Perioperative complications associated with fluoroscopy C1 lateral mass screw fixation (Goel technique) versus computed tomography-guided navigation technique: A review of 202 cases from the German Spine Registry (DWG-Register).

Background: Overview of the literature - Fractures of the C1 constitute 3%-13% of all cervical spine injuries in adults. Most isolated C1 fractures are stable and can be treated nonoperatively with external immobilization. Traditional surgical options for C1 fracture treatment are occiput-to-C2 fusion or C1 with lateral mass screws (LMSs). Purpose - The aim is to assess the management and perioperative complications of C1 fractures undergoing LMS fusion between fluoroscopy and computed tomography (CT)-guided navigation. Methods: This was a retrospective multicenter study of data from the DWG-Register of patients who underwent operative treatment for C1 traumatic fracture with LMSs from January 2017 to September 2022. Inclusion criteria - traumatic injury and age > 18 years old. Results: In total, 202 patients with traumatic C1 fracture requiring spinal surgery were identified in the registry; n = 175 (Group 1) were treated conventionally without CT-guided navigation and n = 27 were treated with CT-guided navigation (Group 2). C1-LMS was principally performed by spine surgeons n = 90 (53.4%) and n = 72 (18.5%) by neurosurgeons in both the groups. Intraoperative adverse events were as follows: dural tear in group 1 n = 0 and in group 2 n = 1, vascular injury, with one case in group 1 and no cases in group 2. General complications were: cardiovasculars in group 1 n = 6 (3.4%) and Group 2 n = 4 (14.8%) (P = 0.03), pulmonary complications in group1 n = 2 (1.1%) and n = 9 in group 2 (33.3%) (P < 0.001), stroke n = 1 (0.57%) in group1 and n = 4 in group 2 (14.8%) (P < 0.001), gastrointestinal bleeding n = 1 (0.57%) in group1 and no cases in group 2, renal insufficiency n = 2 (1.1%) in group 1 and n = 3 (11.1%) in group 2 (P = 0.01). One death was recorded in group 2 (3.7%). Conclusion: This series of 404 screws placed in 202 patients over 5 years who underwent two types of C1 fracture fixation had a considerably lower incidence of screw malposition and vertebral artery injury than has previously been reported in the literature. C1 screws can be safely placed with a low risk of vertebral artery and neurologic injury with and without CT-guided navigation support.

The projected increase of vertebral osteomyelitis in Germany implies a demanding challenge for future healthcare management of aging populations.

PURPOSE: Since an increase in the occurrence of native vertebral osteomyelitis (VO) is expected and reliable projections are missing, it is urgent to provide a reliable forecast model and make it a part of future health care considerations. METHODS: Comprehensive nationwide data provided by the Federal Statistical Office of Germany were used to forecast total numbers and incidence rates (IR) of VO as a function of age and gender until 2040. Projections were done using autoregressive integrated moving average model on historical data from 2005 to 2019 in relation to official population projections from 2020 to 2040. RESULTS: The IR of VO is expected to increase from 12.4 in 2019 to 21.5 per 100,000 inhabitants [95% CI 20.9-22.1] in 2040. The highest increase is predicted in patients over 75 years of age for both men and women leading to a steep increase in absolute numbers, which is fourfold higher compared to patients younger than 75 years. While the IR per age group will not increase any further after 2035, the subsequent increase is due to a higher number of individuals aged 75 years or older. CONCLUSIONS: Our data suggest that increasing IR of VO will seriously challenge healthcare systems, particularly due to demographic change and increasing proportions of populations turning 75 years and older. With respect to globally fast aging populations, future health care policies need to address this burden by anticipating limitations in financial and human resources and developing high-level evidence-based guidelines for prevention and interdisciplinary treatment.

Surgery for Vertebral Osteomyelitis Lowers 1-Year Mortality and Failure Rates Compared with Nonsurgical Treatment: A Propensity-Matched Analysis.

