Paediatric spine injuries in the thoracic and lumbar spine-results of the German multicentre CHILDSPINE study

BACKGROUND

Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking.

OBJECTIVES

The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients.

MATERIALS AND METHODS

A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years).

RESULTS

A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%).

CONCLUSIONS

The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed.

Feasibility, Usability, and Safety of ParaGym, an Intelligent Mobile Exercise App for Individuals With Paraplegia: Protocol for a Pilot Block-Randomized Controlled Trial

BACKGROUND

Exercise is crucial for individuals with paraplegia to reduce the risk of secondary diseases and improve independence and quality of life. However, numerous barriers such as inadequate accessibility restrict their participation in exercise programs. Digital exercise apps can help overcome these barriers. Personalization is considered a crucial feature of mobile exercise apps, as people with paraplegia have individual requirements regarding exercise programs depending on their level of impairment. Despite the increasing popularity of mobile exercise apps, there are none available that target the individual needs of this cohort. The ParaGym mobile exercise app prototype was designed to automatically tailor exercise sessions to the individual needs of users with paraplegia.

OBJECTIVE

This study aims to evaluate the feasibility, usability, safety, and preliminary effectiveness of the ParaGym mobile exercise app prototype.

METHODS

This pilot block-randomized controlled feasibility trial will include 45 adult participants with paraplegia. Eligible participants will be block randomized to either the intervention or waitlist control group. The intervention group will perform a 6-week exercise program using the ParaGym mobile exercise app, comprising three 35-minute exercise sessions per week. The waitlist control group will continue their usual care and receive access to the app after study completion. Participants will record all exercise sessions conducted with the app as well as additional exercise sessions conducted during the study period using exercise diaries. The primary outcomes include feasibility, usability, and safety. Feasibility will be assessed through semistructured interviews, study adherence, and retention rates. Usability will be measured using the System Usability Scale. Safety will be determined by the occurrence of adverse events. Secondary outcomes include the effects of the intervention on peak exercise capacity (VO₂ peak); handgrip strength; independence, which will be measured using the Spinal Cord Independence Measure III (SCIM III); and health-related quality of life, which will be measured using the Short Form-36 Health Survey (SF-36).

RESULTS

Recruitment commenced in November 2022. Overall, 12 participants were enrolled at the time of submission. Data collection commenced in January 2023, with completion expected in April 2023.

CONCLUSIONS

To the best of our knowledge, this is the first study to assess the feasibility, usability, and safety of an intelligent mobile exercise app for individuals with paraplegia. Thereafter, the app should be adapted according to the findings of this trial. Future trials with an updated version of the app should aim for a larger sample size, longer intervention duration, and more diverse target group. In the long term, a fully marketable version of the ParaGym app should be implemented. This would increase the access to personalized, independent, and evidence-based exercise training for this cohort and, in the future, other people who use wheelchairs.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00030370; https://drks.de/search/de/trial/DRKS00030370.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45652.

[Germany-wide, Web-based ParaReg Registry for Lifelong Monitoring of People with Spinal Cord Injury: Data Model, Ethico-legal Prerequisites and Technical Implementation]

OBJECTIVE

In Germany, treatment paths for patients with acute spinal cord injury (SCI) differ considerably depending on intrinsic, disease-specific and extrinsic factors. Which of these factors are associated with improved outcome with fewer subsequent complications and inpatient re-admissions is not clear. The German-wide, patient-centered, web-based ParaReg registry will be implemented to improve the long-term quality of patient care and the planning of treatment paths with increased cost-effectiveness.

METHODS

In the 2017-18 conceptualization phase, the data model of the registry was developed in an iterative process of the ParaReg steering committee together with the extended DMGP board and patient representatives. In ParaReg, routine social and medical data as well as internationally established neurological, functional and participation scores will be documented. The assignment of a unique patient ID allows a lifelong, cross-center documentation of inpatient stays in one of the 27 SCI centers organized in the German-speaking Medical Society for SCI (DMGP). The ParaReg data protection concept and patient information/consent are based on the Open Source Registry for Rare Diseases (OSSE) which were extended by GDPR-relevant aspects.

RESULTS

In the realization phase, which started in 2019, the information technology infrastructure was implemented according to the clinical ID management module of the Technology and Methods Platform for Networked Medical Research (TMF). In parallel, the legal and ethical prerequisites for registry operation under the patronage of the DMGP were created. Recommendations of the working group data protection of the TMF were integrated into ParaReg's data protection concept. Based on the feedback from the alpha test phase with documentation of the hospitalization data of 40 patients, the ergonomics of the electronic case report forms were improved in particular for data entry on mobile devices.

CONCLUSION

After completion of the monocentric alpha test phase, the multicenter data acquisition was started in 5 DMGP-SCI centers. The sustainability of ParaReg is ensured by the structural and financial support of the DMGP after expiry of the funding by the German Federal Ministry of Education and Research (BMBF).

[Diagnostics and treatment of cervical spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]

BACKGROUND

Severe cervical spine injuries in children under the age of 17 years are rare. Recommendations or even guidelines for the diagnostics and treatment of such injuries in children are currently not available.

OBJECTIVE

The aim of the study was to formulate recommendations for diagnostics and treatment of injuries of the cervical spine in pediatric patients.

MATERIAL AND METHODS

First, a search of primary and secondary literature on the topic complex of diagnostics and treatment of cervical spine injuries in children was carried out. An appropriate internal literature database was defined and maintained. Second, within the framework of 9 meetings from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) systematically formulated recommendations for the diagnostics and treatment of injuries of the cervical spine in pediatric patients by a consensus process.

RESULTS

Recommendation for the diagnostics and treatment for injuries of the cervical spine could be formulated for three age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). The diagnostic and therapeutic principles known from adult patients suffering from injuries to the cervical spine cannot be easily transferred to pediatric patients.

CONCLUSION

Injuries to the pediatric spine are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. Classification systems and therapeutic recommendations for injuries to the cervical spine known from adult patients could also be used for adolescent patients. This is not possible for children under the age of 10 years. Only few classification systems exist for this age group. Basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical relationships as well as the protection of all neural structures.

[Pediatric spine trauma-Results of a German national multicenter study including 367 patients]

BACKGROUND

In general, pediatric spinal injuries are rare. No reliable data on the epidemiology of spinal injuries in pediatric patients in Germany are available. Especially in pediatric patients, for whom the medical history, clinical examination and the performance of imaging diagnostics are difficult to obtain, all available information on a spinal injury must be taken into account.

