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Background The consensus for the optimal treatment strategy for chronic Achilles tendinopathy (AT) is still debated and treatment options are limited. This results in a significant medical need for more effective treatment options. Objective The aim of this study is to investigate the therapeutic effects of percutaneous bioelectric current stimulation (PBCS) on AT. Methods A multicenter, randomized, double-blind, placebo-controlled clinical trial will be conducted. A total of 72 participants with chronic (ie, >3 months) midpoint AT will be randomized and receive four PBCS sessions—either verum or placebo—over 3 weeks. Both groups will complete daily Achilles tendon loading exercises in addition to the intervention. Evaluation sessions will be completed at baseline and during the intervention (weeks 0-3). Self-reported outcome measures will be completed at follow-up at weeks 4, 12, 26, and 52. The primary outcomes are the Victorian Institute of Sports Assessment–Achilles questionnaire scores and statistical evaluation of intraindividual differences between baseline and 12-week evaluations after initial treatment of verum therapy compared to control. Secondary outcomes will assess Pain Disability Index scores; average pain, using the 11-point Numeric Rating Scale; return to sports; and use of emergency medication. Results The study began in May 2021. As of October 2022, we randomized 66 out of 72 participants. We anticipate completing recruitment by the end of 2022 and completing primary data analysis by March 2023. Conclusions The study will evaluate the effects of PBCS on pain, physical function, and clinical outcomes. Trial Registration German Clinical Trials Register DRKS00017293; https://tinyurl.com/mvz7s98k International Registered Report Identifier (IRRID) DERR1-10.2196/40894

Study design A study of a series of consecutive full-endoscopic uniportal decompressions of the anterior craniocervical junction with retropharyngeal approach. Objective The aim of this study was to evaluate the direct anterior decompression of the craniocervical junction in patients with bulbomedullary compression using a full-endoscopic uniportal technique via an anterolateral retropharyngeal approach. Summary of background data Acute or progressive myelopathy may necessitate direct anterior decompression of the craniocervical junction and odontoidectomy. Different techniques with individual advantages and disadvantages can be used. In addition to the gold standard - the transoral approach - there is increasing experience with the endoscopic transnasal technique. Other alternative procedures are also being developed. Methods Between 2013 and 2016, eight patients with basilar impression, retrodental pannus, or retrodental infection were operated in the full-endoscopic uniportal technique with a retropharyngeal approach. Anterior decompression of the bulbomedullary junction with odontoidectomy was performed. All patients additionally underwent posterior stabilization. Imaging and clinical data were collected in follow-up examinations for 1 year. Results The bulbomedullary junction was adequately decompressed. No problems due to swelling of pharyngeal soft tissue occurred. One patient required revision due to secondary bleeding. No other complications were observed. All patients had a good clinical outcome with stable regression of the myelopathy symptoms and/or healing of the infection. The imaging follow-up showed sufficient decompression of bone and soft tissue in all cases. No evidence was found of increasing instability or failure of posterior fusion. Conclusion In the operated patients, the full-endoscopic uniportal surgical technique with anterior retropharyngeal approach was found to be a sufficient and minimally invasive method with the known advantages of an endoscopic procedure under continuous irrigation. It should not be viewed only as competition for other surgical techniques - due to its individual technical parameters, it can also be considered to be an alternative or complementary procedure. Level of evidence 4.

Zusammenfassung Ziel der Studie Studierende mit Spezialisierungspräferenz für eines von 3 nervenheilkundlichen Fächern wurden im Hinblick auf ihre Motivation zum Medizinstudium retrospektiv verglichen. Methodik Mit dem Ziel der Identifikation früher Bedingungen von Spezialisierungspräferenzen wurde eine deutschlandweite Online-Befragung an 9079 Medizinstudierenden durchgeführt. Die Angaben der 669 Studierenden mit nervenheilkundlicher Präferenz wurden varianzanalytisch ausgewertet. Ergebnisse Angehende Neurologen wurden vergleichsweise stärker von inhaltlichen Interessen am Fach Medizin und den Naturwissenschaften, weniger jedoch von Aspekten der Lebensführung motiviert. Hingegen spielten bei der Spezialisierungspräferenz für die psychologischen Fächer der Wunsch, aktiv Hilfe zu leisten, und die eigene Krankheitsanamnese eine wichtigere Rolle. Schlussfolgerung Die aufgezeigten Motive zeigen thematische Richtungen auf, die bei der fachspezifischen Werbung um Nachwuchs verfolgt werden können.

