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Background MRSA represents a considerable health threat to orthopaedic patients. Throughout the last decade, livestock-associated MRSA emerged increasingly in livestock all over Europe. LA-MRSA broke the species barrier, colonizing and causing infections in humans. Nevertheless, to date there are no studies concerning livestock-associated MRSA and orthopaedic patients. Therefore, we aimed to investigate the prevalence of LA-MRSA in a regional orthopaedic department localized in an area with high-density livestock. Patients and Methods 1544 persons were enrolled in this prospective study. Nasal swabs and questionnaires were collected in patients admitted to the orthopaedic hospital. Nasal carriage was assessed by using selective MRSA agars. MRSA-positive samples were spa typed. Results Overall, the prevalence of MRSA carriage was 3.3%, nearly all spa types were indicative for LA-MRSA. 91% of all LA-MRSA carriers had contact to livestock during the last 6 months before testing. Conclusion Livestock-associated MRSA emerged rapidly over the last few years and will contribute substantially to MRSA infection rates in orthopaedic hospitals. Livestock-associated patients must be screened before admission in order to control infectious complications., Competing Interests: Interessenkonflikt: Nein., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Before clinical implementation of an approved electromagnetic tracking system (CAPPA IRAD EMT) an experimental trial was performed to investigate the accuracy of the system and its safety in application for transpedicular vertebral punctures in comparison to the classical fluoroscopic method., Material and Methods: A total of 110 transpedicular punctures were performed bilaterally using 11 vertebrae of 5 realistic artificial phantoms and 1 pedicle was punctured with the conventional technique using c-arm fluoroscopy and the other with the electromagnetic tracking system. As a target a radiopaque non-ferromagnetic marker was implanted bilaterally in the anterior wall of the vertebrae. For evaluation of the precision the distance from the end of the puncture to the target and the gradual deviation of the actual channel from the ideal trajectory were assessed in three-dimensional computer tomography. Calculations and statistical analysis were performed according to the Wilcoxon test by means of SPSS 16.0.1 for Windows., Results: The mean distance from the target was 6.6 mm (± 3.9 mm standard deviation SD) with electromagnetic navigation compared to 3.2 mm (± 2.8 mm SD) with fluoroscopic assistance and the mean aberration from the ideal trajectory was 18.4° (± 4.6° SD) compared to 6.5° (± 3.5° SD), respectively. The difference of accuracy was highly significant regarding both parameters (p < 0.001)., Conclusions: The minimum requirement for accuracy of transpedicular punctures could not be achieved with electromagnetic navigation. Unless proven otherwise, the lack of accuracy is attributed to unstable referencing. Despite evidence of successful employment for soft tissue punctures the system cannot currently be recommended for osseous applications of the spine.

Background: The osseointegration of actually rarely implanted cobalt-chromium implants can be critical in an elderly population. The aim of our study was to evaluate the effect of preoperative testosterone treatment on the osseointegration of cobalt-chromium implants., Materials and Methods: Press-fit implantation of 1.6 mm-diameter cobalt-chromium-molybdenum (CoCrMo) implants was performed in rats without pre-treatment in one group (n = 10) and after pre-treatment with 1 mg dihydrotestosterone (DHT) 2 days before surgery in the other group (n = 10). After 14 days, the specimens were examined by a pull-out test, histology and histomorphometry., Results: The biomechanical testing delivered inconsistent data leading to no significant difference (6.45 ± 6.94 N vs. 4.66 ± 3.77 N). Histology showed closed contact between surrounding tissue and the implants in both groups. The bone/implant contact area was significantly enhanced after treatment with DHT (42.23 % ± 9.25 vs. 57.57 % ± 16.71, p < 0.05), while the ratio of osteoid was reduced (38.68 % ± 16.7 vs. 27.38 % ± 13.02, not significant)., Conclusions: Pre-treatment with DHT enhances osseointegration of cobalt-chromium implants through enhanced mineralisation of peri-implant tissue. The treatment might additionally shorten postoperative rehabilitation due to its positive effects on musculature., (Georg Thieme Verlag KG Stuttgart · New York.)