OBJECTIVE

The aim of this study was to provide epidemiological data for pediatric patients with spinal trauma in Germany in order to enhance future decision-making for the diagnostics and treatment of these patients.

MATERIAL AND METHODS

Within the framework of a national multicenter study, data were retrospectively obtained from 6 German spine centers for 7 years between January 2010 and December 2016. In addition to the demographic data, the clinical databases were screened for specific trauma mechanisms, level of injury as well as accompanying injuries. Furthermore, diagnostic imaging and the treatment selected were also analyzed.

RESULTS

A total of 367 children (female: male = 1:1.2) with a total of 610 spinal injuries were included in this study. The mean age was 12 years (±3.5 years). The most frequent trauma mechanisms were falls from <3 m and traffic accidents. The imaging diagnostics were only rarely carried out with the child under anesthesia. Younger children (0-9 years old) suffered more injuries to the cervical spine, whereas injuries to the thoracic and lumbar spine were more frequently found in older children (>10 years old). The children frequently showed accompanying injuries to the head and the extremities. Accompanying spinal injuries mostly occurred in adjacent regions and only rarely in other regions. Around 75% of the children were treated conservatively.

CONCLUSION

The results were different from the knowledge obtained from adult patients with spinal trauma and describe the special circumstances for pediatric patients with spinal trauma. Despite certain limitations these facts may help to enhance future decision-making for the diagnostics and treatment of these patients.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]

BACKGROUND

Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist.

OBJECTIVE

The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients.

MATERIAL AND METHODS

Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process.

RESULTS

Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients.

CONCLUSION

Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.

Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients

BACKGROUND

Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature.

METHODS

In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients.

RESULTS

For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.

Recommendations for the Diagnostic Testing and Therapy of Atlas Fractures

Im Jahr 2017 erstellten die Mitglieder der AG „obere HWS“ der Sektion „Wirbelsäule“ der DGOU in einem Konsensusprozess mit 4 Sitzungen Empfehlungen zur Diagnostik und Therapie oberer Halswirbelsäulenverletzungen unter Berücksichtigung der aktuellen Literatur. Der folgende Artikel beschreibt die Empfehlung für Frakturen des Atlasrings. Etwa 10% aller HWS-Verletzungen betreffen den Atlas. Die Diagnostik zielt im Wesentlichen auf die Detektion der Verletzung sowie die Beurteilung der Gelenkflächen hinsichtlich einer Lateralisationstendenz der Atlasmassive. Zur Klassifikation haben sich die Gehweiler-Klassifikation und ergänzend die Dickman-Klassifikation bewährt. Zum primären klinischen Screening hat sich die Canadian C-Spine Rule bewährt. Bildgebendes Verfahren der Wahl bei klinischem Verdacht auf eine Atlasverletzung ist die CT. Die MRT dient der Beurteilung der Integrität des Lig. transversum atlantis bei vorderer und hinterer Bogenfraktur. Die Indikation zur Gefäßdarstellung sollte großzügig gestellt werden. Viele Atlasfrakturen können konservativ in einer Zervikalorthese behandelt werden. Eine OP-Indikation ist gegeben bei bestehender oder drohender massiver Gelenkinkongruenz oder -instabilität, die am häufigsten bei Gehweiler-IIIB-Frakturen oder bei Gehweiler-IV-Frakturen vorliegt. Operative Standardtherapie ist die dorsale atlantoaxiale Fixation, entweder in transartikulärer Technik oder mittels Fixateur interne. Insbesondere bei jüngeren Patienten sollte die Möglichkeit einer isolierten Atlasosteosynthese geprüft werden. Dislozierte Gehweiler-IV-Frakturen mit sagittaler Spaltbildung können auch probatorisch im Halofixateur unter Ausnutzung der Ligamentotaxis behandelt werden; eine engmaschige Dislokationskontrolle ist obligat. Im Falle einer sekundären Dislokation ist auch hier eine operative Stabilisierung indiziert. Bei Mitbeteiligung des okzipitozervikalen Gelenks ist eine Einbeziehung des Okziputs in die Instrumentierung notwendig.

Treatment of Injuries to the Subaxial Cervical Spine: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Expert consensus.

OBJECTIVES

To establish treatment recommendations for subaxial cervical spine injuries based on current literature and the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma.

METHODS

This recommendation summarizes the knowledge of the Spine Section of the German Society for Orthopaedics and Trauma.

RESULTS

Therapeutic goals are a stable, painless cervical spine and protection against secondary neurologic damage while retaining maximum possible motion and spinal profile. The AOSpine classification for subaxial cervical injuries is recommended. The Canadian C-Spine Rule is recommended to decide on the need for imaging. Computed tomography is the favoured modality. Conventional x-ray is preserved for cases lacking a "dangerous mechanism of injury." Magnetic resonance imaging is recommended in case of unexplained neurologic deficit, prior to closed reduction and to exclude disco-ligamentous injuries. Computed tomography angiography is recommended in high-grade facet joint injuries or in the presence of vertebra-basilar symptoms. A0-, A1- and A2-injuries are treated conservatively, but have to be monitored for progressive kyphosis. A3 injuries are operated in the majority of cases. A4- and B- and C-type injuries are treated surgically. Most injuries can be treated with anterior plate stabilization and interbody support; A4 fractures need vertebral body replacement. In certain cases, additive or pure posterior instrumentation is needed. Usually, lateral mass screws suffice. A navigation system is advised for pedicle screws from C3 to C6.

CONCLUSIONS

These recommendations provide a framework for the treatment of subaxial cervical spine Injuries. They give advice about diagnostic measures and the therapeutic strategy.

Recommendations for Diagnosis and Treatment of Fractures of the Ring of Axis

In a consensus process with four sessions in 2017, the working group “upper cervical spine” of the German Society for Orthopaedics and Trauma Surgery (DGOU) formulated “Therapeutic Recommendations for the Diagnosis and Treatment of Upper Cervical Fractures”, taking their own experience and the current literature into consideration. The following article describes the recommendations for axis ring fractures (traumatic spondylolysis C2). About 19 to 49% of all cervical spine injuries include the axis vertebra. Traumatic spondylolysis of C2 may include potential discoligamentous instability C2/3. The primary aim of the diagnostic process is to detect the injury and to determine potential disco-ligamentous instability C2/3. For classification purposes, the Josten classification or the modified Effendi classification may be used. The Canadian C-spine rule is recommended for clinical screening for C-spine injuries. CT is the preferred imaging modality and an MRI is needed to determine the integrity of the discoligamentous complex C2/3. Conservative treatment is appropriate in case of stable fractures with intact C2/3 motion segment (Josten type 2 and 2). Patients should be closely monitored, in order to detect secondary dislocation as early as possible. Surgical treatment is recommended in cases of primary severe fracture dislocation or discoligamentous instability C2/3 (Josten 3 and 4) and/or secondary fracture dislocation. Anterior cervical decompression and fusion (ACDF) C2/3 is the treatment of choice. However, in case of facet joint luxation C2/3 with looked facet (Josten 4), a primary posterior approach may be necessary.