Zusammenfassung Hintergrund Im Rahmen des Medizinstudiums ist in Deutschland ein dreimonatiges Pflegepraktikum vorgeschrieben. Obwohl kontrovers diskutiert, fehlen bundesweite Daten zur studentischen Evaluation. Fragestellung Hier wurde erstmals untersucht, wie Medizinstudierende das Pflegepraktikum auf einer Station der Inneren Medizin (IM) beurteilen. Zusätzlich stellte sich die Frage, inwiefern die frühzeitigen Erfahrungen im Pflegepraktikum bereits die studentische Einstellung zum Fachgebiet beeinflussen. Material und Methoden In einer bundesweiten Online-Umfrage bewerteten 767 Studierende (mittleres Alter 22,8 Jahre; 58 % weiblich) ihr Pflegepraktikum auf einer Station der IM in Bezug auf Integration ins Team, Lehrende, die Struktur und Qualität der Lehre und Zufriedenheit. Anhand der Frage, ob sich Studierende infolge des Pflegepraktikums auch eine Famulatur in der IM vorstellen können, wurden multivariate Gruppenvergleiche durchgeführt. Ergebnisse 71 % der Studierenden fühlten sich gut ins Team integriert, am meisten wurde vom Pflegepersonal gelernt, wobei die Mehrheit angab, pflegerische Kompetenzen erworben zu haben. Nur 19 % bewerteten Aufbau und Struktur des Praktikums als gut, 40 % gaben an, die Lernziele erreicht zu haben. Studierende, die sich eine Famulatur in der IM vorstellen können (52 %), gaben in allen Bereichen die besten Bewertungen ab. Schlussfolgerungen Ein erfolgreiches Pflegepraktikum kann das Interesse für Innere Medizin fördern. Es besteht jedoch ein deutlicher struktureller und inhaltlicher Verbesserungsbedarf einschließlich einer bislang nicht vorliegenden, klaren Formulierung von Lernzielen für diese erste praktische Erfahrung im Medizinstudium.

Einleitung: Auch im Fach Orthopadie und Unfallchirurgie (O & U) macht sich der Arztemangel bemerkbar. Curriculare Praktika, wie die Famulatur, sind sensible Schnittstellen zwischen theoretischem Studium und praktischer Anwendung. In dieser Studie soll untersucht werden, wie dieses Praktikum vonseiten der Medizinstudierenden wahrgenommen wird, und inwiefern es hier gelingen kann, sie fur O & U zu begeistern. Methode: Aus einer im Sommersemester 2012 durchgefuhrten Umfrage mit 9079 Studierenden analysierten wir die Angaben der Subgruppe, die eine mindestens 4-wochige Famulatur in O & U absolvierte. Insgesamt 37 Fragen zur Evaluation des Praktikums wurden in die Analyse einbezogen. Die Teilnehmer, die sich nach ihrer Famulatur vorstellen konnten, auch das Wahltertial in O & U zu absolvieren (PJ-Ja) wurden getrennt von denen analysiert, die dies verneinten (PJ-Nein) und Gruppenvergleiche durchgefuhrt. Ergebnisse: Insgesamt wurden Daten von 397 Famulanten eingeschlossen, die in O & U eine Famulatur absolviert haben. 55,0 % waren weiblich. 267 (67,3 %) Famulanten gaben an, auch ihr PJ-Wahltertial in O & U machen zu wollen (PJ-Ja), 130 (32,7 %) verneinten dies (PJ-Nein). In Geschlecht und Alter unterschieden sich die Gruppen (Geschlecht: χ2 = 2,50, p = 0,114; Alter: F[1, 93]

