K.-S. Delank

Effectiveness, security and height restoration on fresh compression fractures--a comparative prospective study of vertebroplasty and kyphoplasty.

INTRODUCTION Painful fractures of the spine pose a serious clinical problem which gains in importance with the increasing ageing of our population. When conservative treatment of these fractures fails, with vertebroplasty and kyphoplasty we have two percutaneous minimally invasive stabilising procedures at our disposal. PATIENTS AND METHODS We performed a prospective study of 90 patients with fresh osteoporotic vertebral fractures who had been treated with vertebroplasty or kyphoplasty in our clinic between January 1, 2005, and December 31, 2007. Clinical analysis included Oswestry score and VAS index; the vertebral body height restoration (mean vertebral body height, kyphosis angle, anterior/posterior edge) was evaluated radiologically; furthermore, all occurring complications were recorded. The follow-up time was 1 year, 80 patients could be examined at follow-up; 8 patients had died of a tumour disease, lost to follow-up were 2.2%. RESULTS Both procedures succeeded in significantly (p<0.001) increasing quality of life (Oswestry score) and reducing pain (VAS). Following vertebroplasty there were two cases of cement leakage into the spinal canal with consecutive paraparesis which disappeared completely after the cement had been surgically removed. Altogether, 11 adjacent level fractures were observed, 4 in the vertebroplasty and 7 in the kyphoplasty group. CONCLUSION This study compares vertebroplasty and kyphoplasty with regard to their effectiveness, safety, and restoration of vertebral body height, and complications. There were no differences between the groups with regard to quality of life and pain improvement, but the rate of serious complications was higher after vertebroplasty. Mean vertebral body height restoration at 1 year follow-up was significantly higher (p<0.05) in the kyphoplasty group. It remains to be seen in future long-term studies whether or not restoration of vertebral body height has an effect on the clinical result.

Iatrogenic paraplegia in spinal surgery

IntroductionParaplegia as a result of a surgical spinal procedure is a rare complication. The risk cannot be precisely quantified due to the lack of current data. The aim of this study was to record a sufficiently large number of major spinal operations, especially extended methods in scoliosis surgery. Hereby, a reliable statement regarding the risk of severe neurological complications with these surgical techniques should be possible. First, a retrospective analysis of patients from a German spine centre (spinal fusion) and a survey of 17 German centres of spinal surgery were conducted for the retrospective acquisition of severe iatrogenic neurological complications.Materials and methodsThe study included 1194 patients who underwent a spinal fusion during the period 1992–2002. The incidents of postoperative paraplegia are described in detail, and case studies done. Possible causes, methods of intraoperative monitoring and options of therapy are discussed according to research in relevant publications. Additionally, severe neurological complications of 3115 spinal operations were recorded in a standardised survey conducted throughout major German spinal centres.ResultsOf the 1194 patients surveyed, 7 (0.59%) experienced a postsurgical complete or incomplete paraplegia. In 3 of the recorded cases, the cause could be identified. The survey of 3115 scoliosis surgeries showed that iatrogenic paraplegia occurred with a frequency of 0.55%. The risks associated with short spinal fusions (0.14%), cervical discectomies (0.07%) and lumbar discectomies (0.03%) are considerably less.ConclusionOperative treatment of scoliosis with a high degree of correction carries a risk of neurological complications of about 0.5%. Mechanical as well as ischaemic damage to the spinal cord can be detected early by means of consistent intraoperative neuromonitoring.

Treatment delay of bone tumours, compilation of a sociodemographic risk profile: A retrospective study

BackgroundBone tumours are comparatively rare tumours and delays in diagnosis and treatment are common. The purpose of this study was to analyse sociodemographic risk factors for bone tumour patients in order to identify those at risk of prolonged patients delay (time span from first symptoms to consultation), professional delay (from consultation to treatment) or symptom interval (from first symptoms to treatment). Understanding these relationships might enable us to shorten time to diagnosis and therapy.MethodsWe carried out a retrospective analysis of 265 patients with bone tumours documenting sociodemographic factors, patient delay, professional delay and symptom interval. A multivariate explorative Cox model was performed for each delay.ResultsFemale gender was associated with a prolonged patient delay. Age under 30 years and rural living predisposes to a prolonged professional delay and symptom interval.ConclusionEarly diagnosis and prompt treatment are required for successful management of most bone tumour patients. We succeeded in identifying the histology independent risk factors of age under 30 years and rural habitation for treatment delay in bone tumour patients. Knowing about the existence of these risk groups age under 30 years and female gender could help the physician to diagnose bone tumours earlier. The causes for the treatment delays of patients living in a rural area have to be investigated further. If the delay initiates in the lower education of rural general physicians, further training about bone tumours might advance early detection. Hence the outcome of patients with bone tumours could be improved.