First-in-Man Intrathecal Application of Neurite Growth-Promoting Anti-Nogo-A Antibodies in Acute Spinal Cord Injury

Background. Neutralization of central nervous system neurite growth inhibitory factors, for example, Nogo-A, is a promising approach to improving recovery following spinal cord injury (SCI). In animal SCI models, intrathecal delivery of anti-Nogo-A antibodies promoted regenerative neurite growth and functional recovery. Objective. This first-in-man study assessed the feasibility, safety, tolerability, pharmacokinetics, and preliminary efficacy of the human anti-Nogo-A antibody ATI355 following intrathecal administration in patients with acute, complete traumatic paraplegia and tetraplegia. Methods. Patients (N = 52) started treatment 4 to 60 days postinjury. Four consecutive dose-escalation cohorts received 5 to 30 mg/2.5 mL/day continuous intrathecal ATI355 infusion over 24 hours to 28 days. Following pharmacokinetic evaluation, 2 further cohorts received a bolus regimen (6 intrathecal injections of 22.5 and 45 mg/3 mL, respectively, over 4 weeks). Results. ATI355 was well tolerated up to 1-year follow-up. All patients experienced ≥1 adverse events (AEs). The 581 reported AEs were mostly mild and to be expected following acute SCI. Fifteen patients reported 16 serious AEs, none related to ATI355; one bacterial meningitis case was considered related to intrathecal administration. ATI355 serum levels showed dose-dependency, and intersubject cerebrospinal fluid levels were highly variable after infusion and bolus injection. In 1 paraplegic patient, motor scores improved by 8 points. In tetraplegic patients, mean total motor scores increased, with 3/19 gaining >10 points, and 1/19 27 points at Week 48. Conversion from complete to incomplete SCI occurred in 7/19 patients with tetraplegia. Conclusions. ATI335 was well tolerated in humans; efficacy trials using intrathecal antibody administration may be considered in acute SCI.

Imaging Cell Viability on Non-transparent Scaffolds - Using the Example of a Novel Knitted Titanium Implant

Intervertebral disc degeneration and disc herniation is one of the major causes of lower back pain. Depletion of extracellular matrix, culminating in nucleus pulposus (NP) extrusion leads to intervertebral disc destruction. Currently available surgical treatments reduce the pain but do not restore the mechanical functionality of the spine. In order to preserve mechanical features of the spine, total disc or nucleus replacement thus became a wide interest. However, this arthroplasty era is still in an immature state, since none of the existing products have been clinically evaluated. This study intends to test the biocompatibility of a novel nucleus implant made of knitted titanium wires. Despite all mechanical advantages, the material has its limits for conventional optical analysis as the resulting implant is non-transparent. Here we present a strategy that describes in vitro visualization, tracking and viability testing of osteochondro-progenitor cells on the scaffold. This protocol can be used to visualize the efficiency of the cleaning protocol as well as to investigate the biocompatibility of these and other non-transparent scaffolds. Furthermore, this protocol can be used to show adherence pattern of cells as well as cell viability and proliferation rates on/in the scaffold. This in vitro biocompatibility testing assay provides a propitious tool to analyze cell-material interaction in non-transparent and opaque scaffolds.

Challenges for Restoration of Lower Urinary Tract Innervation in Patients with Spinal Cord Injury: A European Single-center Retrospective Study with Long-term Follow-up

Xiao and colleagues in China reported successful restoration of bladder control in patients with spinal cord injury (SCI) by establishing a somatic-autonomic reflex pathway through lumbar-to-sacral ventral root nerve rerouting. We evaluated long-term results in eight patients who underwent this procedure at a German university clinic between 2005 and 2007. The primary outcome was the occurrence of voiding upon stimulation of the skin, with normalization of bladder pressure when filling, as assessed with videourodynamics at each visit. Videourodynamic variables, urinary tract infections, and bladder/stool events recorded in a patient diary were stored in a prospective database and reviewed retrospectively. Intraoperative testing indicated successful nerve rerouting in all eight patients. Duration of follow-up was 71 mo (range: 56-86). No patient reached the primary goal of voluntary voiding with normalization of detrusor pressure at any point during follow-up. No improvements in videourodynamic or diary variables regarding bladder function were observed. In view of the lack of short (12-18 mo) and long-term (71 mo) success in our patients and others, the risks of any surgical procedure using general anesthesia, and potential for unmet expectations to wreak havoc on patient emotional well-being, we cannot recommend this procedure for patients with SCI.

PATIENT SUMMARY

Although the hope was to improve long-term outcomes of spinal cord injury patients, intraspinal nerve rerouting did not improve or normalize bladder function. In view of the lack of success, we cannot recommend this procedure until proven in clinical studies.

Stress-vs-time signals allow the prediction of structurally catastrophic events during fracturing of immature cartilage and predetermine the biomechanical, biochemical, and structural impairment

OBJECTIVE

Trauma-associated cartilage fractures occur in children and adolescents with clinically significant incidence. Several studies investigated biomechanical injury by compressive forces but the injury-related stress has not been investigated extensively. In this study, we hypothesized that the biomechanical stress occurring during compressive injury predetermines the biomechanical, biochemical, and structural consequences. We specifically investigated whether the stress-vs-time signal correlated with the injurious damage and may allow prediction of cartilage matrix fracturing.

METHODS

Superficial and deeper zones disks (SZDs, DZDs; immature bovine cartilage) were biomechanically characterized, injured (50% compression, 100%/s strain-rate), and re-characterized. Correlations of the quantified functional, biochemical and histological damage with biomechanical parameters were zonally investigated.

RESULTS

Injured SZDs exhibited decreased dynamic stiffness (by 93.04±1.72%), unresolvable equilibrium moduli, structural damage (2.0±0.5 on a 5-point-damage-scale), and 1.78-fold increased sGAG loss. DZDs remained intact. Measured stress-vs-time-curves during injury displayed 4 distinct shapes, which correlated with histological damage (p<0.001), loss of dynamic stiffness and sGAG (p<0.05). Damage prediction in a blinded experiment using stress-vs-time grades was 100%-correct and sensitive to differentiate single/complex matrix disruptions. Correlations of the dissipated energy and maximum stress rise with the extent of biomechanical and biochemical damage reached significance when SZDs and DZDs were analyzed as zonal composites but not separately.