BACKGROUND: The aim of this study was to determine differences between patients who underwent surgical treatment and those who underwent nonsurgical treatment of vertebral osteomyelitis (VO) and to identify potential factors influencing treatment failure (death and/or recurrence within 1 year). METHODS: We performed a retrospective analysis of clinical data prospectively collected from patients treated for VO between 2008 and 2020. The decision between surgical and nonsurgical treatment was made for each patient based on defined criteria. A 1:1 propensity score matching was performed to exclude confounders between the 2 treatments. Univariate and multivariable analyses were performed to identify potential risk factors for death and/or recurrence within the first year after VO diagnosis. RESULTS: Forty-two patients (11.8%) were treated nonsurgically and 313 patients (88.2%) underwent surgery. A higher percentage of the surgically treated patients than the nonsurgically treated patients had an American Society of Anesthesiologists score of >2 (69.0% versus 47.5%; p = 0.007), and the thoracic spine was affected more often in the surgical group (30.4% versus 11.9%; p = 0.013). Endocarditis was detected significantly more often in the nonsurgically treated patients (14.3% versus 4.2%; p = 0.018). The recurrence rate was 3 times higher in the nonsurgically treated patients (16.7% versus 5.4%; p = 0.017), but this difference was no longer detectable after propensity matching. After matching, the nonsurgically treated patients showed an almost 7-fold higher 1-year mortality rate (25.0% versus 3.7%; p = 0.018) and an almost 3-fold higher rate of treatment failure (42.9% versus 14.8%; p = 0.022). Multivariable analysis revealed nonsurgical treatment and bacteremia to be independent risk factors for treatment failure. CONCLUSIONS: In our matched cohort of patients with VO, surgical intervention resulted in a significantly lower rate of treatment failure (death and/or recurrence within 1 year) compared with nonsurgical intervention. Furthermore, nonsurgical treatment was an independent risk factor for treatment failure. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations.

BACKGROUND: Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion's characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients. METHODS: Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed. RESULTS: A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury. CONCLUSIONS: Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.

Case Report: Desmoid tumor response to magnetic resonance-guided high intensity focused ultrasound over 4 years.

Desmoid tumors are a rare form of cancer, which show locally aggressive invasion of surrounding tissues and may occur anywhere in the body. Treatment options comprise conservative watch and wait strategies as tumors may show spontaneous regression as well as surgical resection, radiation therapy, nonsteroidal anti-inflammatory drugs (NSAID), chemotherapy, or local thermoablative approaches for progressive disease. The latter comprises cryotherapy, radiofrequency, microwave ablation, or thermal ablation with high intensity focused ultrasound (HIFU) as the only entirely non-invasive option. This report presents a case where a desmoid tumor at the left dorsal humerus was 2 times surgically resected and, after recurrence, thermally ablated with HIFU under magnetic resonance image-guidance (MR-HIFU). In our report, we analyze tumor volume and/or pain score during standard of care (2 years) and after HIFU treatment over a 4-year follow-up period. Results showed MR-HIFU treatment led to complete tumor remission and pain response.

Molecular In-Depth Characterization of Chondrosarcoma for Current and Future Targeted Therapies.

Chondrosarcoma (CHS) are heterogenous, but as a whole, represent the second most common primary malignant bone tumor entity. Although knowledge on tumor biology has grown exponentially during the past few decades, surgical resection remains the gold standard for the treatment of these tumors, while radiation and differentiated chemotherapy do not result in sufficient cancer control. An in-depth molecular characterization of CHS reveals significant differences compared to tumors of epithelial origin. Genetically, CHS are heterogenous, but there is no characteristic mutation defining CHS, and yet, IDH1 and IDH2 mutations are frequent. Hypovascularization, extracellular matrix composition of collagen, proteoglycans, and hyaluronan create a mechanical barrier for tumor suppressive immune cells. Comparatively low proliferation rates, MDR-1 expression and an acidic tumor microenvironment further limit therapeutic options in CHS. Future advances in CHS therapy depend on the further characterization of CHS, especially the tumor immune microenvironment, for improved and better targeted therapies.

Epidemiology and specific features of shoulder injuries in patients affected by epileptic seizures.