Background and objectives: Until recently, it was almost impossible to perform major surgery on metastases in the spine. This is especially the case for multiple spinal metastases and for older multi-morbid patients with higher OP risks. It is very important in such cases that the operation should be as minimally invasive as possible, and should aim to reduce pain, treat fractures and to improve the quality of life. The aim of this publication is to present and discuss the specific features of the methodology, problems, surgical techniques, as well as the effectiveness of the modernised cavity/coblation method and results of the treatment of 240 patients with spine metastases. Patients/Material and Method: Patients: Patients of every age with bone destruction were treated, with osteolysis and pathological fractures of vertebrae caused by metastases. The pre-operative diagnosis was evaluated by X-Ray, MRT, CT, whole-body F18-FDG-PET, whole-body bone scintigraphy, histology. Cavity/coblation method: Tumour resection was carried out by the plasma field (42 °C, cold energy) over the percutaneous trans-/extrapedicular access and was followed by balloon kyphoplasty. Tumour tissue was removed, deformation corrected and stability enhanced. The treatment clearly reduced the risks of recurrence, fracture and compression of the neural structures. Local radiotherapy and chemotherapy were performed post-operatively. Clinical and radiological follow-ups, included tumour staging, were performed regularly after the OP (after 2 and 14 days and 3, 6,12, 24, 36, 48 and 60 months), including data on pain and improvement in quality of life. Results: Within 6 years (03/08-04/14), we treated 240 patients with multiple spinal metastases (146 female, 94 male, age range 31-92 years, average age 65.5 years) or 784 vertebral bodies. 61 patients were also given dorsal percutaneous instrumentation and straightening. All patients experienced a significant reduction in pain, and improvements in satisfaction and quality of life. Treatment was combined with chemotherapy and local radiotherapy to reduce tumour cell growth or recurrence rate. Patients could be rapidly mobilised after surgery, blood loss was minimal, and the next oncology treatment could be initiated immediately. Discussion/Conclusions: Cavity/coblation is a safe and minimally invasive procedure, as confirmed by our own short- and long-term results, as well as by reports/publications of other workers. OP risks, blood loss, and surgical time are lower and shorter. This new method is very promising for the future. It is important that the indication is correct and the treatment strategy must be adapted individually. Prognosis must be assessed and the surgical technique must be precise.

Das Pflegepraktikum als Zugangsweg in den psychiatrischen Fachbereich ist weitgehend unbeachtet. Eine deutschlandweite Umfrage analysiert das medizinische Pflegepraktikum unter den Aspekten: praktische Fahigkeiten, Lehre im Pflegepraktikum, Kompetenzerwerb und Zufriedenheit. Die wenigen Studierenden im psychiatrischen Pflegepraktikum weisen auf entscheidende praktische inhaltliche Aspekte hin, geben einen Einblick in die Bewertung der Zufriedenheit und zu dem Zugang in das Fachpflegepraktikum. Eine gelungene inhaltliche Strukturierung des praktischen Initialkontaktes kann Studierende bei der Fachauswahl unterstutzen.

Tumoren und Metastasen an der Wirbelsaule sind stark belastende Zustande. Bis vor kurzem standen fur solche Tumorpatienten, v. a. fur altere multimorbide Patienten mit hoheren Operationsrisiken, keine ausreichenden Behandlungsmoglichkeiten zur Verfugung. Die moderne Cavity-Coblation-Methode bietet hier eine sehr gute Therapieoption. In diesem Kapitel werden ausfuhrlich die Indikationen zur Methode, die einzelnen OP-Schritte, Besonderheiten der praoperativen Diagnostik und praoperativen OP-Aufklarung, mogliche Komplikationen, Stellenwert und Problematik der Methode mit deren klinischer Relevanz dargelegt. Zudem werden Kodierungsoptionen und eine Literaturubersicht mit Darstellung eigener Ergebnisse der Behandlung von Patienten mit Wirbelsaulenmetastasen mit der Cavity-Coblation-Methode prasentiert.

OBJECTIVESurgery for thoracic disc herniation and spinal canal stenosis is comparatively rare and often challenging. Individual planning and various surgical techniques and approaches are required. The key factors for selecting the technique and approach are anatomical location, consistency of the pathology, general condition of the patient, and the surgeon’s experience. The objective of the study was to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the interlaminar, extraforaminal, or transthoracic retropleural approach in patients with symptomatic disc herniation and stenosis of the thoracic spine, taking specific advantages and disadvantages and literature into consideration.METHODSBetween 2009 and 2015, decompression was performed in 55 patients with thoracic disc herniation or stenosis using a full-endoscopic uniportal technique via an interlaminar, extraforaminal, or transthoracic retropleural approach. Imaging and clinical data were collected during follow-up examinations for 18 months.RESULTSSufficient decompression was achieved in the full-endoscopic uniportal technique. One patient required revision due to secondary bleeding, and another exhibited persistent deterioration on myelopathy. No other serious complications were observed. All but one patient experienced regression or improvement of their symptoms.CONCLUSIONSThe full-endoscopic uniportal technique with an interlaminar, extraforaminal, or transthoracic retropleural approach was found to be a sufficient and minimally invasive method. To cover the entire range of thoracic disc herniations and stenosis within the criteria named, all full-endoscopic approaches are required.