CONCLUSIONS

The biomechanical stress that occurs during compressive injury predetermines the biomechanical, biochemical, and structural consequences and, thus, the structural and functional damage during cartilage fracturing. A novel biomechanical method based on the interpretation of compressive yielding allows the accurate prediction of the extent of structural damage.

Postoperative functional rehabilitation after repair of quadriceps tendon ruptures: a comparison of two different protocols

PURPOSE

Early functional rehabilitation after surgical tendon repair facilitates the healing process and leads to improved joint function. There is a paucity of studies commenting on rehabilitation after surgical repair of ruptured quadriceps tendons, and most surgeons prefer a prolonged period of immobilization and protected weight bearing. The purpose of the present study is to compare the clinical outcome after a more functional and after a rather restrictive postoperative rehabilitation protocol.

METHODS

All consecutive patients were included who had a surgical repair of a primary unilateral quadriceps tendon rupture in one of the two participating hospitals and a minimum follow-up of 24 months. Patients of site A were only allowed limited flexion and weight bearing while patients from site B were allowed early functional rehabilitation with full weight bearing. Clinical outcome was measured with the subjective IKDC form. Fisher's exact test and Mann-Whitney U test were used for statistical analysis.

RESULTS

Sixty-six patients were included in the study. Twenty-eight patients (Group A) were treated with restrictive and 38 patients (Group B) with early functional postoperative rehabilitation. The two groups did not differ in terms of demographic characteristics. Clinical follow-up was available for 95% of patients after an average of 4.5 years. No clinical difference was identified with the use of IKDC form. Patients of group A returned to work an average of 10 days later than patients from group B, but this difference was not significant. Two re-ruptures were observed in each group. There was no significant difference in terms of complication quality or quantity.

CONCLUSION

Early functional postoperative mobilization with full weight bearing after primary repair of a quadriceps tendon rupture is safe and will not lead to inferior clinical outcome or an increased complication rate.

LEVEL OF EVIDENCE

Therapeutic, III.

[Hardware removal after pelvic ring injury]

BACKGROUND

Pelvic ring fractures are considered as rare injuries. Minimally invasive sacroiliac screw fixation has been used increasingly in recent years as an operative strategy for the treatment of these injuries, if the dorsal pelvic ring needed to be addressed. Treatment options for the anterior pelvic ring comprise plates, screws or external fixation.

METHOD

Based on the limited number of publications on this subject and our own experience with 80 patients who suffered pelvic ring B- or C-type injuries during a period of 8 years we are able to show that the indication for hardware removal in the pelvic ring should be strictly defined.

RESULTS

In some cases like external fixation, implant-associated infection, malpositioning, allergic implant reaction, critical soft tissue covering, palpable hardware and consolidated juvenile fractures implant removal is certainly indicated. In patients without symptoms and in patients with trauma-associated symptoms which are not definitely associated with the hardware, the removal should be only indicated after thorough consideration of the risks versus the benefits and additionally by taking the initial injury pattern into account. If despite all these objections the hardware removal has been indicated it should always be considered that hardware removal may be challenging with several possible severe complications.

[Refracture of long bones after implant removal. An avoidable complication?]

Refractures of long bones after implant removal are a rare but serious complication, which in most cases make a reoperation necessary. We analysed our own cases and reviewed the scarce literature on this subject. As a result we found that it is possible to reduce this complication by performing thorough preoperative preparation, observing an adequate interim time between initial osteosynthesis and hardware removal, cautiously exposing the weakened bone to force for a certain time period after implant removal and taking the character of the fracture healing into consideration. It is not possible to entirely eradicate this complication because a lot of patients demand the implant removal even though it is known that demineralisation and residual screw holes both induce a reduction of energy-absorbing capacity and therefore predispose the patient to refracture. In some cases the surgeon should recommend that the implants remain in situ.

Rheological and biological properties of a hydrogel support for cells intended for intervertebral disc repair

Background

Cell-based approaches towards restoration of prolapsed or degenerated intervertebral discs are hampered by a lack of measures for safe administration and placement of cell suspensions within a treated disc. In order to overcome these risks, a serum albumin-based hydrogel has been developed that polymerizes after injection and anchors the administered cell suspension within the tissue.

Methods

A hydrogel composed of chemically activated albumin crosslinked by polyethylene glycol spacers was produced. The visco-elastic gel properties were determined by rheological measurement. Human intervertebral disc cells were cultured in vitro and in vivo in the hydrogel and their phenotype was tested by reverse-transcriptase polymerase chain reaction. Matrix production and deposition was monitored by immuno-histology and by biochemical analysis of collagen and glycosaminoglycan deposition. Species specific in situ hybridization was performed to discriminate between cells of human and murine origin in xenotransplants.

Results

The reproducibility of the gel formation process could be demonstrated. The visco-elastic properties were not influenced by storage of gel components. In vitro and in vivo (subcutaneous implants in mice) evidence is presented for cellular differentiation and matrix deposition within the hydrogel for human intervertebral disc cells even for donor cells that have been expanded in primary monolayer culture, stored in liquid nitrogen and re-activated in secondary monolayer culture. Upon injection into the animals, gels formed spheres that lasted for the duration of the experiments (14 days). The expression of cartilage- and disc-specific mRNAs was maintained in hydrogels in vitro and in vivo, demonstrating the maintenance of a stable specific cellular phenotype, compared to monolayer cells. Significantly higher levels of hyaluronan synthase isozymes-2 and -3 mRNA suggest cell functionalities towards those needed for the support of the regeneration of the intervertebral disc. Moreover, mouse implanted hydrogels accumulated 5 times more glycosaminoglycans and 50 times more collagen than the in vitro cultured gels, the latter instead releasing equivalent quantities of glycosaminoglycans and collagen into the culture medium. Matrix deposition could be specified by immunohistology for collagen types I and II, and aggrecan and was found only in areas where predominantly cells of human origin were detected by species specific in situ hybridization.

Conclusions

The data demonstrate that the hydrogels form stable implants capable to contain a specifically functional cell population within a physiological environment.

Early predictors of posttraumatic stress in accident victims

This study investigated the predictive value of pretraumatic and peritraumatic variables and early PTSD-like symptoms (within 48 h post-event) in determining the severity of posttraumatic stress in accident victims. Symptom development appears to be related to initial PTSD-like reactions, while demographic variables play a role in predicting symptom severity 6 months post-event.

