[Avoidance-endurance fast screening (AE-FS) : Content and predictive validity of a 9­item screening instrument for patients with unspecific subacute low back pain]. / Avoidance-Endurance Fast-Screen (AE-FS) : Inhalts- und Vorhersagevalidität eines 9­Item-Screeninginstruments für Patienten mit unspezifischen subakuten Rückenschmerzen.

BACKGROUND: Among screening measures to assess psychosocial risk factors (yellow flags) for chronic low back pain (LBP) economic tools which address dysfunctional endurance pain responses besides emotional distress and fear-avoidance pain processing are rare. Targeting contrasting types of pain processing might improve stratified patient counselling. OBJECTIVE: The aim of the study was to develop a short screening method, based on the avoidance-endurance model of pain and to investigate the prognostic validity for pain intensity, disability and physical function. MATERIAL AND METHODS: A prospective observational study was carried out on 144 patients with subacute LBP (<3 months) from 7 general practitioners and 5 orthopedic practices. The 9­item avoidance-endurance fast screening (AE-FS) was derived from a previous 37-item screening using correlational and receiver operating curve (ROC) analyses and the agreement of subgrouping was calculated using Cohen's kappa. Primary outcomes were assessed after 6 months by mail in 124 patients (86%). Endpoints were pain intensity and disability. RESULTS: The classification of subgroups as high and low risk by both measures had considerable agreement with a value of 0.71 (Cohen's Kappa). The sensitivity to predict pain intensity >2 was high (82%) as was the positive predictive value (80%) but the negative predictive value was moderate (61%). The ROC (AUC) characteristics (95% confidence interval CI) were 0.70 (0.60-0.80) for pain intensity and for limitations in the pain disability index (PDI) 0.70 (0.55-0.87). DISCUSSION: The 9­item AE-FS displayed sufficient prognostic validity for all three outcomes in a sample of primary care patients with subacute LBP. The differentiation of the high-risk patients into fear-avoidance and endurance-related pain processing enables the physician to provide an individualized counselling with the aim of a healthy balance between stress and relaxation.

[Epidural injection therapy with local anaesthetics versus cortisone in the lumbar spine syndrome: a prospective study]. / Die epidurale Injektionsbehandlung mit Lokalanästhetikum versus Kortison beim chronischen lumbalen Nervenwurzelkompressionssyndrom: eine prospektive Studie.

AIM: The prospective randomised double-blind study analyses follow-up data of the therapeutic effects of cortisone versus local anaesthetics using an injection technique close to the nerve root in chronic lumbar spine syndrome. METHODS: 57 patients were included with an MRI-assured clinical diagnosis. The study was performed over a 6-month period to evaluate long-term effects. The level of disability (ODQ), the quantitative and qualitative sensations of pain were separately determined. The t-test was used for interval and relation variables, the chi (2) test for nominal variables and the Mann-Whitney-U-test for ordinal variables. RESULTS: Significant differences in favour of cortisone were not found for the measured parameters at any time. An improvement for all parameters was seen in both groups between the time t0 and the definite times t1 and t2. CONCLUSION: The advantage of a combined injection of local anaesthetics and cortisone versus a injection of local anaesthetics alone in epidural-peridural technique in the inpatient treatment of the chronic lumbar spine root compression syndrome could not be detected.

Lumiracoxib 400 mg once daily is comparable to indomethacin 50 mg three times daily for the treatment of acute flares of gout.