PURPOSE: Epileptic seizures can cause multiple shoulder injuries, the most common of which are dislocations, recurrent instability, fractures, and isolated lesions of the rotator cuff. Currently, only limited literature exists which describes the frequency and types of lesions in cohorts of epileptic patients and the corresponding treatment outcome. This study aims to document the occurrence of shoulder lesions in patients affected by seizures and to provide detailed information on trauma dynamics, specific lesion characteristics and treatment complications. METHODS: All patients referring to a tertiary epilepsy center were screened for shoulder injuries and the clinical records of those sustaining them during a seizure were reviewed. Demographic information, lesions' characteristics and trauma dynamics were analysed, as wells as-when carried out-the type of surgical intervention and any postoperative complications. RESULTS: The average age at the time of injury of 106 included patients was 39.7 ± 17.5 years and a male predominance was recorded (65%). Bilateral injuries occurred in 29 patients, simultaneously in 17 cases. A younger age, bilateral shoulder injuries and shoulder dislocations were significantly associated with the occurrence of a shoulder injury solely by muscular activation (p = 0.0054, p = 0.011, p < 0.0001). The complication rate in 57 surgically treated patients with follow-up data was 38.7%, with recurring instability being the most frequently reported complication (62.5%). CONCLUSIONS: Uncontrolled muscle activation during a seizure is a distinctive but not exclusive dynamic of injury in epileptic patients, accounting for more than the half of all shoulder lesions, especially in the younger. This can lead both to anterior and posterior dislocations or fracture-dislocations and is frequently cause of bilateral lesions and of instability recurrence after surgery. The high complication rates after surgical treatment in this selected subgroup of patients require that appropriate preventative measures are taken to increase the probability of treatment success. LEVEL OF EVIDENCE: Cohort study, level III.

Hyaluronic acid-GPRC5C signalling promotes dormancy in haematopoietic stem cells.

Bone marrow haematopoietic stem cells (HSCs) are vital for lifelong maintenance of healthy haematopoiesis. In inbred mice housed in gnotobiotic facilities, the top of the haematopoietic hierarchy is occupied by dormant HSCs, which reversibly exit quiescence during stress. Whether HSC dormancy exists in humans remains debatable. Here, using single-cell RNA sequencing, we show a continuous landscape of highly purified human bone marrow HSCs displaying varying degrees of dormancy. We identify the orphan receptor GPRC5C, which enriches for dormant human HSCs. GPRC5C is also essential for HSC function, as demonstrated by genetic loss- and gain-of-function analyses. Through structural modelling and biochemical assays, we show that hyaluronic acid, a bone marrow extracellular matrix component, preserves dormancy through GPRC5C. We identify the hyaluronic acid-GPRC5C signalling axis controlling the state of dormancy in mouse and human HSCs.

[Use of custom-made acetabular components (CMAC) as part of a two-stage procedure in patients with severe periacetabular bone loss]. / "Custom-made acetabular components" (CMAC) beim zweizeitigen Wechsel und bei höhergradigen periazetabulären Knochendefekten.

OBJECTIVE: Implantation of custom-made acetabular components (CMAC) with load transmission onto the remaining bone stock and reconstruction of the "center of rotation" (COR) in cases of severe periacetabular bone defects. INDICATIONS: Severe periacetabular bone loss (Paprosky type IIIA/B) with or without pelvic discontinuity after septic or aseptic loosening with inadequate load capacity of the dorsal pillar and/or large supraacetabular defects. CONTRAINDICATIONS: Acute or local infections, lack of compliance, taking into account the risks and complications: missing or limited expected postoperative functional gain, multimorbid patients with potential inoperability during the first and/or second intervention. SURGICAL TECHNIQUE: Lateral transgluteal or posterolateral approach while protecting neurovascular and muscular structures. Preparation of the implant site based on preoperative planning with augmentation of bone defects as far as possible. Primarily stable anchoring with 2 angle-stable pole screws in the ilium, an optional pole screw in the pubic bone for determination of COR, and stabilization screws in the iliac wing (optionally angle-stable). Use of dual mobility cup according to the soft tissue tension and intraoperative stability. POSTOPERATIVE MANAGEMENT: For the first 6 weeks postoperative partial weight-bearing (20 kg), followed by a gradual increase of the load (10 kg per week). RESULTS: Between 2008 and 2018, 47 patients with a Paprosky type III defect underwent implantation of a monoflanged CMAC. Main complication was a periprosthetic joint infection with subsequent need for implant removal in 9 of 10 cases. Harris Hip Score improved from 21.1 to 61.5 points. X­ray imaging displayed an angle of inclination of 42.3 ± 5.3°, an anteversion of 16.8 ± 6.2°, a ∆ H of 0.5 ± 0.2 mm and a ∆ V of 17.7 ± 1.1 mm according to Roessler et al.