Onset of preclinical osteoarthritis: the angular spatial organization permits early diagnosis

OBJECTIVE

Superficial articular chondrocytes display distinct spatial remodeling processes in response to the onset of distant osteoarthritis (OA). Such processes may be used to diagnose early events before manifest OA results in tissue destruction and clinical symptoms. Using a novel method of spatial quantification by calculating the angles between a chondrocyte and its surrounding neighbors, we compared maturational and degenerative changes of the cellular organizations in rat and human cartilage specimens.

METHODS

The nuclei of superficial chondrocytes obtained from intact rat cartilage and from human knee cartilage, as well as from cartilage with focal and severe OA, were digitally recorded in top-down views. Their Cartesian coordinates were used to determine the nearest neighbor for each chondrocyte and the angle between these 2 cells and a reference. These angles, cellularity, nearest neighbor distances, and aggregation were analyzed as a function of location and OA severity.

RESULTS

Neighboring rat chondrocytes exhibited intricate angular patterns with 4 dominant angles that were maintained during maturation and during the onset and progression of OA. Within intact cartilage, human chondrocytes demonstrated 1 dominant angle and, thus, a significantly different angular organization. With early OA onset, human chondrocytes that were located within intact cartilage displayed an increased occurrence of 4 angles; the resulting angular patterns were indistinguishable from those observed in rats. The angular remodeling was associated with location- and OA severity-dependent changes in cellularity and aggregation.

CONCLUSION

This study is the first to identify the presence of angular characteristics of spatial chondrocyte organization and species-specific remodeling processes correlating with OA onset. The appearance of distinct angular and spatial patterns between neighboring chondrocytes can identify the onset of distant OA prior to microscopically visible tissue damage and possibly before clinical onset. With further development, this novel concept may become suitable for the diagnosis and followup of patients susceptible to OA.

[Postarthroscopic glenohumeral chondrolysis--are there any causal factors? Case report]

BACKGROUND

Postarthroscopic glenohumeral chondrolysis (PAGCL) is a rare complication of shoulder arthroscopy. PAGCL describes a chondrolysis in the shoulder joint after arthroscopy mostly affecting younger patients. The process leading to chondrolysis is not known yet.

MATERIAL AND METHODS

The case report describes a patient with rapid progress of the PAGCL. A literature review with key words: PAGCL, postarthroscopic glenohumeral chondrolysis, shoulder arthroscopy AND chondrolysis, chondronecrosis AND arthroscopy was carried out.

RESULTS

16 Publications involving case reports with 96 cases were found. The mean age at operation was 28 ± 10 years (range: 13 to 61 years). The majority of patients (62%) were male. 8 diagnoses at index operation were found. 63% received intraarticular local anaesthetics (62% bupivacain, 21% bupivacain and epinephrin, 2% lidocain) through a pain pump.

CONCLUSION

PAGCL is a rare and disturbing complication after shoulder arthroscopy. The majority of the patients are young and male. A relevant causal factor is an intraarticular pain pump with bupivacain. Other factors have not yet been verified. A multifactorial aetiology is likely. No specific and effective treatment regimen is described.

Inter- and intraobserver reliability of the vertebral, local and segmental kyphosis in 120 traumatic lumbar and thoracic burst fractures: evaluation in lateral X-rays and sagittal computed tomographies

Evaluation of the kyphosis angle in thoracic and lumbar burst fractures is often used to indicate surgical procedures. The kyphosis angle could be measured as vertebral, segmental and local kyphosis according to the method of Cobb. The vertebral, segmental and local kyphosis according to the method of Cobb were measured at 120 lateral X-rays and sagittal computed tomographies of 60 thoracic and 60 lumbar burst fractures by 3 independent observers on 2 separate occasions. Osteoporotic fractures were excluded. The intra- and interobserver reliability of these angles in X-ray and computed tomogram, using the intra class correlation coefficient (ICC) were evaluated. Highest reproducibility showed the segmental kyphosis followed by the vertebral kyphosis. For thoracic fractures segmental kyphosis shows in X-ray "excellent" inter- and intraobserver reliabilities (ICC 0.826, 0.802) and for lumbar fractures "good" to "excellent" inter- and intraobserver reliabilities (ICC = 0.790, 0.803). In computed tomography, the segmental kyphosis showed "excellent" inter- and intraobserver reliabilities (ICC = 0.824, 0.801) for thoracic and "excellent" inter- and intraobserver reliabilities (ICC = 0.874, 0.835) for the lumbar fractures. Regarding both diagnostic work ups (X-ray and computed tomography), significant differences were evaluated in interobserver reliabilities for vertebral kyphosis measured in lumbar fracture X-rays (p = 0.035) and interobserver reliabilities for local kyphosis, measured in thoracic fracture X-rays (p = 0.010). Regarding both fracture localizations (thoracic and lumbar fractures), significant differences could only be evaluated in interobserver reliabilities for the local kyphosis measured in computed tomographies (p = 0.045) and in intraobserver reliabilities for the vertebral kyphosis measured in X-rays (p = 0.024). "Good" to "excellent" inter- and intraobserver reliabilities for vertebral, segmental and local kyphosis in X-ray make these angles to a helpful tool, indicating surgical procedures. For the practical use in lateral X-ray, we emphasize the determination of the segmental kyphosis, because of the highest reproducibility of this angle. "Good" to "excellent" inter- and intraobserver reliabilities for these three angles could also be evaluated in computed tomographies. Therefore, also in computed tomography, the use of these three angles seems to be generally possible. For a direct correlation of the results in lateral X-ray and in computed tomography, further studies should be needed.

[Pharyngo-vertebral fistula with transspinous course to the neck skin due to a cervical spondylodesis - case report and review of the literature]

BACKGROUND

Pharyngo-vertebral fistulas - especially with delayed diagnosis - are a rare but grave reported complication in cervical spine surgery.

PATIENTS AND METHODS

We present a patient, sent postoperatively from Italy after cervical spine surgery to our department. The patient has developed a pharyngo-vertebral fistula with transspinous course to the dorsal neck skin due to infected spondylodesis.

CASE REPORT

In the presented patient, the successful closure of the pharyngo-vertebral fistula with transspinous course was made after diverse revisions at the anterior side with a platysma flap, at the posterior one with a drain.

REVIEW OF THE LITERATURE

Aetiology, diagnostic work-up and treatment opinions are discussed in a detailed literature review.