OBJECTIVES: To demonstrate non-inferiority of lumiracoxib 400 mg once daily (o.d.) compared with indomethacin 50 mg three times daily (t.i.d.) in the treatment of acute gout, and to compare the safety and tolerability of these treatments. METHODS: In this 1-week, multicentre, randomized, double-blind, double-dummy, active-controlled, parallel-group study, patients with a clinical diagnosis of gout, an acute attack of gout in four or more joints within the 48 h prior to evaluation, and at least moderate pain intensity in the target joint were randomized to treatment with lumiracoxib 400 mg o.d. (n = 118) or indomethacin 50 mg t.i.d. (n = 117). The primary efficacy endpoint was the mean change in pain intensity from baseline over days 2-5, assessed on a 5-point Likert scale, where non-inferiority could be claimed if the lower limit of the confidence interval (CI) was greater than -0.5. The patient's and physician's global assessment of response to treatment, and physician's assessment of tenderness, swelling and erythema of the study joint were also assessed. RESULTS: The estimated difference between treatments for the change from baseline in pain intensity over days 2-5 was -0.004 (95% CI -0.207 to 0.199, P > 0.05), indicating that lumiracoxib 400 mg o.d. had comparable efficacy to indomethacin 50 mg t.i.d. for the primary efficacy variable. There was no significant difference between treatments in any of the secondary efficacy variables. Adverse events were reported by 10.2% of patients treated with lumiracoxib and 22.2% of those receiving indomethacin. CONCLUSIONS: Lumiracoxib is as effective as indomethacin for treatment of acute gout and may have a better safety and tolerability profile.

[Minimally invasive unicondylar knee replacement with computer navigation]. / Minimal-invasive navigiert implantierte unikondyläre Knieendoprothese.

METHODS: From January 2003 to July 2005 a total of 50 St Georg medial knee monosleds with metal-backed tibial components in stably seated form and Uniglide prostheses (Alphanorm/Corin) with mobile bearing onlays were implanted in minimally invasive operations. Postoperatively the alignment-especially of the tibial components-was investigated, to check whether we had achieved the dorsal slope we had been aiming at, i.e. 5-7 degrees , in the region of these knee replacements. RESULTS: Before surgery there were initial malalignments of up to 10 degrees varus and 3 degrees valgus. All leg axes were restored to between -3 degrees and +3 degrees . The desired dorsal slope of 5-7 degrees for the knee monosleds relative to the tibial component was realized, the average slope being 5.3 degrees . The a-p alignment of the tibial component and of the femoral component was correct. CONCLUSIONS: Use of the navigation system leads to more accurate and reproducible results in terms of tibial dorsal slope, which is extremely important when these monosleds are used. Overcorrection of the leg axis is generally avoided. The use of too-high medial onlays is also reliably avoided by the navigation system's monitoring of the level of the cut.

[Limited, haemoglobin-dependent indication for autologous blood donation in total hip or knee replacement]. / Eingeschränkte, Hämoglobin-abhängige Indikation zum Eigenblutverfahren bei Endoprothesenimplantation des Hüft- oder Kniegelenkes.

AIM: The rejection rate of autologous blood donation before joint replacement is high. The influence of the haemoglobin value and the age of patient before autologous blood donation was examined according to the necessity for blood transfusion. METHOD: In a retrospective study, the data of 233 patients who had donated autologous blood before hip (THR) or knee arthroplasty (TKR) were analysed. RESULTS: 72 patients (30.9 %) received an autologous blood transfusion during surgery or in the further course until the first day after surgery. A multivariate analysis showed no significant influence of age on the need for transfusions (p = 0.093), but a higher haemoglobin value before blood donation reduced the risk significantly to 0.712 per unit (1 g/dl). Therefore the age of the patient was less predictive compared to the haemoglobin value as to whether or not a blood transfusion had been necessary. CONCLUSION: The high security of homologous blood reached in the last years and the knowledge that autologous blood donation reduces the haemoglobin value before surgery has led to the procedure in our hospital only to perform autologous blood donation at the explicit request of the patient.

[Distribution of MRI signal alterations of the cartilage endplate in pre-operated patients with special focus on recurrent lumbar disc herniation]. / Verteilungsmuster von (Modic-)Signalveränderungen an den vertebralen Endplatten voroperierter Patienten und ihr Bezug zu Rezidivvorfällen.

