OF-Pelvis classification of osteoporotic sacral and pelvic ring fractures

Objectives

Osteoporotic fractures of the pelvis (OFP) are an increasing issue in orthopedics. Current classification systems (CS) are mostly CT-based and complex and offer only moderate to substantial inter-rater reliability (interRR) and intra-rater reliability (intraRR). MRI is thus gaining importance as a complement.

This study aimed to develop a simple and reliable CT- and MRI-based CS for OFP.

Methods

A structured iterative procedure was conducted to reach a consensus among German-speaking spinal and pelvic trauma experts over 5 years. As a result, the proposed OF-Pelvis CS was developed. To assess its reliability, 28 experienced trauma and orthopedic surgeons categorized 25 anonymized cases using X-ray, CT, and MRI scans twice via online surveys. A period of 4 weeks separated the completion of the first from the second survey, and the cases were presented in an altered order. While 13 of the raters were also involved in developing the CS (developing raters (DR)), 15 user raters (UR) were not deeply involved in the development process.

To assess the interRR of the OF-Pelvis categories, Fleiss’ kappa (κ_F) was calculated for each survey. The intraRR for both surveys was calculated for each rater using Kendall’s tau (τ_K). The presence of a modifier was calculated with κ_F for interRR and Cohen’s kappa (κ_C) for intraRR.

Results

The OF-Pelvis consists of five subgroups and three modifiers. Instability increases from subgroups 1 (OF1) to 5 (OF5) and by a given modifier. The three modifiers can be assigned alone or in combination.

In both surveys, the interRR for subgroups was substantial: κ_F = 0.764 (Survey 1) and κ_F = 0.790 (Survey 2). The interRR of the DR and UR was nearly on par (κ_F Survey 1/Survey 2: DR 0.776/0.813; UR 0.748/0.766). The agreement for each of the five subgroups was also strong (κ_F min.–max. Survey 1/Survey 2: 0.708–0.827/0.747–0.852). The existence of at least one modifier was rated with substantial agreement (κ_F Survey 1/Survey 2: 0.646/0.629).

The intraRR for subgroups showed almost perfect agreement (τ_K = 0.894, DR: τ_K = 0.901, UR: τ_K = 0.889). The modifier had an intraRR of κ_C = 0.684 (DR: κ_C = 0.723, UR: κ_C = 0.651), which is also considered substantial.

Conclusion

The OF-Pelvis is a reliable tool to categorize OFP with substantial interRR and almost perfect intraRR. The similar reliabilities between experienced DRs and URs demonstrate that the training status of the user is not important. However, it may be a reliable basis for an indication of the treatment score.

Osteoporotic Fractures of the Thoracic and Lumbar Vertebrae: Diagnosis and Conservative Treatment

BACKGROUND

The prevalence of osteoporotic vertebral body fractures in Europe is 18-26%. Although most of these injuries can be treated conservatively, the underlying concepts have not been defined clearly or uniformly. In this article, we present the current state of the evidence on the diagnosis and conservative treatment of osteoporotic fractures of the thoracic and lumbar vertebrae.

METHODS

A systematic review of the literature up to May 2020 was carried out in the PubMed and Web of Science Core Collection databases. 549 articles were identified, of which 36 were suitable for inclusion in the review. Articles were sought in the areas of diagnosis, provision of physical aids, pharmacotherapy, physiotherapy, and treatments from the realm of alternative medicine.

RESULTS

The primary diagnostic technique was conventional x-ray in two planes (with the patient standing, if possible), which had 51.3% sensitivity and 75% specificity. If a fracture was suspected, magnetic resonance imaging (MRI) of the entire spine and regional computed tomography (CT) were carried out. The overall state of the evidence on treatment is poor; the best available evidence is for exercise therapy and physiotherapy, which are supported by three level I and four level II studies. Improvements were seen mainly in mobility and a reduced fear of falling. The use of an active orthosis can be useful as well. No evidence was found on the use of drugs or alternative medicine exclusively in the conservative treatment of osteoporotic vertebral body fractures.

CONCLUSION

It is reasonable to evaluate instability with imaging repeatedly, at regular intervals, over a period of six months. There is still a lack of reliable data on the optimal intensity and duration of physiotherapy, and on the use of orthoses.

Osteoporotic mid-thoracic vertebral body fractures: what are the differences compared to fractures of the lumbar spine?-a systematic review

Purpose

The aim of this systematically review is to detect differences between fractures located at the mid-thoracic spine compared to fractures of the thoracolumbar junction (TLJ) and the lumbar spine in osteoporotic vertebral body fractures.

Methods

This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications regarding osteoporotic fractures of the thoracolumbar spine with respect to the fracture location. Differences in prevalence, cause of fracture, fracture healing, and outcomes between the mid-thoracic spine and the TLJ and the lumbar spine were considered.

