Johannes Struewer

Early or delayed stabilization in severely injured patients with spinal fractures? Current surgical objectivity according to the Trauma Registry of DGU: treatment of spine injuries in polytrauma patients.

BACKGROUND Because of a lack of evidence, the appropriate timing of surgical stabilization of thoracic and lumbar spine injuries in severely injured patients is still controversial. Data of a large international trauma register were analyzed to investigate the medical care situation of unstable spinal column fractures in patients with multiple injuries, so as to examine the outcome related to timing of surgical stabilization. METHODS Data sets of the Trauma Registry of German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (1993–2010) were analyzed. The Trauma Registry of DGU is a prospective, multicenter register that provides information on severely injured patients. All patients with an Injury Severity Score (ISS) of 16 or greater caused by blunt trauma, subsequent treatment of 7 days or more, 16 years or older, and thoracic or lumbar spine injuries (spine Abbreviated Injury Scale [AIS] score ≥ 2) were included in our analysis. Patients with relevant spine injuries classified as having a spine AIS score of 3 or greater were further analyzed in terms of whether they got early (<72 hours) or late (>72 hours) surgical treatment due to unstable spinal column fractures. RESULTS Of 24,974 patients, 8,994 (36.0%) had documented spinal injuries (spine AIS score ≥ 2). A total of 1,309 patients who sustained relevant thoracic spine injuries (spine AIS score ≥ 3) and 994 patients who experienced lumbar spine trauma and classified as having spine AIS score of 3 or greater were more precisely analyzed. Of these, 68.2% and 71.0%, respectively, received an early thoracic or lumbar spine fixation. With an increase in spinal injury severity, an increase in early stabilization in the thoracic and lumbar spine was seen. In the group of patients with early surgical stabilization, significantly shorter hospital stays, shorter intensive care unit stays, fewer days on mechanical ventilation, and lower rates of sepsis were seen. In the case that additional body regions were affected, for example, when patients were critically ill, a delayed spinal stabilization was more often performed. CONCLUSION A spinal stabilization at an early stage (<72 hours) is presumed to be beneficial. Although some patients may require delay due to necessary medical improvement, every reasonable effort should be made to treat patients with instable spinal column fractures as soon as possible. If an early surgical treatment is feasible, severely injured patients may benefit from a shorter period of hospital treatment and a lower rate of complications. LEVEL OF EVIDENCE Therapeutic study, level III.

Use of the gamma3™ nail in a teaching hospital for trochanteric fractures: mechanical complications, functional outcomes, and quality of life

BackgroundTrochanteric fractures are common fractures in the elderly. Due to characteristic demographic changes, the incidence of these injuries is rapidly increasing. Treatment of these fractures is associated with high rates of complications. In addition, the long-term results remain poor, with high morbidity, declines in function, and high mortality. Therefore, in this study, complication rates and patients’ outcomes were evaluated after fixation of geriatric trochanteric fractures using the Gamma3™ nail.MethodsPatients aged 60 years old or older, with pertrochanteric and subtrochanteric femoral fractures, were included. Patients with polytrauma or pathological fractures were excluded. Age, sex, and fracture type were collected on admission. In addition, data were recorded concerning the surgeon (resident vs. consultant), time of operation, and local or systemic perioperative complications. Complications were also collected at the 6- and 12-month follow-ups after trauma. Barthel Index, IADL, and EQ-5D measurements were evaluated retrospectively on admission, as well as at discharge and during the follow-up.ResultsNinety patients were prospectively included between April 2009 and September 2010. The patients’ average age was 81 years old, and their average ASA score was 3. The incision/suture time was 53 min (95% CI 46–60 min). Hospital mortality was 4%, and overall mortality was 22% at the 12-month follow-up. Eight local complications occurred (4 haematomas, 1 deep infection, 1 cutting out, 1 irritation of the iliotibial tract, 1 periosteosynthetic fracture). The incidence of relevant systemic complications was 6%. Forty-two percent of the patients were operated on by residents in training, without significant differences in duration of surgery, complication rate, or mortality rate. The Barthel Index (82 to 71, p < .001), IADL (4.5 to 4.3, p = .0195) and EQ-5-D (0.75 to 0.66, p = .068) values did not reach pre-fracture levels during the follow-up period of 12 months.ConclusionThe results showed a relatively low complication rate using the Gamma3™ nail, even if the nailing was performed by residents in training. The high mortality, declines in function, and low quality of life could probably be attributed to pre-existing conditions, such as physical status.In summary, the Gamma3™ nail seems to be a useful implant for the nailing of trochanteric fractures, although further studies are necessary comparing different currently available devices.