Study Design Case report. Background and Study Aims For stabilizing surgery of the atlantoaxial region, a precise evaluation of the course of the vertebral artery (VA) is essential to avoid vessel injury and life threatening complications. In patients with aberrant VA course, an appropriate way for fusion needs to be found. This article presents a case of an unusual VA course and illuminates the importance of surgical planning with computed tomography angiography identifying VA variations at the atlantoaxial region. Case Report A 71-year-old woman with atlantoaxial arthrosis had a VA variation (persistent first intersegmental artery). She underwent C1–C2 posterior fixation according to Harms/Goel using the typical entry points, requiring VA dissection in caudal direction. The postoperative clinical as well as radiographic result was excellent. Angiography 6 months postoperatively showed the VAs below the C1 screws with normal blood flow. Conclusions Placement of C1 screws in a patient with a persistent first intersegmental VA is possible. Careful VA dissection is the key step for safe screw placement, screw anchoring, and clinical success.

Background: The shortage of skilled personnel is ubiquitous, basic and further training is a key aspect in the recruitment of new medical colleagues. The significance of the nursing practicum in its function as gateway to the gynaecology and obstetrics discipline is practically unexplored. Methods: In an online questionnaire, medical students in all German faculties were questioned about the practica in their courses. The questionnaire reached 9079 medical students. 149 participants in nursing practica were selectively asked to answer 140 questions. We analysed those students who could, on the basis of their experiences in nursing practica, imagine undertaking an internship (clinical elective) in gynaecology (internship yes “Iy”) separately from those who could not or were still undecided (internship no “In” or, respectively, internship perhaps “Ip”). Results: Altogether 149 medical students who participated in a nursing practicum in the gynaecology discipline were selected, of these 94.9 % were female. 92 (61.7 %) of the students replied that, after their gynaecological nursing practicum, they wanted to undertake an internship in gynaecology (Iy); 39 (26.2 %) answered negatively (In) and 18 (12.1 %) were still undecided (Ip). With regard to the parameters gender, age and duration of study, there were no significant differences among the 3 groups (χ 2 0.83). Besides the didactic and professional quality of the training, Iy also mentioned having had a higher practical orientation. They attained their aims more frequently, were better integrated in the health-care team and acquired more practical competences. Satisfaction with the practicum was evaluated as highest among the Iy. Discussion: Those students who could imagine taking an internship in gynaecology were seen to be more satisfied with their practica than those participants who declined or were undecided. The high proportion of females is an early indicator for a feminisation of the specialty. If necessary this could be countered with the help of nursing management.

Einleitung: Im Wettbewerb um die Talente der Generation Y rucken mehr die Wunsche und Anspruche der angehenden Arztinnen und Arzte in den Fokus mit dem Ziel, den kurativen Arztberuf attraktiver zu gestalten. Im Detail wissen wir jedoch noch zu wenig uber die Erwartungen der Medizinstudierenden an die Berufswelt. Methode: In einer bundesweiten Onlinebefragung wurden 9079 Medizinstudierende aller Fakultaten erreicht. Wir stellten sowohl 21 Fragen zur zukunftigen Arbeitsplatzwahl und zur erwarteten Arbeitsplatzzufriedenheit als auch 21 Fragen zu Grunden, nicht kurativ tatig zu sein. Ergebnisse: Mittels Faktorenanalyse konnten 5 Faktoren extrahiert werden: Work-Life-Balance, Karriere, fachlicher Anspruch, Betriebsklima und Prestige. Die Korrelation der Faktoren mit den soziodemografischen Daten der Befragten ergab signifikante Zusammenhange mit dem jeweiligen Geschlecht, der angestrebten Fachspezialisierung sowie dem Familien- und Kinderstatus. Der ebenfalls durchgefuhrte Abgleich mit „Grunden, nicht kurativ tatig zu werden“, lies die Priorisierung einzelner Faktoren zu. Work-Life-Balance, Karriere, fachlicher Anspruch und Betriebsklima wurden geschlechtsubergreifend als besonders wichtige Parameter aufgefuhrt. Diskussion: Erkenntnisse zur Arbeitszufriedenheit der motivierten und leistungsbereiten Generation Y sind von zentraler Bedeutung. Nur wenn es gelingt, diesen geschlechts(un)abhangigen Erwartungen im leistungsverdichteten beruflichen Alltag zu entsprechen, wird der Arztberuf an Attraktivitat gewinnen, werden sich auf Bundesebene Versorgungsengpasse entscharfen lassen und Kliniken die zukunftigen Arztinnen und Arzte gewinnen und halten konnen.