A clinically evident radiculopathy without correlation in the imaging studies represents a serious problem regarding the indication, planning and execution of an operative procedure for its treatment. Both the diagnosis and treatment of such cases are deemed to be difficult without clear morphological correlation. Moreover, the surgeon lacks an important basis for the adequate planning and above all the justification of surgical treatment. Although discography with post-discographic computer tomography (CT discography) is still controversially discussed as an invasive diagnostic measure, the literature shows that this method is not only useful but also indispensable in certain cases. Based on these findings and our own empirical data, we recommend CT discography to be considered for imaging in patients suffering from lumbar radiculopathy with equivocal or insufficient MRI findings. The technique allows an accurate diagnosis and precise planning of a targeted surgical intervention such as endoscopic sequestrotomy or decompression., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim of the Study: Total disc arthroplasty is reported to maintain segmental motion. From finite element studies a rather posterior and central implantation of the prosthesis is recommended. However, there is yet no in vitro study with cadaveric specimens investigating the topic of implant positioning., Methods: Ten human lumbar spines were subjected to biomechanical testing. Flexion/extension and side-bending moments were applied from 2.5-7.5 Nm on a spine load simulator. First, the intact specimens were tested in 3 load cycles while motion was monitored with regard to the facet joints under different loads by an ultrasound-based system. An unconstrained total disc prosthesis was then implanted in a central position and the different load cycles were repeated. Finally the implant was positioned in a decentral position with an average offset of 6.2 mm for repetitive data acquisition., Results: Comparison of the facet joint motion in central and eccentric prosthesis positions resulted in the following averaged differences. During flexion of the lumbar spine an average difference of the reference point excursions of 0.38 mm was recorded on the ipsilateral facet joint with reference to the decentral position. For extension, the difference was 0.33 mm on average, for right side bending a difference of 0.63 mm was recorded while left side bending resulted in an average difference of 0.24 mm. The deviation of the reference markers on the contralateral facet joint showed the following average differences: for flexion 0.23 mm and for extension 0.54 mm, respectively. For side bending right/left the differences amounted to 0.18 mm and 0.39 mm. With regard to segmental motion there was no statistically significant difference for both the ipsilateral (p = 0.0564) and the contralateral (p = 0.2593) reference marker., Conclusions: The comparison of the segmental motion after central and decentral implantation of a lumbar total disc prosthesis reveals differences that have, nevertheless, no statistical significance. However, for clinical use it is recommended to strive for a central position of the implant.

Tuberculosis constitutes an important clinical entity with 90 million new infections worldwide during the last decade. 10 % of these infections affect osseous structures based on haematogenous spread. Therefore, tuberculous spondylodiscitis remains a major illness in orthopaedics which needs to be considered in cases of unspecific back pain. Pathognomonic characteristics are absent and clinical, chemical and radiological parameters are not reliable. The consequences of a delayed surgical intervention are discussed based on a case report with 5 year follow-up. Both adequate early CT and MRI scans and identification of the pathogen are essential in order to plan the therapy. Final re-evaluation of a conservative treatment regime needs to be done no later than six to eight weeks depending on the clinical constellation. Persistent or progressive spondylodiscitis with osseous destructions or neurological deficits demands a radical surgical intervention.

The main objective of orthoMIT is to develop an integrated platform for "gentle" surgery in orthopedics and traumatology with particular emphasis on hip, knee and spinal column surgery. The goal of the 24 partners of the orthoMIT consortium and further associated industrial partners is an integrated approach to reduce the cost of orthopedic interventions: full workflow integration in the operating room, full treatment integration extending through to rehabilitation, and full integration of the typical value chain of medical product development, from the laboratory to production and commercialization by the firms and industrial partners involved in the project including education and training. Development, therefore, focuses on new strategies in minimally invasive surgery and improved, knowledge-based planning and navigation systems. Other topics include the development of improved methods of interventional imaging using ultrasound and computed tomography (flat panel detectors) and new, miniaturized instruments with integrated sensors and a modular integration of various applications and components into an integrated surgical workstation.

We report on the case of an 81-year-old woman who was hospitalised because of severe pain at the sacro-iliacal joint radiating into the left leg without any accompanying neurological defect. X-rays demonstrated a step in the left massa lateralis of the sacrum, thus CT scans and MRI were performed, and multiple perineural cysts (Tarlov's cysts) were found. The patient underwent microsurgical treatment by fenestration of the cyst wall and evacuation of the fluid content in order to avoid further expansion of the cysts. Under consequent treatment with pain killers, complete mobilisation of the patient could be achieved. Ambulant follow-up by clinical controls and X-rays demonstrated a substantial resolution of the patient's preoperative symptoms. Symptomatic perineural cysts should be included into differential diagnosis of severe low back pain, thus CT or MRI scans should be performed in case of long-lasting or intrackable pain.