Dislocation of the mandibular condyle into the middle cranial fossa causing an epidural haematoma

Dislocation of the mandibular condyle into the middle cranial fossa is a rare complication of mandibular trauma due to anatomical and biomechanical factors. Owing to the proximity of the temporal glenoid fossa to the middle meningeal artery, there is the risk of serious sequelae in case of trauma. The authors report the case of a 36-year-old male patient, who was beaten up in a family dispute and presented with complex mandibular and maxillofacial fractures, including mandibular condyle intrusion into the middle cranial fossa causing extensive meningeal bleeding. The patient underwent immediate surgery, with evacuation of the epidural haematoma via a temporal approach. In addition open reduction and reconstruction of the temporal glenoid fossa via anatomic reduction of the fragments was performed. A functional occlusion was re-established via miniplate reconstruction of the complex mandibular body and ramus fractures. Prompt diagnosis and a multidisciplinary approach are essential to minimize the complications. Advanced imaging modalities of computed tomography are indicated. Treatment options should be individualized in particular in case of suspected neurological injury.

Repair of a chondral defect using a cell free scaffold in a young patient - a case report of successful scaffold transformation and colonisation

BackgroundChondral defects of the articular surface are a common condition that can lead to osteoarthritis if not treated. Therapy of this condition is a topic of constant debate and a variety of chondral repair strategies are currently used. One strategy involves implantation of a cell-free matrix of type I collagen (COL1), to provide a scaffold for chondrocyte migration and proliferation and extracellular matrix production. Although several studies have suggested that chondrocytes can move, to the best of our knowledge there is still no proof of chondrocyte occurrence in a former cell-free scaffold for articular cartilage repair in humans.Case presentationAn 18-year-old male patient underwent arthroscopic surgery of the knee for patellar instability and a chondral defect of the femoral condyle. Clinical outcome scores were recorded pre-operatively, after 6 weeks and after 6, 12, 24 and 36 months. MRI was recorded after 6 weeks and after 6, 12, 24 and 36 months postoperatively. At 42 months after implantation of a cell-free type I collagen matrix and reconstruction of the medial patellofemoral ligament, the patient was again treated arthroscopically for a tear of the medial meniscus of the same knee. A biopsy of the previous chondral defect was taken during arthroscopy for histological examination.ConclusionIn addition to good clinical and radiological results reported for cell-free scaffolds for cartilage repair in several other studies, transformation of the scaffold could be observed during re-arthroscopy for the meniscal tear. Histological examination of the specimen revealed articular cartilage with vital chondrocytes and a strong staining reaction for type II collagen (COL II), but no reaction for type I collagen staining. This might indicate a complete transformation of the scaffold and supports the theory that cell free scaffolds could support cell migration. Although the cell source remains unclear, migrating chondrocytes from the periphery remain a possibility.

Bone Morphogenetic Protein 7 (BMP-7) Influences Tendon-Bone Integration In Vitro

Introduction Successful graft ingrowth following reconstruction of the anterior cruciate ligament is governed by complex biological processes at the tendon-bone interface. The aim of this study was to investigate in an in vitro study the effects of bone morphogenetic protein 7 (BMP-7) on tendon-bone integration. Materials and Methods To study the biological effects of BMP-7 on the process of tendon-bone-integration, two independent in vitro models were used. The first model involved the mono- and coculture of bovine tendon specimens and primary bovine osteoblasts with and without BMP-7 exposure. The second model comprised the mono- and coculture of primary bovine osteoblasts and fibroblasts. Alkaline phosphatase (ALP), lactate dehydrogenase (LDH), lactate and osteocalcin (OCN) were analyzed by ELISA. Histological analysis and electron microscopy of the tendon specimens were performed. Results In both models, positive effects of BMP-7 on ALP enzyme activity were observed (p<0.001). Additionally, similar results were noted for LDH activity and lactate concentration. BMP-7 stimulation led to a significant increase in OCN expression. Whereas the effects of BMP-7 on tendon monoculture peaked during an early phase of the experiment (p<0.001), the cocultures showed a maximal increase during the later stages (p<0.001). The histological analysis showed a stimulating effect of BMP-7 on extracellular matrix formation. Organized ossification zones and calcium carbonate-like structures were only observed in the BMP-stimulated cell cultures. Discussion This study showed the positive effects of BMP-7 on the biological process of tendon-bone integration in vitro. Histological signs of improved mineralization were paralleled by increased rates of osteoblast-specific protein levels in primary bovine osteoblasts and fibroblasts. Conclusion Our findings indicated a role for BMP-7 as an adjuvant therapeutic agent in the treatment of ligamentous injuries, and they emphasized the importance of the transdifferentiation process of tendinous fibroblasts at the tendon-bone interface.

