Julia F. Funk

The surgical treatment of the lumbar disc prolapse: nucleotomy with additional transpedicular dynamic stabilization versus nucleotomy alone.

Study Design. Clinical and radiologic study evaluating the outcome after nucleotomy with dynamic stabilization compared with nucleotomy alone. Objectives. To investigate the effect of dynamic stabilization on the progression of segmental degeneration after nucleotomy. Summary of Background Data. Nucleotomy as treatment for lumbar disc prolapse in combination with initial segment degeneration may lead to segmental instability. Dynamic stabilization systems restrict segmental motion and thus prevent further degeneration of the lumbar spine. They are designed to avoid the disadvantages of rigid fixation, such as pseudarthrosis and adjacent segment degeneration. Methods. Eighty-four patients underwent nucleotomy of the lumbar spine for the treatment of symptomatic disc prolapse. Additional dynamic stabilization (DYNESYS) was performed in 35 of those cases. All patients showed signs of initial disc degeneration (MODIC I). They underwent evaluation before surgery, 3 months after surgery, and at follow-up. The mean duration of follow-up was 34 months. Examinations included radiographs, magnetic resonance imaging (MRI), physical examination, and subjective patient evaluation using Oswestry score and visual analog scale (VAS). Results. Clinical symptoms, Oswestry score, and VAS improved significantly in both groups after 3 months. At follow-up, a significant increase in the Oswestry score and in the VAS was seen only in the nonstabilized group. In the dynamically stabilized group, no progression of disc degeneration was noted at follow-up, whereas radiologic signs of accelerated segmental degeneration existed in the solely nucleotomized group. There were no implant-associated complications. Conclusions. The applied dynamic stabilization system is useful to prevent progression of initial degenerative disc disease of lumbar spinal segments after nucleotomy.

Is botulinum toxin A effective for the treatment of plantar fasciitis

Objectives:Botulinum toxin A (BoNT-A) is used as an alternative treatment for chronic orthopedic conditions. This study was conducted to investigate the efficacy and safety of BoNT-A on pain and functional outcome in patients with chronic plantar fasciitis. Methods:In this short-term, randomized, multicenter, double-blind, placebo-controlled study, patients (N=40) were randomized to receive 200 units of BoNT-A (Dysport) or saline placebo. The injection was administered in a fan-shaped manner directly at the calcaneal origin of the plantar fascia. The primary outcome measure was the proportion of responders at week 6 [≥50% decrease from baseline in pain score (visual analog scale) while moving during the previous 48 h). Global assessments were performed by the patient and physician at each visit up to week 18. Results:More patients in the BoNT-A group achieved a response at week 6 (25% vs. 5% for placebo; P=0.18). Differences between treatments were in favor of BoNT-A on secondary measures of pain, but did not reach statistical significance. In the BoNT-A group, 52.7% (vs. 40% for placebo) assessed their condition as slightly/significantly improved at week 6. At study endpoint (week 18), 63.1% of the BoNT-A group perceived an improvement versus 55% of the placebo group. There was no difference in global assessment between physician and patient. No adverse events related to treatment were noted. Discussion:There is a need for larger, prospective, long-term, placebo-controlled studies to fully establish the role of BoNT-A for the treatment of plantar fasciitis.

Off Label Use of Botulinum Toxin in Children under Two Years of Age: A Systematic Review

The treatment of children with cerebral palsy with Botulinum Toxin is considered safe and effective, but is only approved for children older than two years of age. The effect of BoNT-A injection on juvenile skeletal muscle especially on neuromuscular junction density, distribution and morphology is poorly delineated and concerns of irreversible damage to the motor endplates especially in young children exist. In contrast, earlier treatment could be appropriate to improve the attainment of motor milestones and general motor development. This review systematically analyzes the evidence regarding this hypothesis. A database search, including PubMed and Medline databases, was performed and all randomized controlled trials (RCTs) comparing the efficacy of Botulinum Toxin in children younger than two years were identified. Two authors independently extracted the data and the methods of all identified trials were assessed. Three RCTs met the inclusion criteria. The results of the analysis revealed an improvement in spasticity of the upper and lower extremities as well as in the range of motion in the joints of the lower limbs. However, evidence of an improvement of general motor development could not be found, as the assessment of this area was not completely specified for this patient group. Based on available evidence it can not be concluded that Botulinum Toxin treatment in children younger than two years improves the achievement of motor milestones. However, there is evidence for the reduction of spasticity, avoiding contractures and delaying surgery. Due to some limitations, the results of this review should be cautiously interpreted. More studies, long-term follow up independent high-quality RCTs with effectiveness analyses are needed.