PURPOSE: To study the location of (Modic) MR signal alterations (SA) of the cartilage endplate (CEP) in pre- and non-operated segments L3-S1 with special focus on the presence of recurrent lumbar disc herniation (RLDH). MATERIALS AND METHODS: In a retrospective study the MR images of vertebrae L3-S1 of 65 consecutive patients with a history of microdiscectomy were evaluated. Of the 190 segments studied, 67 were pre-operated. These were divided into a group with recurrent lumbar disc herniation (RLDH) (n = 19) and a group without evidence of RLDH (n = 48). Non-operated segments (n = 123) were also considered as a separate group. In these three groups the prevalence of different Modic types was determined using the sag. T1- and T2-weighted images, and, in particular, the distribution of SA at the upper and lower CEP was examined by evaluating the sag. T2-weighted images. In order to achieve this, each CEP was divided into nine regions. RESULTS: Pre-operated segments showed significantly more frequent (p < 0.001) and more expansive (p < 0.001) SA than non-operated segments. Non-operated segments showed SA less frequently in the central region of both upper and lower CEP (p = 0.056 and p = 0.015, respectively). In operated segments without RLDH, the upper CEP had significantly more SA on the operation side than in the mid-sagittal and contra-lateral regions (p = 0.016, p = 0.037) and significantly more on the operation side of the lower CEP than in the contra-lateral region (p = 0.027). Operated segments with RLDH did not show an emphasis of SA on the operation side. In this group SA occurred significantly more often in the central and ventral mid-sagittal regions of the upper CEP than in the pre-operated segments without RLDH. CONCLUSION: 1. There are different patterns of signal alterations in the three groups. 2. The importance of the central region of the CEP for the integrity of the disc is strongly supported by the low incidence of signal alterations in this location in non-operated segments. 3. There are clear indications for the influence of the operation on the development and distribution of signal alterations. 4. In pre-operated segments signal alterations occurring in the central and ventral mid-sagittal regions of the upper CEP can be indicative of the development of RLDH.

[Surgical anatomy of the lumbar spine]. / Chirurgische Anatomie der Lendenwirbelsäule.

The success and risks of spinal surgery depend on a correct diagnosis and detailed knowledge of anatomy. This report provides information on relevant structures of the lumbar spine and possible surgical complications. Anatomical topography and different surgical approaches are described step by step.

[Medical and cost efficiency of autologous blood donation in total hip or knee replacement]. / Medizinische und ökonomische Effizienz des Eigenblutverfahrens bei Endoprothesenimplantation des Hüft- oder Kniegelenkes.

AIM: Preoperative autologous blood donation before joint replacement has become standard practice. However, this procedure is discussed controversially regarding medical benefit and cost-effectiveness. METHOD: In a retrospective study the data of 994 patients scheduled for hip (THR) or knee arthroplasty (TKR) between 1/2000 and 9/2002 were analysed. RESULTS: Altogether 612 patients donated autologous blood (61.6 %). 50.2 % of the patients got blood transfusions during surgery or in the course of their hospitalisation. Donors received blood units more often than non-donors (55.2 vs. 41.9 %). On average 1.4 +/- 1.7 blood units were given during or after THR and 0.8 +/- 1.1 units during or after TKR. Clear predispositions for an increased use of blood transfusions were cemented endoprosthesis, old age (> 70 years) as well as exclusive general anaesthesia. Since 57.8 % of the blood units were wasted, the additional expenses (only laboratory and material costs were calculated) for each retransfused autologous blood unit were calculated to be 28.76. CONCLUSION: Besides saving homologous blood, autologous blood donation causes mainly an increased probability of giving transfusions and higher costs. Therefore autologous blood donation should be indicated more critically, especially in younger patients and knee replacements.

[Side effects and complications of injection therapy for degenerative spinal disorders]. / Nebenwirkungen und Komplikationen der Injektionsbehandlung bei degenerativen Erkrankungen der Wirbelsäule.

