osteonecrosis, the mean corrections of (1) kyphosis were 10 and 4 degrees (p=0.099), (2) anterior vertebral height were 33% and 5% (p<0.001), (3) middle vertebral height were 38% and 18% (p=0.004), and (4) posterior vertebral height were 19% and 2% (p=0.031). CONCLUSION: In patients with vertebra plana, it is important to identify any osteonecrosis, which is an indication for balloon kyphoplasty to restore vertebral height and correct kyphosis.

Cement leakage into the posterior spinal canal during balloon kyphoplasty: a case report.

We report a case of cement leakage into the posterior spinal canal due to inadvertent pedicle perforation during balloon kyphoplasty. The leakage was corrected immediately without any sequelae. Features seen on radiography and the minimally invasive procedure used for removal are described. The postoperative radiographs of 100 consecutive patients treated with balloon kyphoplasty were subsequently reviewed. Only one patient had a similar leakage but had no neurological complications.

Contamination during removal of cement in revision hip arthroplasty. A cadaver study using ultrasound and high-speed cutters.

Instruments used in surgery which rotate or vibrate at a high frequency can produce potentially contaminated aerosols. Such tools are in use in cemented hip revision arthroplasties. We aimed to measure the extent of the environmental and body contamination caused by an ultrasound device and a high-speed cutter. On a human cadaver we carried out a complete surgical procedure including draping and simulated blood flow contaminated with Staphylococcus aureus (ATCC 12600). After cemented total hip arthroplasty, we undertook repeated extractions of cement using either an ultrasound device or a high-speed cutter. Surveillance cultures detected any environmental and body contamination of the surgical team. Environmental contamination was present in an area of 6 x 8 m for both devices. The concentration of contamination was lower for the ultrasound device. Both the ultrasound and the high-speed cutter contaminated all members of the surgical team. The devices tested produced aerosols which covered the whole operating theatre and all personnel present during the procedure. In contaminated and infected patients, infectious agents may be present in these aerosols. We therefore recommend the introduction of effective measures to control infection and thorough disinfection of the operating theatre after such procedures.

[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.

Environmental and body contamination through aerosols produced by high-speed cutters in lumbar spine surgery.

STUDY DESIGN: A cadaver study to evaluate contamination in the operating room through the use of a high-speed bone cutter. OBJECTIVES: To determine the grade of contamination of animate and inanimate objects through an aerosol intraoperatively, produced by a high-speed cutter during lumbar laminectomy. SUMMARY OF BACKGROUND: In spinal surgery, high-speed cutters are used that produce an aerosol consisting of a mixture of irrigation solution, blood, and tissue debris. Such aerosols can be contaminated with potential pathogens. The surgical personnel and the environment are therefore exposed to a contamination risk. METHODS: Laminectomies at three points (L2-L4) were performed on a human cadaver using a high-speed cutting device. The aerosol produced by the irrigation solution was contaminated with Staphylococcus aureus ATCC 12600. To detect the contamination of the environment and of the surgical team, surveillance cultures were used. RESULTS: By air sampling, staphylococci were detected in the operating room at an extension of 5 by 7 m. The surgical team showed extensive face and body contamination with S. aureus. Despite protection by a barrier drape, similar contamination was observed on both the cadaver's head and the anesthesiologist. CONCLUSIONS: The use of high-speed cutters in spinal surgery produces an aerosol that can be contaminated with blood-borne pathogens from infected patients. This aerosol is spread over the whole surgical room and contaminates the room and all personnel present. It is therefore critical to ensure that effective infection control measures are performed, not only by the surgeons but by everyone present in the operating room. The room itself must be sufficiently disinfected after such procedures.

Radiologic abnormalities and low back pain in elite skiers.

Lumbar radiographs of 120 adolescent elite skiers were evaluated for radiologic abnormalities by two independent observers. All athletes had no symptoms before the study. Radiographs were taken before enrollment of the students in elite level training. To determine the clinical significance of these abnormalities, all athletes were observed prospectively during the subsequent 2-year period for development of low back pain under high performance training. Anterior end plate lesions, Schmorl's nodes, posterior end plate lesions, spondylolysis, scoliosis, and spina bifida occulta were found. The depth of anterior end plate lesions showed a two-peak distribution, with peaks at 11% and 22% and a valley at 18% vertebral body height. The overall low back pain incidence was 12.5%. Students with severe anterior lesions (greater than 18% vertebral body height, n = 25) had significantly more low back pain (incidence, 32%) than did students without severe anterior lesions (incidence, 7.4%). Accordingly, students with severe anterior lesions had a significantly higher risk of having low back pain develop. Moderate end plate lesions and other abnormalities were not related to an increased incidence of low back pain. Adolescent students of elite sports with severe lumbar anterior end plate lesions have an increased risk of having low back pain develop under high performance training.