Background Radical surgery for metastases in the spine is in many cases not possible, includingthe higher risk of surgery in older patients with co-morbidities. The aims of treatment are: minimally invasive and maximally effective tumour removal, fracture position, stabilization, pain reduction, and improved quality of life. The specific features and problems of diagnosis and treatment using the cavity/coblation method, , the surgical technique, and the results of the treatment of 250 patients with spinal tumours/metastases are presented. Materials and methods Tumour resection is carried out by plasma field, via percutaneous trans-/extrapedicular access, followed by kyphoplasty. Clinical and radiological follow-up was carried out postoperatively, including data on pain reduction and improvement of quality of life. Results Within 6 years (March 2008t February 2014) a total of 250 patients, or 812 spines were treated. In 59 cases dorsal percutaneous instrumentation and straightening were carried out. Minimal blood loss and a very low complication rate were recorded. After surgery, significant pain reduction, satisfaction, early mobilization, and improvement in quality of life were demonstrated in all patients. Immediate radio- and chemotherapy could be carried out. In 38 cases cement escaped laterally into the intervertebral space, but this had no clinical relevance. 188 patients have since died because of tumour manifestations. Conclusions The cavity/coblation method has been demonstrated to be a safe, minimally invasive procedure, with good short- and long-term results and lower complication rates. A comprehensive diagnostic, including tumour staging, the correct indication, and prognosis estimation, is important.

OBJECTIVEAcute or progressive myelopathy may necessitate direct anterior decompression of the craniocervical junction and odontoidectomy. Different techniques with individual advantages and disadvantages can be used. In addition to the gold standard—the transoral approach—there is also increasing experience with the endoscopic transnasal technique. Other alternative methods are also being developed to reduce technical and perioperative problems. The aim of this anatomical study was to investigate the feasibility of the full-endoscopic uniportal technique with a retropharyngeal approach for decompression of the craniocervical junction, taking into consideration the specific advantages and disadvantages compared with conventional methods and the currently available data in the literature.METHODSFive fresh adult cadavers were operated on. The endoscope used has a shaft cross-section of 6.9 × 5.9 mm and a 25° viewing angle. It contains an eccentric intraendoscopic working channel with a diameter of 4.1 mm. An anterior retropharyngeal approach was used. The anatomical structures of the anterior craniocervical junction were dissected and the bulbomedullary junction was decompressed.RESULTSThe planned steps of the operation were performed in all cadavers. The retropharyngeal approach allowed the target region to be accessed easily. The anatomical structures of the anterior craniocervical junction could be identified and dissected. The bulbomedullary junction could be adequately decompressed. No resections of the anterior arch of the atlas were necessary in the odontoidectomy.CONCLUSIONSUsing the full-endoscopic uniportal technique with an anterior retropharyngeal approach, the craniocervical region can be adequately reached, dissected, and decompressed. This is a minimally invasive technique with the known advantages of an endoscopic procedure under continuous irrigation. The retropharyngeal approach allows direct, sterile access. The instruments are available for clinical use and have been established for years in other operations of the entire spine.