Aim: The diagnosis of spondylodiscitis is often prolonged, but it is an important differential diagnosis of backache. The discrimination between a bacterial infection and an aseptic inflammation with laboratory examinations like ESG, CRP or leukocytes is not possible. The aim of the present study was to determine the value of procalcitonin (PCT) as a diagnostic tool and monitoring parameter for spondylodiscitis and for the discrimination between bacterial infection and aseptic inflammation of the spine., Method: A total of 17 patients with spondylodiscitis and 18 patients with disc herniation as control were included in this study and ESG, CRP, leukocytes, fibrinogen, PNM elastase und PCT were examined for 50 days. The median age was 65 (17-78) years and the ratio of males to females was 8 : 9 in patients with spondylodiscitis and 62 (32-87) years and 7 : 11 in patients with disc herniation. For microbiological examination, CT-guided punctures were performed in patients with spondylodiscitis., Results: In 64 % of the 17 patients with spondylodiscitis a microbiological agent was detected, in 73 % of these cases staphylococcus aureus was isolated. The laboratory parameters indicating an infection were increased except for two cases in patients with spondylodiscitis, the mean value of CRP was 115 mg/dL. Influenced by the therapy these parameters decreased during the observation period. Except for one patient with an infection of a cardiac pacemaker, the PCT concentration was not elevated in both groups (< 0.5 ng/mL). In the group with disc herniation there were no elevated laboratory parameters during the entire observation period., Conclusion: PCT is not useful as diagnostic tool or monitoring parameter for spondylodiscitis. Furthermore, it is not useful for the discrimination between a bacterial infection and an aseptic inflammation of the spine.

Aim of the Study: Maintaining segmental motion is one of the most reported theoretical advantages of total disc replacement (TDR). Several inlay sizes are available for reconstruction of the physiological disc height. The influence of the implant height on the range of motion (ROM) was investigated in a biomechanical study., Methods: A total of 10 human lumbar cadaver spines were subjected to biomechanical testing. Flexion/extension and side-bending moments were applied from 2.5-7.5 Nm on a spine load simulator allowing for all 6 degrees of freedom. Motion under different loads was monitored by the Zebris system in 3 dimensions. Initially intact specimens were tested in 3 load cycles. Then a total disc prothesis was implanted with an 8.5 mm inlay and the cycles were repeated. Finally in 5 cases a 1-mm larger inlay was inserted while in the remaining 5 cases the inlay was exchanged with a 2-mm larger implant. Neutral zone (NZ) and ROM were recorded under the different loads., Results: The average motion for the various loads showed no significant difference when the intact motion segment was compared to the specimen containing the 8.5-mm inlay. After the larger inlay had been mounted the average reduction of the ROM in flexion/extension was 25% under the load of 7.5 Nm, 26% under a torque of 5.0 Nm and 30% when 2.5 Nm were applied. The NZ was reduced by 37%. For side-bending the ROM was reduced by 21% under a load of 7.5 Nm, by 26% under 5.0 Nm and by 35% under a torque of 2.5 Nm. The NZ was decreased by 27%. The reduction of the ROM was significant (p=0.0057)., Conclusion: Segmental lumbar motion is maintained after TDR. The size of the inlay can significantly change the ROM in lumbar spine segments treated by TDR.

Echinococcosis of human pathogenetic relevance is a very rare disease in Europe. The vertebral manifestation of the latter zoonosis constitutes one percent of all cases. Intraspinal echinococcosis appears worldwide just sporadically, whereas extradurally located cysts are identified more often than intradurally located ones. The diagnostic and specific therapeutic consequences of this very seldom entity are discussed based on a case report.

Aim: The treatment of slipped capital femoral epiphysis (SCFE) is usually treated operatively, but there is still no consensus about the method to be used. Up to a 30 degrees degree of slipping, the epiphysis is normally fixed in situ. The aim of our study was to compare the intermediate results after fixation in situ by K-wires versus cannulated titanium screws (Königsee-Implantate, Königsee-Aschau, Germany)., Methods: In this study 46 patients with SCFE grade I and II and mostly chronic slipping of the epiphysis were included. After fixation in situ and, if necessary, careful, closed reposition, the patients were clinically and radiologically followed-up for one year. The clinical results were documented by the score adapted from Heyman and Herndon. Furthermore, MRI scans were done to evaluate the vitality of the epiphysis pre- and postoperatively, when titanium screws were used., Results: Clinical follow-up showed comparable results in the clinical scores after fixation by K-wires or cannulated titanium screws (3.13 +/- 1.02 vs. 3.10 +/- 1.01). After the treatment with titanium screws we saw a higher rate of abnormal gait (33.3 % vs. 19 %), a decreased rate of the positive Drehmann sign (10 % vs. 38 %) and a lower rate of revisions (16 % vs. 50 %) in comparison to K-wire fixation. After displacement of the K-wires we saw chondrolysis and prearthrosis in one case. Removal of the K-wires was done without any complications, while the removal of the cannulated titanium screws failed in 4 of 10 cases., Conclusion: The treatment of SCFE with K-wires and cannulated titanium screws showed comparable results in the clinical follow-up. The treatment with cannulated titanium screws reduces the number of necessary revisions, but the removal of the material is hindered. Because of the lower rate of complications we prefer in the meantime the use of cannulated steel screws.