Pulsed lavage improves fixation strength of cemented tibial components

Pulsatile lavage is purported to improve radiographic survival in cemented total knee arthroplasty (TKA). Similarly, a potential improvement of fixation strength of the tibial tray has been assumed based on the increased cement penetration. In this study, the influence of pulsed lavage on fixation strength of the tibial component and bone cement penetration was evaluated in six pairs of cadaveric specimens. Following surgical preparation, the tibial surface was irrigated using pulsatile lavage on one side of a pair, while on the other side syringe lavage was applied. All tibial components were implanted using the same cementing technique. Cement penetration and bone mineral density was assessed based on computed tomography data. Fixation strength of the tibial trays was determined by a pull-out test with a material testing machine. Median pull-out forces and cement penetration were significantly (p = 0.031) improved in the pulsed lavage group as compared to the syringe lavage group. Enhanced fixation strength is suggested as being a key to improved survival of the implant. Consequently, pulsatile lavage should be considered as a mandatory preparation step when cementing tibial components in TKA.

Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine

In the treatment of multilevel degenerative disorders of the lumbar spine, spondylodesis plays a controversial role. Most patients can be treated conservatively with success. Multilevel lumbar fusion with instrumentation is associated with severe complications like failed back surgery syndrome, implant failure, and adjacent segment disease (ASD). This retrospective study examines the records of 70 elderly patients with degenerative changes or instability of the lumbar spine treated between 2002 and 2007 with spondylodesis of more than two segments. Sixty-four patients were included; 5 patients had died and one patient was lost to follow-up. We evaluated complications, clinical/radiological outcomes, and success of fusion. Flexion-extension and standing X-rays in two planes, MRI, and/or CT scans were obtained pre-operatively. Patients were assessed clinically using the Oswestry disability index (ODI) and a Visual Analogue Scale (VAS). Surgery performed was dorsolateral fusion (46.9%) or dorsal fusion with anterior lumbar interbody fusion (ALIF; 53.1%). Additional decompression was carried out in 37.5% of patients. Mean follow-up was 29.4±5.4 months. Average patient age was 64.7±4.3 years. Clinical outcomes were not satisfactory for all patients. VAS scores improved from 8.6±1.3 to 5.6±3.0 pre- to post-operatively, without statistical significance. ODI was also not significantly improved (56.1±22.3 pre- and 45.1±26.4 post-operatively). Successful fusion, defined as adequate bone mass with trabeculation at the facets and transverse processes or in the intervertebral segments, did not correlate with good clinical outcomes. Thirty-five of 64 patients (54%) showed signs of pedicle screw loosening, especially of the screws at S1. However, only 7 of these 35 (20%) complained of corresponding back pain. Revision surgery was required in 24 of 64 patients (38%). Of these, indications were adjacent segment disease (16 cases), pedicle screw loosening (7 cases), and infection (one case). At follow-up of 29.4 months, patients with radiographic ASD had worse ODI scores than patients without (54.7 vs. 36.6; P<0.001). Multilevel fusion for degenerative disease still has a high rate of complications, up to 50%. The problem of adjacent segment disease after fusion surgery has not yet been solved. This study underscores the need for strict indication guidelines to perform lumbar spine fusion of more than two levels.

Immediate fullweightbearing after tarsometatarsal arthrodesis for hallux valgus correction—Does it increase the complication rate?

