Matthias Buchner

Acute traumatic primary patellar dislocation: long-term results comparing conservative and surgical treatment.

Objective:This report evaluates the subjective, clinical, and functional long-term results comparing surgical and conservative treatment in patients with a primary traumatic patellar dislocation. Design and Setting:This retrospective clinical study focuses on patients with primary acute traumatic patellar dislocation. Patients with radiologic signs indicative of a predisposition for recurrent patellar instability were excluded from this study. Patients:A total of 126 patients were examined a mean of 8.1 years after initial treatment of their primary patellar dislocation. Interventions and Main Outcome Measurements:Patients were retrospectively divided into groups with conservative therapy (n = 63), diagnostic arthroscopy only (n = 20), immediate surgical reconstruction of the parapatellar ligament complex (n = 37), and refixation of osteochondral fragments (n = 6). Redislocation and resurgery rate, activity level, and subjective, clinical, and functional results were evaluated in these patients, and the outcomes in these groups were compared. Results:In the long term, functional results (as expressed in the Lysholm score) were excellent or good in 85% of the patients, and good subjective results were reported by 71%, but follow-up revealed a recurrence rate of 26% in the total study population. The high activity level before the initial trauma could not be completely regained after treatment. There was no significant difference between the surgically and conservatively treated groups in the redislocation and reoperation rates, level of activity, or functional and subjective outcomes. Conclusions:Even with a focus on acute traumatic etiology and when factors predisposing to recurrent instability are largely excluded, the redislocation rate after treatment of acute patellar dislocation is still high, despite good clinical and subjective results. Conservative management seems to be the treatment of choice in patients with acute patellar dislocation, provided that the generally accepted indications for surgery, such as evidence of osteochondral fragments and major defects of the parapatellar ligament complex, are given due consideration.

Epidural corticosteroid injection in the conservative management of sciatica.

In this prospective randomized clinical trial, the results of epidural corticosteroid injections were evaluated in patients with lumbosciatic pain caused by herniated nucleus pulposus. Thirty-six patients with radicular lumbosciatic pain and positive straight leg raising test because of confirmed prolapsed intervertebral lumbar discs were randomized into two groups with (17 patients) and without (19 patients) epidural corticosteroid injection. Members of the treatment groups received three injections of 100 mg methylprednisolone in 10 mL bupivacaine 0.25% each. Additional therapy was standardized and identical in both groups. Followup examinations were performed at 2 weeks, 6 weeks, and 6 months. The examinations included pain level (visual analogue scale), straight leg raising test, and functional status (Hannover Functional Ability Questionnaire). At 2 weeks, patients receiving methylprednisolone injection showed a significant improvement in straight leg raising test results compared with patients in the control group. Results were better in the methylprednisolone group, although not statistically significant for pain relief and mobility. At 6 weeks and 6 months, pain relief, improvement of straight leg raising, and improvement of functional status showed no statistical significance. Epidural corticosteroid injections can be recommended as additional therapy only in the acute phase of the conservative management of lumbosciatic pain.

The Role of TNF-α in Patients With Chronic Low Back Pain—A Prospective Comparative Longitudinal Study

ObjectivesIn this prospective longitudinal clinical study with a matched-pair design, we evaluated the role of tumor necrosis factor-α (TNF-α) and its clinical relevance in patients with chronic low back pain. MethodsOne hundred twenty patients with chronic low back pain were matched to a healthy control group. Patients and controls were prospectively followed for 6 months. At 4 fixed time points (day 0, day 10, day 20, and 6 mo) blood samples were taken and TNF-α levels compared in the 2 groups, and correlations with pain level and clinical function were analyzed. ResultsAt the beginning and at all other time points, there was a significantly higher proportion of TNF-α positive participants in the patients group than in the control group. The proportion of TNF-α positive patients decreased during the first 10 days of a multidisciplinary therapy in the patient group, but after this initial period, TNF-α levels remained constantly high with no further change until the final follow-up. In the healthy control group, the proportion of participants with positive TNF-α levels remained constant throughout the entire period. No significant correlation between TNF-α levels and pain or clinical function was detected. DiscussionTNF-α seems to have a significant role in patients with chronic low back pain. However, the pathophysiology of this process, the clinical relevance of TNF-α and, especially, its part in a potential therapy regimen in these patients need to be more closely examined and defined in additional studies.