Results

Altogether, 238 articles could be retrieved from the literature search. A total of 222 articles were excluded. Thus, 16 remaining original articles were included in this systematic review comprising the topics prevalence, bone mineral density and regional blood flow, biomechanics, subsequent fractures, and outcome, respectively. The overall level of evidence of the vast majority of studies was moderate to low.

Conclusion

Several differences between osteoporotic fractures of the mid-thoracic spine compared to the TLJ and the lumbar spine could be identified. Thereby, osteoporotic mid-thoracic fractures seem to be particularly more related to frailty without a history of traumatic injury compared to osteoporotic fractures of the TLJ and the lumbar spine. Additionally, the presence of severe mid-thoracic fractures predicts subsequent fractures of the hip. In contrast, subsequent fractures of the spine are less likely.

[Minimally invasive stabilization of thoracolumbar osteoporotic fractures]

BACKGROUND

Minimally invasive stabilization of thoracolumbar osteoporotic fractures (OF) in neurologically intact patients is well established. Various posterior and anterior surgical techniques are available. The OF classification and OF score are helpful for defining the indications and choice of operative technique.

OBJECTIVE

This article gives an overview of the minimally invasive stabilization techniques, typical complications and outcome.

MATERIAL AND METHODS

Selective literature search and description of surgical techniques and outcome.

RESULTS

Vertebral body augmentation alone can be indicated in painful but stable fractures of types OF 1 and OF 2 and to some extent for type OF 3. Kyphoplasty has proven to be an effective and safe procedure with a favorable clinical outcome. Unstable fractures and kyphotic deformities (types OF 3-5) should be percutaneously stabilized from posterior. The length of the pedicle screw construct depends on the extent of instability and deformity. Bone cement augmentation of the pedicle screws is indicated in severe osteoporosis but increases the complication rate. Restoration of stability of the anterior column can be achieved through additional vertebral body augmentation or rarely by anterior stabilization. Clinical and radiological short and mid-term results of the stabilization techniques are promising; however, the more invasive the surgery, the more complications occur.

CONCLUSION

Minimally invasive stabilization techniques are safe and effective. The specific indications for the individual procedures are guided by the OF classification and the individual clinical situation of the patient.

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.

Is proximal femoral nailing a good procedure for teaching in orthogeriatrics?

BACKGROUND

Proximal femoral nailing is a common operation in orthogeriatrics and a highly standardized procedure. For teaching purposes, this operation is often performed by residents and supervised by attending physicians. The objective of this study is to investigate if teaching this operation influences the surgical in-house complication rate.

PATIENTS AND METHODS

All patients who received a proximal femoral Targon PF nail (Aesculap AG, Tuttlingen, Germany) for trochanteric fractures were included in a cohort at our urban academic teaching hospital between 1998 and 2010. To evaluate potential effects of patient age, we separately analyzed several age groups. Complications including wound infection, hematoma, intraoperative malreduction or implant malpositioning causing revision, pain, cut-out and readmission due to nonunion were recorded.

RESULTS

Our collective consists of 1,516 patients (m/f: 410/1,106). The mean age was 78.7 years (range: 19-103 years). The overall complication rate was 7.9 %. In 857 cases operated by attending physicians, the complication rate was 6.9 %. However in the 659 operations performed by residents, we found a higher complication rate of 9.3 %. Further investigating this difference by χ(2) test, we found no significance (p = 0.09). Whilst analyzing the complication rates for the different age groups, we did not find a statistically significant difference except in the age group between 71 and 80 years, for which the odds ratio indicated a 2.6-fold increased complication risk for operations performed by residents (p = 0.01). Further analysis revealed that this increased complication rate was mainly due to increased numbers of cut-out.

CONCLUSION

We conclude that proximal femoral nailing is an operation suitable for teaching purposes. However, patients between 71 and 80 years of age seem to be at an increased risk for cut-out if operated by a resident.

Properties of the human long and short isoforms of the uncoupling protein-3 expressed in yeast cells

Two splice variants of the human uncoupling protein-3 (UCP3L and UCP3S) are highly expressed in skeletal muscle. The properties of UCP3L and S have been compared to those of UCP1 in a heterologous yeast expression system under the control of the galactose promoter. Both UCP3 isoforms were found to strongly impair the coupling efficiency of respiring cells thus resulting in increased thermogenesis. The uncoupling properties of both UCP3L and S could be clearly demonstrated also in isolated yeast mitochondria both in terms of coupled respiration and in the capacity to polarize the inner membrane in conditions of limited substrate availability. Contrary to what was observed with mitochondria containing UCP1, millimolar GDP and ATP had little if any effect on the uncoupling activity of UCP3. A very marked uncoupling of whole cells and isolated mitochondria was observed at very low expression levels of UCP3S indicating that the short isoform is more active than the long one.