CONCLUSION

To the best of the authors' knowledge the presented pharyngo-vertebral fistula with transspinous course to the dorsal neck skin as a complication after anterior cervical spine surgery has not been reported in the literature before.

[Traumatic lumbosacral dislocation - an underrated injury]

Traumatic lumbosacral dislocations are rare. We report two cases with initially missed posttraumatic lumbosacral dislocations. The reported cases and the review of the literature show that, especially, accident victims with multiple fractures of the lumbar transverses processes may require a CT scan to confirm fractures or dislocations of L5/S1. Follow-up examinations due to persisting pain after physiotherapy should include lateral X-rays of the lumbar spine of the patient standing. According to the literature and our experience, the treatment of traumatic lumbosacral dislocation usually consists of open reduction and postero-lateral or dorso-ventral fusion of the unstable segments.

Akute Belastungsreaktionen und neuroendokrine Stressachsenregulation nach Unfalltraumen

Zusammenfassung. Theoretischer Hintergrund: Einige Studienbefunde deuten darauf hin, dass eine Posttraumatische Belastungsstörung mit spezifischen Alterationen in der endokrinen Stressachsenaktivität assoziiert ist. Es wird angenommen, dass eine stark erhöhte Cortisolausschüttung in der traumatischen Akutphase zu einer Dysregulation des Systems und schließlich zu dauerhaft erniedrigter basaler Cortisolsekretion (Hypocortisolismus) führt. Fragestellung: Lassen sich Hinweise auf spezifische Verläufe in der diurnalen endokrinen Sekretion bei akut traumatisierten Personen in Abhängigkeit von der Symptomschwere finden? Methode: Eine Stichprobe von 50 akut verunfallten Patienten wurde nach der Schwere der Belastungssymptome in zwei Gruppen unterteilt. Die während der stationären Versorgung sowie 6 Wochen später dokumentierten Tagescortisolprofile wurden auf differenzielle Verläufe zwischen den Gruppen hin analysiert. Ergebnisse: Nach 6 Wochen zeigten die belasteten Patienten zwar leicht erhöhte Tagescortisolwerte, es konnten jedoch keine Anhaltspunkte für regelhaft spezifische Veränderungen in der Stressachsenaktivität zwischen den Gruppen gefunden werden. Diskussion: Auffälligkeiten in der Cortisolsekretion, als ereignisnahe Indikatoren/Prädiktoren einer posttraumatischen Belastungsreaktion, lassen sich in dieser Stichprobe nicht belegen.

Immune depression syndrome following human spinal cord injury (SCI): a pilot study

Experimental spinal cord injury (SCI) has been identified to trigger a systemic, neurogenic immune depression syndrome. Here, we have analyzed fluctuations of immune cell populations following human SCI by FACS analysis. In humans, a rapid and drastic decrease of CD14+ monocytes (<50% of control level), CD3+ T-lymphocytes (<20%, P<0.0001) and CD19+ B-lymphocytes (<30%, P=0.0009) and MHC class II (HLA-DR)+ cells (<30%, P<0.0001) is evident within 24 h after spinal cord injury reaching minimum levels within the first week. CD15+ granulocytes were the only leukocyte subpopulation not decreasing after SCI. A contributing, worsening effect of high dose methylprednisolone cannot be excluded with this pilot study. We demonstrate that spinal cord injury is associated with an early onset of immune suppression and secondary immune deficiency syndrome (SCI-IDS). Identification of patients suffering spinal cord injury as immune compromised is a clinically relevant, yet widely underappreciated finding.

Ketamine aggravates symptoms of acute stress disorder in a naturalistic sample of accident victims

The glutamatergic N-methyl-D-aspartate receptor antagonist ketamine produces transient dissociative states and alters cognitive functioning in healthy humans, thus resembling the core symptoms of acute and chronic post-traumatic stress disorder (PTSD). First evidence exists that the common use of the analgesic and sedative properties of ketamine during emergency care correlates with sustained symptoms of PTSD in accident victims. The aim of the present study was to examine whether ketamine administration after moderate accidental trauma modulates dissociation and other symptoms of acute stress disorder (ASD) in the direct aftermath of the event. Accident victims were screened within the third day after admission to hospital for symptoms of ASD (Peritraumatic Dissociative Experiences Questionnaire, ASD Scale) and prior stressful life events (Traumatic Life Events Questionnaire). Subjects had received a single or fractionated dose of either racemic ketamine (n=13), opioids (n=24) or non-opioid analgesics (n=13) during initial emergency treatment. There were no significant differences between medication groups in demographic and clinical characteristics such as injury severity or prior traumatization. With respect to ASD symptomatology three days post-event there were significant associations between ketamine analgosedation and increased symptoms of dissociation, reexperiencing, hyperarousal and avoidance relative to the comparison groups.Growing evidence exists that ketamine might modulate or aggravate early post-traumatic stress reactions when given in the acute trauma phase, which in turn might contribute to long-lasting symptomatology.

[CT-based assessment score after ventral spondylodesis for thoracolumbar spine fracture]

BACKGROUND

Dorsoventral stabilization is a common procedure to treat thoracolumbar spine fractures. Especially in respect of the evaluation of alternative procedures to autogenous bone graft, a standardized evaluation score for ventral spondylodesis is necessary.

PATIENTS AND METHODS

In a group of 44 patients a follow-up CT scan was evaluated with a standardized scoring system by four different independent evaluators (a trauma surgeon, an orthopedic surgeon, and two radiologists). The score is based on the morphologic classification of the region between graft and vertebral body. It allows a classification of the spondylodesis as sufficient, partial, and not sufficient.

RESULTS

The statistical evaluation of the classification of the different evaluators shows very good interobserver agreement in monosegmental fusion and good agreement in bisegmental fusion.

CONCLUSION

The demonstrated score is easy to handle, does not need special equipment for CT scans, and shows good interobserver agreement in the classification of spinal fusion after ventral spondylodesis for thoracolumbar spine fracture.

Effects of peritraumatic ketamine medication on early and sustained posttraumatic stress symptoms in moderately injured accident victims

RATIONALE

Ketamine, an N-methyl-D: -aspartate receptor antagonist, produces transient dissociative and psychotic states in healthy humans that resemble symptoms shown by subjects with acute and chronic posttraumatic stress disorder (PTSD). Since ketamine is widely used as an analgesic and sedative in emergency care, it might be one factor triggering, modulating, or exacerbating PTSD in accident victims when given in the acute trauma phase.

OBJECTIVES

The purpose of the present study was to determine whether the peritraumatic administration of ketamine affects acute and sustained PTSD symptoms in accident victims.