AIM: The type and frequency of side effects due to treatment of vertebral pain syndromes with local injections were examined. Risks and complications were evaluated and precautions are presented in order to avoid these problems. METHODS: The medical records of 453 patients who had undergone injection therapy in hospital for spinal pain syndromes were investigated retrospectively. RESULTS: Paravertebral injections with cervical and lumbar spinal nerve analgesia, facet joint injections, lumbar epidural-perineural injections, epidural-dorsal and epidural-sacral injections, and injections next to the ileosacral joint were administered, amounting to a total of 7 963 injections. In 25 cases (0.3 %) unfavourable side effects were observed. Epidural-perineural injections led to headache in 10 cases and paravertebral lumbar nerve analgesia in 3 cases. Five times after epidural-perineural injections circulatory dysregulation with vertigo, nausea and decreased blood pressure was observed. One patient fell after an epidural-perineural injection, and one patient developed a sensory block up to the thoracic segment 6. Five patients showed local allergic reactions at the injection site after Mepivacain. All complications could be treated with simple symptomatic measures and had no severe effects. CONCLUSION: Compared to other studies, only few side effects were observed. The injections described above may thus be regarded as low-risk therapy.

[In vitro effects of diclofenac and selective cyclooxygenase-2 inhibitors on prostaglandin release from inflamed bursa subacromialis tissue in patients with subacromial syndrome]. / Effekte von Diclofenac und selektiven Cyclooxygenase-(COX-)2-Inhibitoren auf die Prostaglandinfreisetzung aus entzündetem Bursa-subacromialis-Gewebe von Patienten mit Subakromialsyndrom in vitro.

BACKGROUND: To compare the in vitro effects of selective COX-2 inhibitors (L-745,337, NS-398 and DFU) and of COX-unspecific diclofenac on release of PGE(2 )and 6-keto-PGF(1alpha) from inflamed bursa subacromialis tissue (IBST) obtained from a total of 35 patients with shoulder impingement syndrome (SIS). PATIENTS AND METHODS: Bursal specimens were incubated in the presence of drugs (0.01-1000 microM) for 20 min and 16 h. RESULTS: After 20 min 10 microM diclofenac significantly inhibited formation of PGE(2) and 6-keto-PGF(1alpha), whereas L-745,337 and NS-398 (10-1000 microM) induced significant inhibition only at concentrations > or =100 microM. In contrast to equimolar diclofenac, DFU (0.01-10 microM) induced no inhibition of bursal PGE(2) release but a dose-dependent, although statistically not significant inhibition after 16 h. The inhibitory potency of diclofenac (0.01-10 microM) was even more increased during long-term incubation showing greater inhibition than DFU at all concentrations studied. CONCLUSION: The data suggest that in IBST in SIS in vitro the majority of PG is generated via the COX-1 pathway.

Molecular evidence for local denervation of paraspinal muscles in failed-back surgery/postdiscotomy syndrome.

A study was performed to analyze whether local denervation of the medial branch of the dorsal ramus of the lumbar spinal nerve occurs in a patient with postoperative failed-back surgery syndrome/postdiscotomy syndrome (FBSS/PDS). We investigated the effect of the loss of innervation of the multifidus muscle on neuronal nitrite oxide synthetase (n-NOS) and endothelial nitrite oxide synthetase (e-NOS) applying realtime RT-PCR and immunohistochemistry. Our study demonstrates a substantial reduction of n-NOS expression, supporting the view that local denervation of the multifidus is involved in the pathology of FBSS. No regulation of e-NOS was detectable. Interestingly, this change is region-specific and does not occur throughout the entire multifidus segment. This result supports the hypothesis that local denervation of the multifidus muscle is involved in the pathology of FBSS/ PDS.

[Therapy of rheumatoid cubarthritis]. / Therapie der rheumatischen Kubarthritis.