Risk factors for failed closed reduction in dislocated developmental dysplastic hips.

AIM OF THE STUDY: The present study aimed to identify risk factors for unsuccessful CR. INTRODUCTION: Closed reduction (CR) represents the gold standard for treatment of developmental dysplasia of the hip (DDH), but to a minor percentage, it fails to reduce dysplastic hips successfully. METHODS: Seventy-three dysplastic hips underwent closed reduction and post-interventional MRI of the pelvis. MRIs were evaluated for successful reduction of the hip, volumes of femoral heads, and acetabular diameter. Initial treatment results were correlated to AC angles at two years of follow-up. Contralateral, healthy hips served as control. RESULTS: Out of 73 instable, dysplastic hips, there were nine cases of CR failure. These cases showed significantly increased femoral head volumes (p = 0.002) and a significantly (p = 0.02) larger ratio of femoral head volume to acetabular opening area. There was no significant difference (p = 0.15) in acetabular diameter between both groups. At two years of follow-up, AC angles were significantly (p = 0.003) larger and pathologic in cases of CR failure. CONCLUSION: Exclusive enlargement of the femoral head is a risk factor for unsuccessful reduction and its ratio to the acetabular opening surface is predictive for CR success in DDH.

The use of negative pressure wound therapy increases failure rate in debridement and implant retention for acute prosthetic joint infection.

BACKGROUND: To date only scanty data exist regarding the effect of failed debridement, antibiotics, irrigation and retention of the prostheses (DAIR) and negative pressure wound therapy (NPWT) on the outcome of a subsequent exchange arthroplasty. OBJECTIVE: The objective of this study was to determine the success rate of a two- or multi-stage procedure after initial failed DAIR/NPWT in patients with an acute periprosthetic joint infection (PJI) and to evaluate the influence of possible risk factors for treatment failure. METHODS: Nineteen consecutive patients with a persisting PJI and ongoing NPWT after treatment of an acute PJI with DAIR of the hip or knee joint from October 2010 to June 2017 were included. All patients were treated according to a structured treatment algorithm after referral to our hospital. The endpoint was a successful reimplantation with absence of signs of infection two years after replantation ("replantation group") or treatment failure ("treatment failure group") in terms of a permanent girdlestone arthroplasty, fistula, amputation or death. A risk factor analysis was performed between the two groups. RESULTS: Explantation was performed in 15 cases, amputation in one case, and DAIR/establishment of a fistula in three cases. The treatment success rate after reimplantation in terms of "definitively free of infection" two years after surgery according to Laffer was 36.85% (seven out of 19 patients). Statistical analysis revealed the number of surgeries until wound consolidation (p= 0.007), number of detected bacterial strains (p= 0.041), a polymicrobial PJI (p= 0.041) and detection of a difficult-to-treat organism (p= 0.005) as factors associated with treatment failure. After failed DAIR/NPWT we could detect a significant higher number of different bacterial strains (p= 0.001). CONCLUSIONS: The treatment success rate after failed DAIR and NPWT with 36% is low and associated with a high treatment failure rate (permanent girdlestone arthroplasty, fistula or amputation, death). Thus, the definition of risk factors is crucial. We found that the number of revisions until wound consolidation, a polymicrobial PJI and detection of a difficult-to-treat organisms were risk factors for treatment failure. Furthermore, after failed DAIR/NPWT we could detect a significant higher number of different bacterial strains, with a possible adverse effect on a consecutive exchange.

The Phenomenon of the Apparent (Double) Femoral Head in Infant Hip Sonography According to Graf-Description, Incidence and Clinical Relevance. / Das Phänomen des scheinbar (ver)doppelten Hüftkopfes bei der Säuglingssonografie nach Graf-Beschreibung, Inzidenz und klinische Relevanz.