METHODS

A sample of 56 moderately injured accident victims was screened retrospectively for acute (Peritraumatic Dissociative Experiences Questionnaire; Acute Stress Disorder Scale) and for current PTSD symptoms (Impact of Event Scale) approximately 1 year postaccident. All subjects had received a single or fractionated dose of either racemic ketamine (n = 17), (S)-ketamine (n = 12), or opioids (n = 27) during emergency ambulance transportation.

RESULTS

Retrospectively assessed acute symptomatology was strongly increased in (S)-ketamine subjects in terms of dissociation, reexperiencing, and avoidance, and slightly heightened in racemic ketamines. Current PTSD symptoms were substantially elevated in (S)-ketamine subjects, while there was no difference observed between opioids and racemic ketamines. Medication groups did not differ in regard to demographic variables, previous or postaccidental traumatic events, time between accident and investigation, and injury severity.

CONCLUSIONS

The data provide first evidence for a modulating effect of a single-dose ketamine on the severity and duration of posttraumatic stress symptoms in accident victims.

[Development of the spine after traumatic spinal cord injury in children and adolescents]

In the 1970s, there was growing concern about the risk of secondary deformations of the spine as these seemed to endanger the otherwise improving prognosis for the life of paraplegic subjects, especially of paralyzed children and adolescents. According to the literature, the level and extent of the spinal cord injury and the age at the time of injury are determinants of the development of scoliosis, hyperlordosis or global kyphosis. Correction of the deformity by brace orthosis is not indicated except for children. The indications for surgical intervention in terms of the extent of the scoliosis and technical performance corresponds to the well known situation for idiopathic scoliosis except for the length of fusion. A special form of scoliosis, the so called "collapsing spine", allows good surgical correction because it is usually not rigid. Early, substantial degenerative processes such as segmental intervertebral instability at the level of the paraplegia, as well as distinct uncarthrosis proximally distant from the innervated zones with secondary radicular damage, are observed. By means of modern surgical procedures, the appearance of the patient's body, as well as the quality of life, can be favorably influenced.

Preoperative marking of musculoskeletal tumors guided by magnetic resonance imaging

BACKGROUND

The purpose of this study was to evaluate a new stereotactic method for preoperative coil-marking of musculoskeletal tumors with use of interventional magnetic resonance imaging.

METHODS

Nine patients with a soft-tissue or bone-marrow tumor were referred to our department for preoperative marking of the extent of the lesion. In one patient, two lesions were marked. Guidance for the punctures and the delivery of the coils was provided by an open low-field magnetic resonance imaging system with horizontal access. After imaging of the extent of the lesion, magnetic resonance imaging-compatible titanium coils were placed with use of nearly real-time or step-by-step magnetic resonance imaging control. The coils were placed up to seventy-two hours before the surgery. The inclusion of the tumor borders within the area of the excision was examined with cross-sectional histological analysis of surgical specimens.

RESULTS

The tumor-marking intervention was successfully performed with the guidance of magnetic resonance imaging only in all patients. Preoperatively, nineteen coils were used to mark the ten lesions in the nine patients. All of the coils were easily located with intraoperative fluoroscopy. No coil migrated between the time of the percutaneous marking and the surgery. Histological examination of the resection borders revealed no residual tumor cells. No complications were observed, and, after a mean of twenty-three months of follow-up, no tumor had recurred.

CONCLUSIONS

Preoperative coil-marking guided by magnetic resonance imaging for exact delineation of a musculoskeletal tumor is technically feasible and can readily demonstrate the full extent of the tumor. Use of magnetic resonance fluoroscopy reduces the time needed for the intervention. We recommend the coil-marking technique.

Distalization of the patella during tibial callus distraction

Consecutive distalization of the patella is described in two patients undergoing segmental transportation after high tibial corticotomy. Revision surgery with loosening and proximal reattachment of a portion of the patellar ligament bridging the callus distraction zone could re-establish the correct patellar position. Despite excellent callus formation after tibial corticotomy just below the tibial tuberositas, this procedure should be performed more distally as the fibers of the patellar tendon spread laterally and distally.

[Treatment and rehabilitation of post-traumatic tetraplegia in advanced age. A report of experiences]

We report about the results of the treatment of patients older than 70 years with posttraumatic tetraplegia. In 7 out of 11 patients treatment in a specialised department lasting for many months makes it possible to live a subjective satisfactory life at home in spite of being severely handicapped. The goals and limits of rehabilitation of patients with posttraumatic tetraplegia cannot only be derived from the age but from the individual capability of the injured patient.

[Traumatic damage to the lower cervical spine--a diagnostic problem?]

Even today fractures and dislocations of the lower cervical spine are usually not recognized, or the interpretation of the results of the diagnostic procedures is not correct. These diagnostic failures are often caused by an incomplete representation of the cervical spine in the conventional radiograms, particularly in the lateral projection. Beyond that, the interpretation of the results of the neurological examination of patients with motoric or sensoric deficits after spine injury can be incorrect. Ignorance of the distribution of the segmental innervation of the upper extremities could lead to the wrong diagnosis of paraplegia in a tetraplegic patient. Two patients with injuries of the lower cervical spine are reported, in whom these problems led to an incorrect diagnosis. With regard to these cases we propose a standard diagnostic procedure for the clinical and radiological emergency examination of patients with neurological deficits after spine injury. The technical possibilities of obtaining correct radiographs of the lower cervical spine are described in detail.

[Unilateral, paramedian spinal contusion after athletic injury with complete recovery]

The acute injury of the spinal column and the spinal cord asks for immediate diagnostic techniques and adequate therapeutical intensive care in order to secure the possibility of a maximum of neurologic recovery. An impact trauma of the spinal cord in sports accidents can cause an incomplete paraplegia. In some cases, morphologic lesions of the myelon cannot be detected. We present an exceptional and striking case of a 15-year old young woman who suffered from a contusio spinalis after high jump with the clinical signs of an incomplete, sensomotoric paraplegia which showed a strictly unilateral and paramedian border at the right side of her body for about two weeks. Additionally, the diagnostic possibilities of physical examination, magnetic resonance imaging, computed tomography and neurophysiologic diagnostic techniques in detecting spinal cord injuries are demonstrated.