With the progression of rheumatoid arthritis (RA),more than half of the patients develop an affliction of the elbow.Cub arthritis has to be regarded as a part of systemic rheumatoid disease. Thus, the indication for operative treatment depends not only on local changes but is determined by the pattern of all affected joints, the activity of the basic rheumatic disease as well as the effect of physical therapy and medication. The complexity of the rheumatic disease, which typically affects many joints, demands an individual therapeutic plan that can only be developed and accomplished successfully when rheumatologists, rheumatoid surgeons and other specialists cooperate. In cases of recurrent cub arthritis,in spite of adequate medication, synoviorthesis or synovectomy should be performed. This may relieve pain and swelling,however if lesions of the cartilage already exist,progressive joint destruction cannot be prevented. Arthroscopic surgery of the elbow provides all of the known advantages of minimal traumatisation. In RA,it is used mainly when there is ligament laxity in late synovectomies eventually combined with arthroscopically assisted resection of caput radii. In contrast to monoarticular diseases in RA,the adjoining bursa olecrani, neighbouring joints and nerve entrapment syndromes also require treatment. The treatment for advanced cub arthritis is arthroplasty. Due to progress in the development of elbow endoprotheses, the range of indications for resection (interposition) arthroplasty has increased. It is now preferred mainly in younger patients with ankylosing arthritis. Rheumatoid changes in the bone and soft tissue impede the implantation of artificial joints and require time consuming and precise preparation techniques. When choosing either an unconstrained or semi-constrained prosthesis,one has to bear in mind the actual ligament stability and its often unpredictable changes during the course of the disease.Perioperative measures, postoperative care and therapy is made even more difficult due to the involvement of several joints, often extensive permanent medication, secondary lesions such as ldquo;corticoid skin" and in most cases the multimorbidity of patients after many years of chronic disease. When comparing elbow surgery in osteoarthritis and RA,we found that patients with RA clearly required more elaborate surgery and more extensive perioperative and postoperative care.

[Lumbar intraspinal juxtafacet cysts: MR imaging and CT-arthrography]. / Lumbale intraspinale Juxta-Facettenzysten: Kernspintomographie und CT-Arthrographie.

PURPOSE: To present data on the MR imaging appearance of lumbar intraspinal juxtafacet cysts (JFC) and to assess the importance of additional CT arthrography. MATERIAL AND METHODS: Twenty-eight patients (16 women, 12 men) with a mean age of 64 years (range: 43 - 82), who underwent MR imaging because of radicular pain or spinal claudication, were found to have an intraspinal cyst associated with the facet joint. In 14 patients, additional CT-arthrography was performed to determine whether a communication exists between the cyst and the facet joint and to try to rupture the cyst. RESULTS: In T(2)-weighted images, juxtafacet cysts show a typical pattern consisting of a hyperintense center and hypointense rim. The center is likely to be inhomogeneous because of recurrent hemorrhage in the cyst. In T1-weighted images, the cysts are hypo/isointense. Irregular hyperintensity may indicate subacute hemorrhage, which may aggravate the clinical symptoms. MR allows superior visualization of the cyst in all anatomical planes. It also enables assessment of typical accompanying changes, such as degenerative spondylolisthesis and facet hypertrophy. All patients, who had CT-arthrography, were found to have a direct communication between joint space and cyst. Transarticular rupture of the cyst was possible in five patients. Two of these five patients had good to excellent improvement, and the remaining three patients underwent surgery. CONCLUSION: MR imaging is the method of choice for diagnosing lumbar intraspinal juxtafacet cysts. CT-arthrography of the facet joint is helpful in cases with difficult differential diagnosis, and in the preoperative planning. Furthermore, it assists in the primary interventional treatment.

[Prosthesis implantation of the rheumatoid arthritis shoulder]. / Endoprothetik der rheumatischen Schulter.

Omarthritis occurs frequently during the early course of rheumatoid arthritis. Many rheumatoid patients ignore omarthritis because of the good compensation mechanism of the shoulder. Sonography and tomography enable early diagnosis of omarthritis before deterioration is radiologically visible. Arthroplasty gives better results when the musculotendinous rotator cuff is still intact. Therefore, arthroplasty should be performed before severe damage develops. Early indication for cup arthroplasty of the humeral head is justified because of better options in revision surgery. Glenoid components show a high incidence of radiolucency and loosening in rheumatoid patients. Cemented hemiarthroplasties show the lowest rate of loosening.

Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis--a matched-pair analysis of 100 patients.