The Role of Il-8 in Patients With Fibromyalgia: A Prospective Longitudinal Study of 6 Months

Objective In this prospective longitudinal clinical study, we evaluated the role of proinflammatory cytokine IL-8 and its clinical relevance in patients with fibromyalgia (FM) who fulfilled clearly defined inclusion and exclusion criteria and underwent a 3-week inpatients multidisciplinary pain therapy. Methods IL-8 in sera was measured in 20 patients with FM and 80 healthy participants at 4 fixed time points: at the beginning of the study, at 10 days, 21 days, and 6 months, respectively. Pain intensity, back function, depression, nicotine/alcohol consumption, and medication were assessed in the patient group and correlated with IL-8 levels. Results Before and during the inpatient therapy, the serum level of IL-8 was significantly higher in patients with FM compared with controls (P<0.001), but did not correlated with pain intensity and medication. Already at T1 there was a significant reduction of IL-8 serum level (P=0.023) in patient group. Six months after multidisciplinary pain therapy, IL-8 serum level in FM patients was still significantly higher than controls (P=0.044) but reduced approximately to normal range and correlated significantly negatively with pain intensity (r=−0.782, P=0.001). Patients with FM had significantly less pain (P<0.001) and better back function (P<0.001) at day 2 than at day 0. In addition, in patients with FM, IL-8 serum level correlated with nicotine consumption (r=0.471, P=0.042). Conclusions Our results suggest that IL-8 level contributes in patients with FM whose pain intensity and back function can be improved under influence of multidisciplinary pain therapy without need of an anti-IL-8 therapy.

Therapy outcome after multidisciplinary treatment for chronic neck and chronic low back pain: a prospective clinical study in 365 patients

Objectives: This prospective longitudinal clinical study analyses the therapy outcome of 365 patients with either chronic neck (n = 134) or low back (n = 231) pain treated with a multidisciplinary biopsychosocial therapy approach. Methods: Patients with chronic neck pain (NP) or low back pain (LBP) for 3 months or longer, corresponding sick leave for longer than 6 weeks, and clearly defined inclusion and exclusion criteria underwent a 3‐week standardized inpatient multidisciplinary biopsychosocial therapy. Baseline sociodemographic, occupational, functional, and psychological data at entry into the study (T0) were comparable in both groups. At the 6‐month follow‐up (T1), five different therapy outcomes were analysed in both groups: back‐to‐work status, generic health status (the 36‐item Short Form Health Survey, SF‐36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy. Results: Both treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back‐to‐work rate was 67.4%. At the final follow‐up there were no significant differences between the group with chronic NP and the group with chronic LBP in the outcome criteria back‐to‐work status, improvement of health status and functional capacity, satisfaction with therapy, and reduction of pain. Conclusion: Evaluation of the main results of this study suggests that patients with chronic NP also derive significant benefit from a multidisciplinary treatment strategy, demonstrated in the literature so far mainly for patients with chronic LBP.

The influence of the grade of chronicity on the outcome of multidisciplinary therapy for chronic low back pain.

Study Design. Prospective longitudinal clinical study. Objective. The objective of the study was to analyze the outcome of different stages of chronicity in patients with chronic low back pain treated with a multidisciplinary therapy. Summary of Background Data. Results of studies comparing different grades of chronicity in therapy for chronic low back pain have not been published so far. Methods. A total of 387 patients with chronic low back pain for 3 months or longer and a corresponding sick leave for longer than 6 weeks underwent a 3-week standardized multidisciplinary therapy. At baseline (T0), patients were assigned into 3 groups of chronicity grades according to the classification of von Korff et al (Group A, Grades I and II; Group B, Grade III; Group C, Grade IV) and were prospectively followed. At the the 6-month follow-up (T1), 5 different therapy outcomes were analyzed and compared in the 3 groups: back-to-work status, generic health status (SF-36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy. Results. At T0, patients in Group C had a higher pain level, a longer history of pain, and more general and more psychosomatic comorbidities than patients with lower levels of chronicity. All 3 treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back-to-work rate was 67.4%. At the final follow-up, there were significantly better results in terms of functional capacity and pain level in patients with lower grades of chronicity but mostly due also to worse initial baseline values. Back-to-work rate, satisfaction with therapy, and the Mental Component Summary of the SF-36 did not show a significant difference at T1 between the groups analyzed. Conclusion. According to the results of this study, patients with chronic low back pain also derive significant benefit from a multidisciplinary treatment strategy in higher stages of chronicity. Therefore, therapy should not be limited to the patients in lower stages of chronicity.

Medial gastrocnemius muscle flap in limb-sparing surgery of malignant bone tumors of the proximal tibia: mid-term results in 25 patients.

Twenty-five patients in whom the medial head of the gastrocnemius muscle was transposed to cover defects in limb-sparing surgery of malignant bone tumors in the proximal tibia were evaluated prospectively in a tumor register. Surgical technique and mid-term clinical–functional results after a mean follow-up of 4 years 6 months are presented in this study. Twenty-four of the 25 gastrocnemius muscle flaps survived without complications. In 1 patient, infection and necrosis of the transposed muscle developed 10 days after surgery, requiring revisional muscle transposition. The total revision rate after primary tumor surgery was high (48%), but this had no impact on the viability of the transposed muscle flap. The mean Musculoskeletal Tumor Society score at follow-up was 75.1% (range, 20–97%) and the mean postoperative range of motion in the operated knee was 60 deg (range, 30–100 deg). Because of its easy, safe, and quick preparation, the medial gastrocnemius muscle flap is exceptionally valuable as a means of covering defects arising during the course of this extensive tumor surgery. It guarantees a high survival rate of the transposed muscle and supports vascularity of the skin flaps, helps to reestablish joint function and mobility by stabilization and reinforcement of the extensor mechanism, and provides protection against infection.