Massive hematothorax after thoracic spinal manipulation for acute thoracolumbar pain

Spinal manipulation usually represents a widely used and effective method for physicians in order to relieve acute patient pain and muscular dysbalance. Although life-threatening complications (e.g. pneumothorax, vertebral artery dissection, stroke) after manual treatment are reported with regard to actual medical literature millions of patients undergo manual treatment to manage thoracolumbar pain each year. The authors present the case of a 17 year old male patient with a life-threatening hematothorax after thoracic high velocity spinal manipulation for acute thoracolumbar pain. The patient required emergency chest tube thoracostomy and afterwards thoracoscopic haemostasis for an intercostal venous lesion. A massive hematothorax after spinal manipulation represents an extremely rare but life-threatening complication. Physicians are encouraged to promote the benefits of manual/chiropratic therapy on the one hand but on the other hand are obliged to educate about potential serious dangers and adverse events.

Effect of Bone Morphogenetic Protein-2 on Tendon–Bone Integration in an In Vitro Cell Culture

The goal of this study was to evaluate the influence of bone morphogenetic protein-2 (BMP-2) on tendon-bone integration in a bovine in vitro cell culture. Seventy-two bovine tendons were cultivated over 3 months. The effects of BMP-2 were evaluated by generation in 4 subgroups. The groups differed in 2 parameters: the application of BMP-2 and the application of primary bovine osteoblasts. Results were analyzed biochemically by determining alkaline phosphatase activity and histologic tendon calcification, both markers for graft incorporation. Histological analysis demonstrated a positive effect of BMP-2 on the production of extracellular matrix and therefore the induction of osteogenesis. In addition, the results showed a superior cell ingrowth on the tendon in the BMP-2-stimulated groups. Calcium carbonate-like structures and organized ossification zones could only be detected in the BMP-2-stimulated tendons. The histological results matched those of the biochemical alkaline phosphatase analysis. The highest alkaline phosphatase activity was detected using BMP-2 stimulation in the first month (P<.001). High alkaline phosphatase values suggest high osteoblast activity and a high potential for mineralization. Furthermore, a positive effect of BMP-2 on fibroblasts existed with regard to the overall integration process. These results confirm the positive influence and triggering effect of BMP-2 on the mineralization process. Bone morphogenetic protein-2 seems to accelerate and optimize tendon-bone integration in the early process of graft incorporation. Besides the influence of BMP-2 on bovine osteoblasts, an additional positive effect of BMP-2 on bovine fibroblasts was detected; therefore, graft incorporation may be carried out by osteoblasts and fibroblasts.

Height restoration and preservation in osteoporotic vertebral compression fractures: a biomechanical analysis of standard balloon kyphoplasty versus radiofrequency kyphoplasty in a cadaveric model.

Study Design: Biomechanical cadaver study. Objective: The aim of the present study was to evaluate 2 different methods with respect to height restoration and preservation in a cadaver model under cyclic loading. Summary of Background Data: Standard balloon kyphoplasty (BKP) represents a well-established treatment opportunity for osteoporotic vertebral compression fractures. BKP was developed to restore vertebral height and improve sagittal alignment. Its use has grown significantly over the last 2 decades. In contrast, distinct biomechanical data are missing. Within the last few years, several alternative techniques with regard to height restoration have emerged, such as radiofrequency kyphoplasty (RFK). Methods: Twenty-five vertebral bodies of 2 female cadavers with secured osteoporosis were examined. Standardized vertebral wedge compression fractures were created. Afterward, 2 groups were randomly assigned: 12 vertebral bodies were treated with BKP and 13 vertebral bodies by RFK under a preload of 100 N. Then the vertebral bodies underwent cyclic loading (100,000 cycles, 100 to 600 N, 5 Hz). Anterior, central, and posterior vertebral body heights were evaluated by CT scans. Results: Anterior height was reduced after fracture 6.3 mm (SD 3) for the BKP group and 7.2 mm (SD 3) in the RFK group (P>0.1). After treatment, the difference in the initial anterior height was 4.5 mm (SD 2) for the BKP group and 4.7 mm (SD 3) for the RFK group (P>0.1). After cyclic loading, the difference was 5.3 mm (SD 3) for the BKP group and 5.2 mm (SD 3) for the RFK group (P>0.1). The average cement volume used was 8.7 mL (SD 1) for the BKP group and 4.8 mL (SD 2) for the RFK group (P<0.0001). Conclusions: On the basis of our results, the unipedicular RFK in osteoporotic compression fractures might represent a promising alternative for the clinical setting.