Periosteal cells compared with autologous cancellous bone in lumbar segmental fusion.

OBJECT Despite modern stabilization techniques and the use of autologous cancellous bone, bone consolidation does not occur in 10-15% of spinal fusion operations. There is also considerable donor site morbidity. Therefore, there is a definite need for material that has a larger measure of osteoinductivity, osteoconductivity, and osteogenic potential. METHODS In this study, 24 patients with degenerative spinal disease underwent single-level circumferential lumbar fusion. The patients were randomly placed in 2 groups, each with different cage filling (Group 1, autologous iliac crest cancellous bone; Group 2, autologous periosteal cells in a fibrin/polyglactin-poly-p-dioxanone fleece). After 3, 6, 9, and 12 months, the patients underwent clinical (Oswestry Disability Index, patient satisfaction, willingness to undergo the operation again, visual analog scale for pain) and radiological (plain and flexion/extension radiographic and thin-layer computed tomography [CT]) examinations. RESULTS The 6-month CT scans and 9-month radiographs obtained in Group 2 patients showed a significantly higher rate of fusion than those in Group 1 patients. Aside from this, there were no further significant differences. After 12 months, radiographic results showed a fusion rate of 80% in Group 1 and 90% in Group 2. No implant- or transplant-related complications were observed. CONCLUSIONS The use of autologous periosteal cells on carrier material with osteoinductive and osteoconductive properties showed comparable results with autologous cancellous bone and better results with regard to consolidation at 6-9 months postoperatively. The shorter consolidation time, as well as lower donor site morbidity, justifies the clinical use and further development of this tissue-engineering strategy.

Effects of tacrolimus, cyclosporin A and sirolimus on MG63 cells

The reduction in bone mineral density after organ transplantation results in increased morbidity (post‐transplantation bone disease) and remains an unsolved problem. A connection with the long‐term application of nonglucocorticoidal immunosuppressants is the subject of controversial discussion. We hypothesized that such substances have an influence on the skeletal system on the cellular level by modulating osteoblast differentiation. Therefore, we investigated the effects of tacrolimus, cyclosporin A and sirolimus as representative substances of nonglucocorticoidal immunosuppressants on cell proliferation and expression of bone tissue‐specific genes of human osteoblasts (MG63). None of the examined substances affected cell proliferation, but all influenced the gene expression pattern towards change in cell differentiation. In detail, collagen III and XII, matrix metalloproteinase 2, SMAD2, epithelial growth factor receptor, annexin V and osteonectin expression were increased by all of the examined substances. Tacrolimus, cyclosporin A and sirolimus influence intracellular signalling pathways, transmembranous receptors and bone‐specific matrix synthesis. They do not have antiproliferative or toxic effects. We postulate that the shown changes of osteoblast differentiation cause post‐transplantation disease.

Development of Treatment Concepts for the Use of Botulinum Toxin A in Children with Cerebral Palsy

The treatment of children with cerebral palsy with Botulinum toxin A injections is well established, safe and effective. However, a standardized injection strategy is still missing and the used dosage has escalated over the years. In the recent past, the recommended dosages in Europe were, however, reduced due to a better understanding of the relationship between dosage, severe side effects and the kind of anesthesia used. To combine safety and efficacy, the trend tends to a lower dosage, but combined with a more specific selection of injected muscles. The treatment of these key-muscles takes into account the best support for motor development to attain each individual motor milestone.

Predictors for the benefit of selective dorsal rhizotomy

Selective dorsal rhizotomy (SDR) is a spasticity reducing treatment option for children with spastic cerebral palsy. Selection criteria for this procedure are inconclusive to date. Clinical relevance of the achieved functional improvements and side effects like the negative impact on muscle strength are discussed controversially. In this prospective cohort study one and two year results of 54 children with a mean age of 6.9 (±2.9) years at the time of SDR are analyzed with regard to gross motor function and factors affecting the functional benefit. Only ambulatory children who were able to perform a gross motor function measure test (GMFM-88) were included in this study. Additionally, the modified Ashworth scale (MAS), a manual muscle strength test (MFT), and the body mass index (BMI) were evaluated as possible outcome predictors. MAS of hip adductors and hamstrings decreased significantly (p<0.001) and stayed reduced after two years, while GMFM improved significantly from 79% to 84% 12 months after SDR (p<0.001) and another 2% between 12 and 24 months (p=0.002). Muscle strength did improve significantly concerning knee extension (p=0.008) and ankle dorsiflexion (p=0.006). The improvement of function correlated moderately with age at surgery and preoperative GMFM and weakly with the standard deviation score of the BMI, the dorsiflexor and plantarflexor strength preoperatively as well as with the reduction of spasticity of the hamstrings and the preoperative spasticity of the adductors and hamstrings. Correctly indicated SDR reduces spasticity and increases motor skills sustainably in children with spastic cerebral palsy corresponding to clinically relevant changes of GMFM without compromising muscular strength. Outcome correlates to GMFM and age rather than to MAS and maximal strength testing. The data of this evaluation suggest that children who benefit the most from SDR are between 4 and 7 years old and have a preoperative GMFM between 65% and 85%.