BACKGROUND The arthrodesis of the first tarsometatarsal joint has a high correction potential in the treatment of hallux valgus deformity. Compared to distal correction procedures, a pseudarthrosis rate of 12-20% is quoted, however. In a prospective study the results of two different treatment procedures after correction arthrodesis were compared. METHODS In 17 cases the patients were mobilised with a short arthrodeses shoe with floor contact (NWB group) and in 17 cases in a short arthrodeses shoe with immediate fullweightbearing (FWB group). Clinical and radiological evaluation was done preoperatively, six weeks and one year postoperatively, including visual analogue pain scale and AOFAS score pre- and one year postoperatively. RESULTS There was no increased complication rate in the group with FWB group. The patients in the FWB group were significantly earlier fit for work. CONCLUSION Immediate fullweightbearing after TMT I arthrodesis using a plantar plate should be established as a standard posttreatment.

Degeneration und Osteoporose der Wirbelsäule

Reduced bone quality due to osteoporosis poses a fundamental problem in spine surgery instrumentation. The consequences observed most often are insufficient implant anchoring and adjacent fractures. In cases of manifest osteoporosis, several modern anchoring possibilities are at our disposal that, to differing degrees, increase the stability of the instrumentation. Cement augmentation of a fractured vertebra by means of kyphoplasty or vertebroplasty verifiably leads to significantly better pain reduction than conservative treatment does, at least in the short-term postoperative course. A difference between these two techniques has not yet been substantiated. The rate of adjacent fractures occurring after cement augmentation is not higher than in conservatively treated patients.ZusammenfassungEine reduzierte Knochenqualität infolge einer Osteoporose stellt eine wesentliche Problematik bei der instrumentierten Wirbelsäulenchirurgie dar. Die zunehmende Ausweitung der Operationsindikationen auf ältere und alte Patienten führt im klinischen Alltag zu einer großen Relevanz dieser Problematik. Eine insuffiziente Implantatverankerung sowie die Anschlussfraktur sind die häufigsten beobachteten Folgen. Bei einer manifesten Osteoporose stehen verschiedene moderne Verankerungsmöglichkeiten zur Verfügung. Zementierbare Schrauben, die Kombination von Pedikelschrauben und Hakenverankerungen (Hybridinstrumentation), ein verändertes Schraubendesign und spezielle chirurgische Techniken können die Stabilität der Instrumentation mehr oder weniger erhöhen. Ob additiv applizierte Bisphosphonate die Verankerung tatsächlich verbessern, ist bislang noch nicht bewiesen. Die Zementaugmentation eines frakturierten Wirbels mittels Kypho- oder Vertebroplastie führt gegenüber einer konservativen Behandlung nachweislich zu einer signifikant besseren Schmerzreduktion, zumindest im kurzfristigen postoperativen Verlauf. Ein Verfahrensunterschied ist diesbezüglich bislang nicht nachgewiesen. Die Rate der sog. Anschlussfrakturen ist im Vergleich zu konservativ behandelten Patienten nach erfolgter Zementaugmentation nicht erhöht.AbstractReduced bone quality due to osteoporosis poses a fundamental problem in spine surgery instrumentation. The consequences observed most often are insufficient implant anchoring and adjacent fractures. In cases of manifest osteoporosis, several modern anchoring possibilities are at our disposal that, to differing degrees, increase the stability of the instrumentation. Cement augmentation of a fractured vertebra by means of kyphoplasty or vertebroplasty verifiably leads to significantly better pain reduction than conservative treatment does, at least in the short-term postoperative course. A difference between these two techniques has not yet been substantiated. The rate of adjacent fractures occurring after cement augmentation is not higher than in conservatively treated patients.