Cauda equina syndrome caused by intervertebral lumbar disk prolapse: mid-term results of 22 patients and literature review.

This retrospective study analyzes the mid-term results of 22 patients who underwent diskectomy following a diagnosis of cauda equina syndrome due to prolapsed intervertebral lumbar disks (mean follow-up: 3 years and 9 months). Postoperatively, 17 of 22 patients had complete urinary function recovery within the follow-up period, 4 patients had a persistent stress incontinence, and 1 patient, incontinent 4 years postoperatively, required catheterization. Thirteen of 17 patients had recovery of motor deficits, 14 of 21 of sensory deficits, and 13 of 15 patients regained perianal sensation. There was no statistically significant difference concerning the time between onset of symptoms and surgical decompression and subsequent outcome. Complete evaluation must include imaging and urodynamic investigations. After an accurate diagnosis and adequate operative treatment, postoperative results of cauda equina syndrome appear satisfactory.

The course of high-sensitive C-reactive protein in correlation with pain and clinical function in patients with acute lumbosciatic pain and chronic low back pain – A 6 months prospective longitudinal study

In this prospective longitudinal study with a follow‐up of 6 months, the course of serum concentration of C‐reactive protein was measured by an ultrasensitive immunoassay in 31 patients with acute lumbosciatic pain and 41 patients with chronic low back pain. High‐sensitive CRP (hsCRP), pain and clinical function were assessed at ten fixed time‐points during follow‐up. The course of hsCRP values was assessed in relation to the course of pain and clinical function adjusting for possible confounding factors. At the beginning of the study, there were no statistically significant differences in mean hsCRP levels in patients with acute lumbosciatic pain (1.49 mg/l) compared to the levels obtained in patients with chronic low back pain (1.30 mg/l) and those in a control group from the general population (1.26 mg/l). In patients with acute lumbosciatic pain, hsCRP declined significantly in the initial period of 3 weeks with a corresponding decrease in pain and improvement in function and clinical evaluation as assessed with the straight leg raising test (SLR), whereas after this period, the course of the hsCRP did not correspond with the clinical parameters. In patients with chronic low back pain, hsCRP remained approximately constant throughout the whole period with no correlation with pain or function. As a conclusion, according to this study levels of hsCRP do not have a major clinical relevance when evaluating the long‐term course of patients with acute lumbosciatic pain and chronic low back pain and therefore should not be taken into primary consideration when decisions on therapy are made.

[Bone and soft-tissue tumors of the foot and ankle].

ZusammenfassungHintergrundDiese Studie berichtet über die Epidemiologie der Knochen- und Weichteiltumoren des Fußes und Sprunggelenkes, stellt eine differenzierte Therapieplanung vor und evaluiert mittelfristige klinisch-funktionelle Ergebnisse nach Operation der malignen Tumoren.Methode204 Patienten mit Tumoren des Fußes wurden analysiert (163 benigne und 41 maligne Tumoren). Epidemiologie und operative Versorgung werden dargestelltErgebnisseHäufigste benigne Tumoren waren Exostosen, Knochenzysten und Osteoidosteom, häufigste maligne Tumoren Metastasen, Chondrosarkom und Ewing-Sarkom. Bei benignen Tumoren konnte in über 90% eine lokale Resektion durchgeführt werden, während sich bei malignen Tumoren Amputation und Arthrodese einerseits und Extremitäten- oder Gelenkerhalt andererseits die Waage hielten. Klinisch ergaben sich nach operativer Versorgung der primär malignen Tumoren gute funktionelle Resultate und eine 5-Jahres-Überlebensrate von 84%.SchlussfolgerungTumoren des Fußes erfordern eine differenzierte Versorgungsstrategie. Trotz eines hohen Anteils an extremitäten- und gelenkopfernden Operationen sind die mittelfristigen funktionellen Ergebnisse und die Überlebensrate gut.AbstractBackgroundThis study reports the epidemiology of bone and soft-tissue tumors of the foot and ankle, presents therapy strategies, and evaluates mid-term clinicofunctional outcome after surgery for malignant tumors.MethodsTwo hundred four patients with tumors of the foot and ankle were analyzed (163 benign and 41 malignant). Epidemiology and surgical therapy are reported.ResultsThe most frequent tumors were exostosis, bone cyst, and osteoid osteoma for benign tumors and metastases and chondrosarcoma and Ewing’s sarcoma for malignant tumors. In more than 90% of the benign tumors, local resection could be carried out, whereas in malignant tumors, ablative procedures and arthrodeses were almost as common as limb- and joint-sparing techniques. However, follow-up revealed good functional results and a 5-year survival rate of 84% for patients with primary malignant tumors.ConclusionTumors of the foot and ankle require a thorough therapeutic strategy. Mid-term functional results and survival rate after surgical treatment are good, although a high percentage of ablative procedures or fusions could not be avoided in our patients.