Biomechanical evaluation of the impact of various facet joint lesions on the primary stability of anterior plate fixation in cervical dislocation injuries: a cadaver study

OBJECT Injuries of the subaxial cervical spine including facet joints and posterior ligaments are common. Potential surgical treatments consist of anterior, posterior, or anterior-posterior fixation. Because each approach has its advantages and disadvantages, the best treatment is debated. This biomechanical cadaver study compared the effect of different facet joint injuries on primary stability following anterior plate fixation. METHODS Fractures and plate fixation were performed on 15 fresh-frozen intact cervical spines (C3-T1). To simulate a translation-rotation injury in all groups, complete ligament rupture and facet dislocation were simulated by dissecting the entire posterior and anterior ligament complex between C-4 and C-5. In the first group, the facet joints were left intact. In the second group, one facet joint between C-4 and C-5 was removed and the other side was left intact. In the third group, both facet joints between C-4 and C-5 were removed. The authors next performed single-level anterior discectomy and interbody grafting using bone material from the respective thoracic vertebral bodies. An anterior cervical locking plate was used for fixation. Continuous loading was performed using a servohydraulic test bench at 2 N/sec. The mean load failure was measured when the implant failed. RESULTS In the group in which both facet joints were intact, the mean load failure was 174.6 ± 46.93 N. The mean load failure in the second group where only one facet joint was removed was 127.8 ± 22.83 N. In the group in which both facet joints were removed, the mean load failure was 73.42 ± 32.51 N. There was a significant difference between the first group (both facet joints intact) and the third group (both facet joints removed) (p < 0.05, Kruskal-Wallis test). CONCLUSIONS In this cadaver study, primary stability of anterior plate fixation for dislocation injuries of the subaxial cervical spine was dependent on the presence of the facet joints. If the bone in one or both facet joints is damaged in the clinical setting, anterior plate fixation in combination with bone grafting might not provide sufficient stabilization; additional posterior stabilization may be needed.

Response letter concerning: correctly identify practitioners and put adverse events of spinal manipulation into perspective.

Dear Editor Thanks for your interest concerning our case report: Massive hematothorax after thoracic spinal manipulation for acute thoracolumbar pain, published in Orthopedic Reviews.1 Firstly we agree that chiropractics represent in general a very safe procedure. With regard to the comment of Cramer and Smith,2 we agree that the use of the correct terminology for the description of chiropractic/osteopathic procedures is problematic. In our opinion this is based on different and often synonymous use of the termini in different countries. In our case report we tried to accommodate this major concern by detailed description (please refer to lines 5 to 15 within the Case Report section: The osteopathic physician used the so called Bauerngriffmaneuver which consists of a high velocity thrust to the middle portion of the thoracic spine and the adjacent costo-vertebral joints….). As we stated in our manuscript the procedure was performed by a medical physician with additional chiropractic and osteopathic education (osteopathic physician). The spinal manipulation leading to the hematothorax was not performed by another healthcare practitioner. We are sorry that the terminus osteopathic physicain lead to your misunderstanding. Furthermore chiropractics including manipulative care is not an unlicensed profession. It represents an additional education for approbated medical doctors. Concerning the second issue of Cramer and Smith with regard to the reported frequency of adverse events we definitely agree that the majority of adverse events reported are benign and transitory. But the occurrence of serious or even life-threatening events cannot be excluded. As we stated within the discussion section the risk of adverse reactions has been reported 1 in 40,000 manipulations for mild complications and 1 in 400,000 to over millions manipulations for serious complications ranging from stroke to spinal injuries. Nevertheless we believe that it is our duty to report even of very rare side events also with emphasis on medical jurisprudence to provide quality control for future patient treatment and to minimize even these very rare risks. We still believe that chiropractics represent a safe procedure in professionalized well educated hands.