Degeneration and osteoporosis of the spine. Is there a modified procedure

Reduced bone quality due to osteoporosis poses a fundamental problem in spine surgery instrumentation. The consequences observed most often are insufficient implant anchoring and adjacent fractures. In cases of manifest osteoporosis, several modern anchoring possibilities are at our disposal that, to differing degrees, increase the stability of the instrumentation. Cement augmentation of a fractured vertebra by means of kyphoplasty or vertebroplasty verifiably leads to significantly better pain reduction than conservative treatment does, at least in the short-term postoperative course. A difference between these two techniques has not yet been substantiated. The rate of adjacent fractures occurring after cement augmentation is not higher than in conservatively treated patients.ZusammenfassungEine reduzierte Knochenqualität infolge einer Osteoporose stellt eine wesentliche Problematik bei der instrumentierten Wirbelsäulenchirurgie dar. Die zunehmende Ausweitung der Operationsindikationen auf ältere und alte Patienten führt im klinischen Alltag zu einer großen Relevanz dieser Problematik. Eine insuffiziente Implantatverankerung sowie die Anschlussfraktur sind die häufigsten beobachteten Folgen. Bei einer manifesten Osteoporose stehen verschiedene moderne Verankerungsmöglichkeiten zur Verfügung. Zementierbare Schrauben, die Kombination von Pedikelschrauben und Hakenverankerungen (Hybridinstrumentation), ein verändertes Schraubendesign und spezielle chirurgische Techniken können die Stabilität der Instrumentation mehr oder weniger erhöhen. Ob additiv applizierte Bisphosphonate die Verankerung tatsächlich verbessern, ist bislang noch nicht bewiesen. Die Zementaugmentation eines frakturierten Wirbels mittels Kypho- oder Vertebroplastie führt gegenüber einer konservativen Behandlung nachweislich zu einer signifikant besseren Schmerzreduktion, zumindest im kurzfristigen postoperativen Verlauf. Ein Verfahrensunterschied ist diesbezüglich bislang nicht nachgewiesen. Die Rate der sog. Anschlussfrakturen ist im Vergleich zu konservativ behandelten Patienten nach erfolgter Zementaugmentation nicht erhöht.AbstractReduced bone quality due to osteoporosis poses a fundamental problem in spine surgery instrumentation. The consequences observed most often are insufficient implant anchoring and adjacent fractures. In cases of manifest osteoporosis, several modern anchoring possibilities are at our disposal that, to differing degrees, increase the stability of the instrumentation. Cement augmentation of a fractured vertebra by means of kyphoplasty or vertebroplasty verifiably leads to significantly better pain reduction than conservative treatment does, at least in the short-term postoperative course. A difference between these two techniques has not yet been substantiated. The rate of adjacent fractures occurring after cement augmentation is not higher than in conservatively treated patients.

Ergebnisse der pedobarographischen Untersuchung nach Girdlestone-Taylor-Sehnentransfer bei flexibler Kleinzehdeformität

AIM The aim of the study was to analyze the biomechanical effects of flexible claw toe correction by tendon transfer with the Girdlestone-Taylor approach using dynamic pedobarography. MATERIAL AND METHODS In the study 12 patients were examined preoperatively and 12 months postoperatively. The results obtained by pedobarography 12 months postoperatively were compared with those of a healthy control group of matched age and body mass index (BMI). For clinical evaluation the American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue pain scale (VAS) were evaluated. RESULTS The results showed a significant increase in the average AOFAS score from 72 (range 63-79) preoperatively to 92 (84-96) points 12 months postoperatively. The pedobarography revealed significantly increased values in the force-time integral and the maximum force for the second and third toes 12 months postoperatively. Compared with preoperative measurement values a significantly increased peak pressure could be assessed for the third toe only. It is assumed that the combination of functional arthrodesis of the proximal interphalangeal (PIP) joint and the strain shift by tendon transfer causes this increase in peak pressure. CONCLUSION Atter Girdlestone-Taylor tendon transfer reestablishment of floor contact of flexible claw toes could be demonstrated by dynamic pedobarography.

Preliminary results of a plantar plate for Lapidus arthrodesis

The TMT I arthrodesis is an established procedure for the correction of hallux valgus deformity associated with the instability of the TMT-I joint. A risk of transfer metatarsalgia is reported in the literature associated with persistant elevation of MT-I. Detailed information for ideal positioning of the arthrodesis is missing so far. Clinical, radiological and padobarografical results and their correlations were analyzed with special consideration of the elevation position of the MT-I in a TMT-I arthrodesis using the plantar plate osteosynthesis. Postoperative changes in plantar pressure and force distribution occured after TMT-I arthrodesis. A postoperative increase of the load under the medial forefoot and the dependence on the positioning of MT-I in the sagittal plane has been shown. The authors suggest, that increased load of the medial forefoot and constant pressures and forces under the central forefoot may lead to a relative relief of the area, which might explain the postoperative reduction of metatarsalgia.