[Risk analysis of primary endoprosthetic management of proximal femur fractures]

From 1984 to 1991 439 patients with fractures of the coxal femur (303 femoral neck fractures, 136 pertrochanteric fractures) were treated by primary arthroplasty. The average age of the 370 female and 69 male patients was 80.9 (+/- 9.9) years. In 368 patients (83.8%) concomitant diseases were diagnosed and 212 patients (48.3%) showed more than 1 risk factor. There were 205 alloarthroplasties and 234 hemiarthroplasties performed. The percentage of patients treated by total hip endoprosthesis was 31.2% in 1984 and increased to 63.1% in 1991. In 49.2% of all cases general complications occurred, pre-dominantly nosocomial infections and pressure sores. Local (surgical) complications were diagnosed after 10.5% of all operations. The 30-day-mortality was 5.2%, the in-hospital-mortality 5.9%. Statistical analysis by multivariate logistic regression showed an independent negative influence of pre-operative immobility, pertrochanteric fractures, diabetes mellitus and multiple concomitant diseases on mortality. Age, sex or other single risk factors were not independently associated with an increased mortality. Patients with the above mentioned risk factors are easy to identify pre-operatively and do perform better after intensive preparation, short operation time and early mobilisation after surgery.

[Total endoprosthesis or dual head prosthesis in endoprosthetic management of femoral neck fractures?]

From 1.1.1984 to 31.12.1992, a total of 363 femoral neck fractures were treated by primary hip arthroplasty, with 213 total hip endoprostheses (58.7%) and 150 bipolar endoprostheses (41.3%). The average age of the 51 (14.0%) male and 312 (86.0%) female patients was 80.3 (+/- 8.9) years. While only 15.8% of all patients were treated with alloarthroplasty in 1984, the proportion treated in this way increased to 88.9% in 1992. In the same period, the percentage of patients with total hip arthroplasty who were above 80 years rose from 15.6% to 54.5% (p < 0.05), and the percentage in this group with multiple concomitant diseases rose from 28.1% to 48.2% (p < 0.05). General postoperative complications occurred after 43.5% of the operations (total arthroplasty 38.0%, bipolar prosthesis 51.3%, p < 0.01), with no substantial change during the observation period (1984-1986, 43.6%; 1990-1992, 43.2%). Surgical complications were observed in 9.1% of all cases (total arthroplasty 11.7%, bipolar prosthesis 5.6%, p < 0.05), decreasing slightly from 11.7% in 1984-1986 to 8.1% in 1990-1992. The postoperative mortality was 3.3% (total arthroplasts 1.9%, bipolar prosthesis 5.3%, p > 0.05). The higher rate of general complications and the insignificantly higher mortality after insertion of bipolar endoprostheses cannot be attributed to the endoprosthetic technique itself; they are probably due to the higher age and poorer general condition of patients in whom hemiarthroplasty was performed. Although there has been an increasing frequency of total hip replacement even in older and sicker patients in recent years, no significant changes in morbidity and mortality were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of management of pertrochanteric comminuted fractures in the elderly with a tumor shaft endoprostheses]

Pertrochanteric fractures are typical injuries of elderly people, that can be treated with osteosynthesis in most cases. From 1984 to 1991 we performed 105 implantations of tumor-endoprosthesis in elderly patients with comminuted pertrochanteric fractures with simultaneous coxarthrosis or osteoporosis. The mean age of these patients was 82.7 years. 81.9% of the patients had concomitant systemic diseases (coronary heart disease, hypertension, diabetes etc.), 51.4% showed several risk factors. General postoperative complications were diagnosed in 63.8% of all cases, mostly nosocomial urinary tract infections, pressure sores and cardiovascular disorders. In 14.3% of the patients local (surgical) complications occurred. 83.3% of the patients were able to walk when they left the hospital, the in-hospital mortality was 13.3% (30-day-mortality 12.4%). Although primary osteosynthesis of pertrochanteric fractures with dynamic hip screw or gamma-nail show a smaller risk, implantation of a tumor-endoprosthesis can be an alternative in patients with severe osteoporosis, coxarthrosis or after instable osteosynthesis.

[Histopathological changes of gallbladder and liver parenchyma in symptomatic cholelithiasis]

In a retrospective study of 1101 patients (302 men, 799 women; mean age 56,7 [19-88] years) with symptomatic cholelithiasis who had undergone elective cholecystectomy and intraoperative liver biopsy, histological examination revealed inflammatory changes in the gallbladder in 96.7%, chronic fibrotic cholecystitis in 94.5% and a severe form of cholecystitis in 8.8%. Clinically relevant changes in the liver parenchyma were present in 27.9%, most frequently intrahepatic cholangitis (21.8%). The latter was significantly more common in choledocholithiasis than in isolated cholecystolithiasis. 27 patients had signs of severe liver disease, namely viral hepatitis, cirrhosis or fatty liver. Since the gall-bladder in cholelithiasis is almost always inflamed, cholecystectomy is the treatment of choice. Not uncommonly liver biopsy will reveal clinically relevant changes in the liver parenchyma. This will be useful information, especially in the management of symptoms which persist postoperatively.

[Preoperative esophagogastroduodenoscopy before elective surgical therapy of symptomatic cholelithiasis]

We evaluated the data of 1143 patients who underwent preoperative gastroscopy or upper gastrointestinal series before elective surgical treatment of cholelithiasis between January 1, 1981 and December 31, 1990. On these 824 women and 319 men we performed 1064 (93.1%) gastroscopies and only 78 (6.8%) upper gastrointestinal series. The incidence of pathological findings was 30.2% (345 patients), with 68.3% findings of inflammatory nature. In 28 patients (2.5%) cholecystectomy or bile duct exploration was combined with an additional gastrointestinal surgical procedure. In 227 cases (19.8%) biliary surgery was followed by pharmacological treatment of the gastrointestinal disease. Because of the high incidence of simultaneous disease of the upper gastrointestinum we believe that routine preoperative gastroscopy is indicated before elective surgical treatment of cholelithiasis.

Maturation of transmission in reinnervated mouse soleus muscle

After the tibial nerve of the mouse was cut unilaterally and immediately resutured, reinnervation of soleus muscle proceeded rapidly and muscle isometric contraction characteristics reached normal levels within 2 months. In contrast, synaptic transmission remained immature since resistance to presynaptic (magnesium) or postsynaptic (curare) blocking solutions remained reduced. Results suggest that release probability and transmitter stores were smaller than normal. To study the effect of training, animals were allowed to run in wheels. Running caused a delay in reinnervation at 18-20 days, which was, however, abolished by 4 weeks. On the other hand, exercise counteracted development of denervation atrophy. The safety margin of transmission in runners was higher than in nonrunners at 4 weeks, indicating enhanced maturation, but was lower at 2 months of reinnervation. These results suggest that recovery of muscle precedes maturation of synaptic transmission.