Footwear affects the behavior of low back muscles when jogging.

Use of modified shoes and insole materials has been widely advocated to treat low back symptoms from running impacts, although considerable uncertainty remains regarding the effects of these devices on the rate of shock transmission to the spine. This study investigated the effects of shoes and insole materials on a) the rate of shock transmission to the spine, b) the temporal response of spinal musculature to impact loading, and c) the time interval between peak lumbar acceleration and peak lumbar muscle response. It was hypothesised that shoes and inserts a) decrease the rate of shock transmission, b) decrease the low back muscle response time, and c) shorten the time interval between peak lumbar acceleration and peak lumbar muscle response. Twelve healthy subjects were tested while jogging barefoot (unshod) or wearing identical athletic shoes (shod). Either no material, semi-rigid (34 Shore A), or soft (9.5 Shore A) insole material covered the force plate in the barefoot conditions and was placed as insole when running shod. Ground reaction forces, acceleration at the third lumbar level, and erector spinae myoelectric activity were recorded simultaneously. The rate of shock transmission to the spine was greater (p < 0.0003) unshod (acceleration rate: Means +/- SD 127.35 +/- 87.23 g/s) than shod (49.84 +/- 33.98 g/s). The temporal response of spinal musculature following heel strike was significantly shorter (p < 0.023) unshod (0.038 +/- 0.021 s) than shod (0.047 +/- 0.036 s). The latency between acceleration peak (maximal external force) and muscle response peak (maximal internal force) was significantly (p < 0.021) longer unshod (0.0137 +/- 0.022s) than shod (0.004 +/- 0.040 s). These results suggest that one of the benefits of running shoes and insoles is improved temporal synchronization between potentially destabilizing external forces and stabilizing internal forces around the lumbar spine.

Aerosols produced by high-speed cutters in cervical spine surgery: extent of environmental contamination.

High-speed cutters are used in the surgery of the cervical spine. Such high-speed devices can produce an aerosol cloud. As a patient can be a reservoir for pathogens, with aerosol-borne paths of transmission, such an aerosol has to be seen as a potential risk of infection for health care professionals present during the surgery and for patients if micro-organisms are transferred through the medical personnel. The study was performed in order to measure the extension of environmental and body contamination through contaminated aerosols produced by a high-speed cutter. Three laminectomies (C4-C6) were performed on an intact human cadaver with a high-speed 0.6-mm ball cutter. A complete surgical setup was arranged, including surgical draping and a barrier drape to the anesthesiologist's workplace. Body and environmental contamination was detected by the use of surveillance cultures. The irrigation solution was artificially contaminated with Staphylococcus aureus ATCC 12600. Following the surgery, staphylococci were detected in the operating room at an extension of 5x7 m. Everybody showed extensive face and body contamination with Staphylococcus aureus. The study showed that the use of high-speed cutters in surgery of the cervical spine produces an aerosol cloud that is spread over the whole surgical room and contaminates the theater and all personnel present. Such aerosols can be contaminated with pathogens if the patient was infected or colonized. Therefore, sufficient protective measures have to be recommended for everyone present in the operating room during such surgeries. In addition, efficient disinfection of the room and all mobile equipment is necessary after each surgery involving high-speed cutting devices.

Radiographic evaluation of cervical spine trauma. Plain radiography and conventional tomography versus computed tomography.

Different imaging modalities are available for the diagnosis of cervical spine injuries. There is a controversial discussion about whether plain radiography (PR), conventional tomography (CTO) or computed tomography (CT) should primarily be used. PR and CTO are more often available and less costly than CT. Especially in second-care hospitals, CT is not always available. The diagnostic work-up in these centres has to rely on conventional techniques. The aim of this study was to define the role of PR supplemented by CTO in the diagnosis of cervical spine trauma in comparison to CT. Twenty-five patients were identified who underwent plain radiography (PR), conventional tomography (CTO) and computed tomography (CT) for the diagnosis of a cervical fracture. In 19 patients a fracture of the cervical spine was identified. All images were reviewed by two independent observers to estimate the interobserver variability. The highest detection rate was achieved by CT (18/18 fractures detected for observer 1/2), followed by CTO (16/16 fractures) and then PR (15/14 fractures). When the detection rates of PR and CTO are combined, 18 fractures were detected by each of the observers. The results were analysed for the dens and the rest of the cervical spine independently. For PR and CTO the detection rates were lower for fractures of the dens than for the rest of the cervical spine. We conclude that the combination of PR and CTO accurately detects fractures of the cervical spine compared with CT. If a fracture of the dens is suspected, the patients should be referred to CT due to its superior accuracy in this region.

Fistula between a total hip arthroplasty and the rectum: a case report.