PURPOSE: Hip screening sonography according to Graf in rare cases yields the appearance of a double femoral head, aptly named the Double-Head-Sign. The goal of this retrospective study is to offer a definition of this rare sign, evaluate its incidence of occurrence and compare the sonographic findings with the clinical findings. MATERIALS AND METHODS: This Double-Head-Sign is caused by the overlap of the trochanter major with the actual head of the femur in cases of coxa vara. This was observed in 13 of 2800 neonates we screened as part of our sonographical neonatal hip screening. RESULTS: 13 neonates presented themselves with ultrasound findings in accordance with our description, yielding an incidence of 0,46% in our patient cohort. In correlation, these neonates also exhibited increased external and decreased internal rotation of the hip. Two had an underlying condition (achondroplasia). CONCLUSION: In these rare cases, clinical examination of hip rotation in 90° hip flexion has proved helpful and further interdisciplinary examination of such infants to distinguish a possible underlying primary condition is recommended.

Shoulder Stiffness - How to Treat? / Schultersteife ­ wann und wie behandeln?

Shoulder stiffness is a condition of restricted glenohumeral range of motion, which can arise spontaneously or as consequence of a known cause, including surgical procedures on the shoulder. Several approaches to shoulder stiffness have been proposed and high-level evidence is available to analyze and discuss their results. The aim of this review was to summarize the current concepts on conservative and operative treatment of shoulder stiffness and discuss the results of the available studies with a high level of evidence, which should be considered to guide clinical practice. Treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its shoulder pathology and should aim at pain reduction, restoration of range of motion, functional regain and shortening of symptoms duration. When possible, known risk factors for primary shoulder stiffness and causes of secondary shoulder stiffness should be addressed to avoid relapse. Conservative therapy is the mainstay of treatment for shoulder stiffness and should include a multimodal and activity-oriented program. Intra-articular injection of a low dose of corticosteroid is safe and effective, provides immediate benefits, and is recommended in combination to an appropriate rehabilitation protocol. In conservative refractory cases, arthrolysis and capsular release can be performed with an arthroscopic approach.

Enhanced Bone-Tendon-Bone Approach for Open Anterior Cruciate Ligament Replacement With Conservation of the Joint Capsule.

Arthroscopic procedures for ruptured anterior cruciate ligament (ACL) tears are a common standard. However, there are strong alternatives to this standard. The purpose of this study is to present a precise, fast, and minimally invasive but open procedure for reconstruction of the ruptured ACL. The torn ACL is substituted by a widely used bone-patellar tendon-bone (BPTB) autograft. After the BPTB graft has been harvested, the Hoffa body is exposed and mobilized ventrally. The surgeon then has a free view of the remnants of the torn ACL, which are to be removed completely. Through the tibial and femoral footprints of the ACL, a tunnel is drilled under a direct view, thus ensuring optimal anatomic positioning of the BPTB graft. The described approach is simple in handling and advantageous because all steps are performed under a direct view, which improves overall precision and intraoperative functional control.

Impact of heme and heme degradation products on vascular diameter in mouse visual cortex.

BACKGROUND: Delayed cerebral vasospasm is the most common cause of mortality and severe neurological impairment in patients who survive subarachnoid hemorrhage. Despite improvements in the field of diagnostic imaging, options for prevention and medical treatment-primarily with the calcium channel antagonist nimodipine or hemodynamic manipulations-are insufficient. Previous studies have suggested that heme and bilirubin oxidation end products, originating from degraded hemoglobin around ruptured blood vessels, are involved in the development of vasospasm by inhibiting large conductance BKC a potassium channels in vascular smooth muscle cells. In this study, we identify individual heme degradation products regulating arteriolar diameter in dependence of BKC a channel activity. METHODS AND RESULTS: Using differential interference contrast video microscopy in acute brain slices, we determined diameter changes of intracerebral arterioles in mouse visual cortex. In preconstricted vessels, the specific BKC a channel blockers paxilline and iberiotoxin as well as iron-containing hemin caused vasoconstriction. In addition, the bilirubin oxidation end product Z-BOX A showed a stronger vasoconstrictive potency than its regio-isomer Z-BOX B. Importantly, Z-BOX A had the same vasoconstrictive effect, independent of its origin from oxidative degradation or chemical synthesis. Finally, in slices of Slo1-deficient knockout mice, paxilline and Z-BOX A remained ineffective in changing arteriole diameter. CONCLUSIONS: We identified individual components of the oxidative bilirubin degradation that led to vasoconstriction of cerebral arterioles. The vasoconstrictive effect of Z-BOX A and Z-BOX B was mediated by BKC a channel activity that might represent a signaling pathway in the occurrence of delayed cerebral vasospasm in subarachnoid hemorrhage patients.