Conservative or operative treatment for rotator cuff calcifying tendinitis was investigated in 100 patients in a matched-pair analysis. They were examined clinically and ultrasonographically 35-60 months after the initial visit. The mean Patte score was 91.8 for the patients who underwent surgical treatment and 81 for the ones who received conservative therapy (p < 0.004), while the age-related Constant-score was 103.4 and 95, respectively. Ultrasonography showed 28% calcifications in the surgical group, 18% newly formed and 10% that did not resolve after surgery. In the conservatively treated group, 33% calcifications were seen, of which 67% resolved. The number of rotator cuff ruptures was significantly higher in the conservative group. In the surgical group, 2% of partial tears and in the conservative group 5% of partial and 4% of complete cuff ruptures were found. Conservative treatment for calcifying tendinitis leads to less favourable pain results in the long term than surgical treatment. Surgery shortens the painful period and may reduce the number of future rotator cuff ruptures. Finally, the subjective functional outcome is significantly better after surgery.

Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome.

Fifty patients with impingement syndrome refractory to long-term conservative treatment were randomized to three treatment groups. All patients received an injection of 10 ml 0.5% bupivacaine, in group 1 without corticosteroid, in group 2 with crystalline corticosteroid and in group 3 with lipoid corticosteroid. Treatment in group 1 had to be stopped because of inefficacy. In groups 2 and 3 favorable results were achieved in 19 out of 40 patients.

Bilateral Madelung's deformity without signs of dyschondrosteosis within five generations in a European family--case report and review of the literature.

The paper presents a European family showing bilateral Madelung's deformity within five consecutive generations. Females as well as males are affected alternately indicating autosomal dominant inheritance. Despite of a body height within the lower normal range in two patients the diagnosis of dyschondrosteosis could not be clearly established as further hints for dwarfism are missing. The etiology of Madelung's deformity may be difficult to establish. There seems to be the possibility of an inheritance independent from the complete syndroma of dyschondrosteosis. Therefore the genetic counselling will always be difficult and has to regard the wide variety of symptoms ranging from little pain and cosmetic disturbance to moderate pain and functional impairment.

Ten-year follow-up of silicone arthroplasty of the metacarpophalangeal joints in rheumatoid hands.

In resection arthroplasty of destroyed metacarpophalangeal joints stabilisation with a silicone spacer is regarded as the gold standard. In 28 patients with rheumatoid arthritis (34 hands) 102 arthroplasties of the metacarpophalangeal joint were assessed a median of 10 years postoperatively (range 8.7-12.5). All patients reported pronounced subjective relief of pain, and in three quarters function of the hand had improved. The median active range of movement decreased from 40 degrees (range 10 degrees-90 degrees) preoperatively to 35 degrees (range 5 degrees-85 degrees) postoperatively. Ulnar deviation was corrected from a median of 35 degrees (range 0 degrees-60 degrees) preoperatively to 10 degrees (range 0 degrees-40 degrees) postoperatively. The extension deficit was improved from a median of 35 degrees (range 10 degrees-80 degrees) before surgery to a median of 10 degrees (range 0 degrees-30 degrees) at follow up. Grip strength remained unchanged. Radiological examination showed surrounding osteolysis in 89% of the implants and 28% had broken. The well-known discrepancy between fair clinical and good subjective results with distinct radiological findings such as osteolysis was therefore confirmed. Material fatigue and sharp bony edges that result from osteolysis may be the cause of the relatively common implant fractures and ulnar deviation in this long-term follow-up.

The effect of the additional use of grommets in silicone implant arthroplasty of the metacarpophalangeal joints.

After silicone arthroplasty of the metacarpophalangeal (MP) joint there is increasing osteolysis, subsidence and fracture of the implants in the longer postoperative term. In 44 patients with rheumatoid arthritis (54 hands) 151 arthroplasties of the metacarpophalangeal joint were assessed at a mean of 3.9 years postoperatively. In 57 arthroplasties titanium protectors (grommets) were used. There were no significant differences in the clinical outcomes with respect to swelling, correction of ulnar deviation, range of active movement and grip strength. The additional use of grommets in MP joint arthroplasty slightly reduced reactive osteolysis, protected the spacers from breakage and slightly reduced the amount of pain with only a few additional complications in the midterm follow-up.