Recombinant human uncoupling protein-3 increases thermogenesis in yeast cells

The long form of human uncoupling protein-3 (hUCP3L) is highly homologous to thermogenin (UCPI), the uncoupling protein of brown fat mitochondria, but is expressed predominantly in skeletal muscle. Its putative role is to regulate the coupling efficiency of oxidative phosphorylation and thus thermogenesis in skeletal muscle, a major thermogenic tissue in higher mammals. To study the functional relevance of hUCP3L, the protein was expressed in yeast cells under the control of the galactose promoter. Expression of hUCP3L induced a series of phenotype changes in the yeast cells. The cellular growth and the mitochondrial membrane potential were both diminished. The portion of cellular respiration coupled to oxidative phosphorylation decreased from 57% to 11% (P<0.001) and the cellular heat production, as measured by direct microcalorimetry, was increased by 33.3 +/- 3.2% (P<0.001) after induction of UCP3L. These observations demonstrate for the first time the intrinsic thermogenic properties of hUCP3L in intact cells.

Detection and quantification of the leptin receptor splice variants Ob-Ra, b, and, e in different mouse tissues

Ob-Ra, b, and e are the major splice forms of the leptin receptor. This study was performed to map the tissue distribution and to quantify the 3 receptor isoforms by heterologous competitive Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) and RNase Protection Assay (RNase PA). The mRNA of the truncated, membrane bound isoform Ob-Ra was found to be represented ubiquitously. Messenger RNA for the putative functional isoform Ob-Rb could be detected in brain, hypothalamus and in some peripheral tissues (e.g. heart, lung, lymph nodes). The highest ratio between Ob-Rb and Ob-Ra mRNA was found in the hypothalamus, where leptin probably exerts its satiety action. The fact that Ob-Rb mRNA was found in peripheral tissues could indicate possible additional functions of leptin. Transcripts for the shortest splice variant, Ob-Re, which is expected to encode a soluble form of the receptor, were detected in relatively high amounts in many tissues. The levels were comparable to those of leptin mRNA in fat tissue. It is conceivable, therefore, that Ob-Re might be secreted in sufficient amounts to act as a buffering system for freely circulating leptin.

Ca2+ sensitization in idiopathic dilated human myocardium. Differential in vitro effects of (+)-(5-methyl-6-phenyl)-1,3,5,6-tetrahydro-3,6-methano-1,5-benzodiazoci ne-2,4-dione, a novel purely Ca2+sensitizing agent, and (+)-5-(1-(3,4-dimethoxybenzoyl)-1,2,3,4-tetrahydroquinolin-6-yl)-6-meth yl-3, 6-dihydro-2H-1,3,4-thiadiazin-2-one on skinned fibres and isolated ventricular strips

(+)-(5-Methyl-6-phenyl)-1,3,5,6-tetrahydro-3,6-methano-1, 5-benzodiazocine-2,4-dione (CAS 165755-40-8, CGP 48506) is a novel Ca2+ sensitizing agent devoid of any other positive inotropic mechanism, particularly phosphodiesterase (PDE) III inhibition. 5-(1-(3,4-Dimethoxybenzoyl)-1,2,3,4-tetrahydroquinolin-6-yl)-6-met hyl-3, 6-dihydro-2H-1,3,4-thiadiazin-2-one (CAS 120223-04-3, EMD 53998) is a PDE III inhibitor with a Ca2+ sensitizing activity residing in its (+)-enantiomer, EMD 57033 (CAS 147527-31-9). In skinned fibres and electrically stimulated left ventricular strips from idiopathic dilated human hearts, New York Heart Association (NYHA) class IV, the Ca2+ sensitizing and inotropic effects of the benzodiazocine CGP 48506 and the thiadiazinones EMD 53998 or EMD 57033 were compared. Both CGP 48506 and EMD 53998 induce a left shift of the Ca2+ activation curve of force towards lower Ca2+ concentrations in skinned fibres, which indicates Ca2+ sensitization. Only EMD 53998, but not CGP 48506, increases skinned fibre force at both minimum (resting) and maximally activating Ca2+ concentrations. This is taken as an argument for a principal difference in the mechanisms of the Ca2+ sensitizing actions of the two compounds. CGP 48506 is shown not to influence the amplitude of the Ca2+ transient in rat cardiomyocytes. On the other hand, both CGP 48506 and EMD 57033 show comparable, though quantitatively different, positive inotropic effects in electrically stimulated left ventricular strip preparations. It is unclear whether the PDE III inhibitory component of the profile of actions of EMD 57033 may play a role in preventing the increase in diastolic tension as expected from the skinned fibre experiments. It is noteworthy that both Ca2+ sensitizing agents act as positive inotropic compounds in the end-stage failing human heart where other inotropic agents like beta 1-adrenergic agonists or PDE inhibitors have been described to fail.

[5-year experience with De Bastiani's method of extremity lengthening]

From 1987-1991 19 patients had 20 lengthenings in 23 bones. The average hospitalisation time was 54 days. The time to lengthen one limb was 30 weeks on an average. In a retrospective study the cases were analysed according to Paley's criteria. Our complication rate is compared to that of other authors. We have to cope with a rather high rate of complications. 17 out of 19 patients showed good or very good final results.