An 81-year-old man was referred to the authors for examination of the gastrointestinal tract. A proctoscopy revealed a draining sinus tract in the terminal rectum. Plain radiographs revealed a failed total hip arthroplasty that had migrated into the pelvis. Hip aspiration revealed an infection with bacteria commonly found in the gastrointestinal tract. A fistulogram confirmed a connection between the rectum and the hip replacement. The development of a fistula between the colon and the hip is extremely uncommon. A fistula between the hip and the rectum is a previously unreported complication of total hip arthroplasty.

Radiographic assessment in total knee arthroplasty.

Sixty-five total knee arthroplasties were evaluated by the Knee Society Radiological Evaluation System which was developed to encourage uniform reporting of the results of total knee arthroplasty. All patients were examined by three independent experienced radiologists 8.9 years after surgery (range, 3-16 years) to analyze the interobserver variability. For measurement of angles, high interobserver correlation was calculated for the prosthetic component angles and the femorotibial shaft angle. The comparison of the means indicated no significant differences except for the femorotibial shaft angle. For measurement of radiolucent lines, interobserver correlation was low for all components. The differences of the means were significantly different for all components. The results of interobserver variability of the patellar evaluation revealed high interobserver correlation for the patellar angle and for patellar subluxation and dislocation evaluation. For assessment of patellar mediolateral and superoinferior displacement, a low interobserver correlation was found. For radiographic assessment of total knee arthroplasty, the measurement of angles, including alpha, beta, femorotibial shaft angle, sagittal femoral and tibial component angle, patellar angle, and patellar subluxation and dislocation evaluation are recommended. The method of assessing radiolucent lines should be reconsidered.

Excessive heat generation during cutting of cement in the Robodoc hip-revision procedure.

The ROBODOC system is a promising new method for removing cement with high-speed milling. Heat is generated during the milling process. This study was designed to measure temperatures in the cutting area, and to assess the risk of heat injury and the effectiveness of irrigation. We measured temperatures at the bone-cement cutting area in three experimental settings, two involving the proximal area comprising a cement mantle, and one the distal cement plug beneath the prosthesis. Without cooling facilities, a mean temperature of 94 degrees C was measured in proximal areas. However, this could effectively be reduced below 70 degrees C with irrigation. In the area of the distal cement plug, we measured a mean temperature of 172 degrees C without irrigation. In this area, the integrated irrigation system with an additional high-flow irrigation system could not guarantee cooling to an acceptable temperature of below 70 degrees C since the irrigation stream was impeded by the cutter in the narrow cavity. We need an integrated irrigation device that guarantees continuous cooling at the cutting interface in front of the cutter.

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.

Glenohumeral osteoarthrosis after the Eden-Hybbinette procedure.

Thirty-six patients (36 shoulders) who underwent the Eden-Hybbinette procedure for recurrent anterior dislocation of the shoulder with an average followup of 15 years were evaluated. Evaluation consisted of radiographic assessment in a true anteroposterior view and an axillary lateral view of both shoulders, physical examination, and a questionnaire. Mild glenohumeral osteoarthrosis was present in 1/3 of the patients, and moderate and severe osteoarthrosis was evident in 1/2. There were no signs of osteoarthrosis in four shoulders. Function, as assessed by the Rowe score as modified by Young and Rockwood, was excellent or good in 27 shoulders and fair or poor in nine shoulders. The extent of osteoarthrosis was related to restriction of external rotation, length of followup, and function.

Does arch height affect impact loading at the lower back level in running?

The purpose of this study was to evaluate the influence of the medial longitudinal arch height on the shock wave that repetitively reaches the lower back in running. Impact forces were measured simultaneously at the ground by a force plate and at the level of the low back, by means of an accelerometer, skin-mounted at the L3 spinal process. The medial longitudinal arch height was calculated as navicular height divided by foot length. Twelve healthy subjects ran barefoot and with an identical sport shoe at a constant speed. The sample size was divided equally into a low-arch and a high-arch group. Statistical analysis was performed by multivariate analysis of variance and Pearson's correlation. At low back level, there was a significantly lower acceleration amplitude and rate in the high-arch group (amplitude = mean, 1.74 g and SD, 0.94 g; rate = mean, 71.2 g/sec and SD, 58.0 g/sec) compared with the low-arch group (amplitude = mean 2.25 g and SD, 1.11 g; rate = mean, 111.5 g/sec and SD, 68.6 g/sec) (P < 0.001, each). At the ground, there was a slight negative correlation between arch height and initial loading rate in AP (-0.19; P < 0.01) and vertical (-0.22; P < 0.001) directions and a positive correlation between arch height and initial loading rate in the medial direction (0.22, P < 0.05). The results indicate that the high-arch foot is a better shock absorber with regard to the low back level than the low-arch foot.