Development of rice bodies in 2 children younger than 3 years.

Rice bodies are synovial fluid nodules macroscopically resembling shiny white rice beans. They have been seen in synovial fluid from several types of inflammatory arthritis including tuberculosis, pyogenic arthritis, and juvenile idiopathic arthritis and adult rheumatoid arthritis. Microscopically, they consist of amorphous material, fibrin, and collagen. We report the rare cases of 2 children younger than 3 years with multiple rice body formations in the knee joints.

Die Tübinger Hüftbeugeschiene als Repositionsorthese

BACKGROUND The indication for the use of the Tübingen hip flexion splint is a dysplastic hip without instability. According to current knowledge dysplastic unstable or dislocated hips should be treated with a stable retention device such as a modified Fettweis cast. The aim of this study was to evaluate the treatment effect of the Tübingen hip flexion splint when applied to dysplastic unstable hips (type IIc unstable according to the classification of Graf) and dislocated hips (types D, III and IV according to the classification of Graf) within the first week of life. PATIENTS AND METHODS All newborns with an unstable hip type IIc or worse detected by ultrasound in the first week of life were treated with a Tübingen hip flexion splint. A prospective cohort trial was performed between November 2007 and December 2010. The initial hip type according to the ultrasound classification of Graf, the start and the duration of treatment with the Tübingen hip flexion splint as well as the rate of success were evaluated. Due to the small number of patients non-parametric tests were used for statistical analysis. RESULTS A total of 50 dysplastic unstable or dislocated hips in 42 newborns were treated with the Tübingen hip flexion splint. The distribution of pathological hip types was 6 type IIc unstable, 33 type D, 10 type III and 1 type IV. Therapy was started on average on day 3.5 (range 1-8 days) of life and 49 out of 50 hips were successfully treated with the Tübingen hip flexion splint. Solely the type IV hip could not be reduced in the Tübingen hip flexion splint. Thus 98% of the dysplastic unstable or dislocated hips were successfully converted into type I hips with an α-angle of more than 64° in the splint. The mean time for achieving an α-angle ≥ 64° was 51.6 ± 18.9 days (range 21-87 days). No statistically significant relationship was found between the duration of therapy and the time when treatment was started, early or late within the first week of life (p = 0.152). Furthermore, no correlation was detected between the duration of therapy and the initial hip type determined by ultrasound (p = 0.886). In all successfully treated cases therapy could be discontinued during the exponential part of Tschauners maturation curve of hip development. CONCLUSION When recognized within the first week of life dysplastic unstable hips (type IIc unstable according to the classification of Graf) and dislocated hips with a cranially dislocated cartilage roof (types D and III according to the classification of Graf) can be successfully treated with the Tübingen hip flexion splint provided that the parents show good compliance concerning the treatment regimen.

Biomechanical analysis of screw fixation vs. K-wire fixation of a slipped capital femoral epiphysis model

Abstract Introduction: Previous data have shown that due to the technical ease, low-morbidity, and lower complication rates, the in situsingle-implant fixation is the current standard for stabilization of slipped capital femoral epiphysis (SCFE) fixation. Multiple-implant fixation is thought to be combined with a higher incidence of serious complications. The purpose of the current study was to evaluate single- vs. multiple-implant fixation regarding strength and stiffness. Furthermore, different screw designs, including telescopic screw, were evaluated regarding the stiffness, strength, and especially fixation failure. Methods: Forty porcine proximal femurs were sectioned through the physeal line using a gigli saw and stabilized with a 7.3-mm stainless steel AO screw, a dynamic telescopic screw, three 1.6-mm Kirschner wires (K-wires), and three 2.0-mm K-wires. The femurs were biomechanically tested to determine failure load (N) and stiffness (N/mm). Results: No significant differences were found regarding failure load and stiffness between the two screw groups. The 2.0-mm K-wire construct was significantly the strongest and stiffest fixation. The 1.6-mm K-wire fixation had the lowest values, but not statistically significant. Regarding the fixation failure, no femoral shaft fracture occurred. Conclusion: SCFE stabilization with three 2.0-mm K-wires leads to increased stability over single-screw fixation and 1.6-mm K-wire fixation. However, none of the two screws seemed to be superior in fixation stability and fixation failure.