Hintergrund/Problemstellung/Fragestellung: Die Durchfuhrung einer grosen Operation bei Tumoren/Metastasen der Wirbelsaule ist in vielen Fallen unmoglich, vor allem bei alteren, multimorbiden Patienten mit hoheren OP-Risiken. Behandlungsziele: Minimalinvasiv, aber maximal effektiv, Schmerzreduktion, Tumorentfernung, Reduktion der Fraktur- und Deformationsgefahr, Verbesserung der Lebensqualitat. Die moderne Methode der perkutanen Cavity Coblation wird bei uns seit uber 5,5 Jahren erfolgreich eingesetzt. Ziel dieser Arbeit/Fragestellung: Die Besonderheiten der Methodik, Problematik, OP-Technik, Ergebnisse der Behandlung von uber 218 Patienten mit Wirbelkorpertumoren/Metastasen zu ermitteln und zu prasentieren. Patienten/Material und Methodik: Mannliche und weibliche Patienten jeden Alters mit Metastasen/Osteolysen bzw. Frakturen an der Wirbelsaule. Diagnosesicherung durch klinische und radiologische Untersuchungen. Follow-up in regelmasigen Abstanden. Mithilfe der Cavity-SpineWand-Sonde (Fa. ArthroCare) wird durch die sog. Coblation (= kontrollierte Ablation auf der Basis plasmavermittelter Hochfrequenzenergie) eine Hohlung im Tumor erzeugt bzw. eine Tumorresektion bewirkt, zusatzlich erfolgt eine Wirbelstabilisierung durch Kypho-/Vertebroplastie. Zugang: perkutan trans-/extrapedikular. Durch die Beseitigung von Tumorgewebe erreicht man Folgendes: Platz zur Zementauffullung ohne Druck, fast komplette Zerstorung von Tumorzellen, Rezidivrisiko, Frakturgefahrdung und Kompression der neuralen Strukturen werden deutlich reduziert 1 , 2 . Ergebnisse: Innerhalb von 5,5 Jahren (03/08–09/13) wurden 218 Patienten (144 w., 74 m., Alter 31–92 J.) mit Wirbeltumoren (symptomatische grose Hamangiome) und -metastasen mit dieser Methode behandelt. In 59 Fallen wurde zusatzlich eine dorsale perkutane Instrumentation und Aufrichtung durchgefuhrt. Die Ergebnisse wurden klinisch und radiologisch 2 und 14 Tage bzw. 3, 6, 12, 24, 36, 48 und 60 Monate postoperativ kontrolliert (noch nicht bei allen Patienten), und zwar auf folgende Parameter: Schmerzen, neurologische Defizite, Stabilitat, Lokalrezidiv, Materiallockerung, Zufriedenheit. Es zeigten sich: Deutliche Schmerzreduktion, Zufriedenheit und Lebensqualitatsverbesserung sofort und im Verlauf bei allen Patienten. Auserdem schnelle Mobilisation nach OP, minimaler Blutverlust, sofortige Radiatio und Chemotherapie. Die Kombination der Cavity-Coblation-Methode mit Chemotherapie und Radiatio minderte deutlich die Rezidivrate. Komplikationen: in 29 Fallen geringe Zementaustritte nach ventral, lateral bzw. in das BS-Fach, ohne klinischer Relevanz, ohne Verletzung der Organe, Gefase und Nerven. 65 Patienten (43 Frauen, 22 Manner) sind inzwischen wegen Tumormanifestation bei der Metastasierung in die inneren Organe verstorben. Schlussfolgerung: Die Cavity-Coblation-Methode zur Behandlung der Tumoren/Metastasen der Wirbelsaule stellt ein sicheres minimalinvasives Verfahren dar, was durch kurz- und langfristige Ergebnisse belegt wurde. OP-Risiken, v. a. Blutverlust und OP-Zeiten, werden deutlich geringer und kurzer. Die Methode ist aus unserer Sicht fur die Zukunft vielversprechend.

Purpose: Determining whether implantation of an expandable titanium mesh cage (Osseofix® system) is a successful and safe minimally invasive therapy for osteoporotic and tumorous vertebral compression fractures (VCFs). Materials and Methods: 32 patients (25 women, 7 men, mean age 71) with 46 osteoporotic or tumorous VCFs (T6 to L4) from June 2010 to January 2012 were included. All of them were stabilized with the Osseofix® system. Preinterventionally we performed X-ray, MRI, and bone density measurements (DXA). The clinical and radiological results were evaluated preop, postop and 12 months postop based on the visual analog scale (VAS) and the Oswestry Disability Index (ODI), X-ray (Beck Index, Cobb angle) and CT. Results: There was a significant improvement in pain intensity (VAS) (7.8 to 1.6) as well as a significant reduction in the mean ODI (71.36 % to 30.4 %) after 12 months. The mean kyphotic angle according to Cobb showed significant improvements (12.3° to 10.8°) after 12 months. Postinterventional imaging showed one case of loss of height in a stabilized lumbar vertebral body (2.2 %) in osteoporosis and one case with adjacent fracture (2.2 %) in osteoporosis. We saw no changes in the posterior vertebral wall. Except for one pronounced postoperative hematoma, we saw no surgical complications including no cement leakage. Conclusion: The clinical mid-term results are good at a low complication rate. The stabilization of symptomatic osteoporotic and tumorous VCFs with the Osseofix® system is a safe and effective procedure, even in fractures with posterior wall involvement. The Osseofix® system is an interesting alternative to the established procedures of cement augmentation. Key Points: • The Osseofix® system is well suited for stabilizing osteoporotic and tumorous VCFs. • It is a safe and effective procedure without cement leakage and with a low complication rate. • The procedure is an interesting alternative to established cement augmentation procedures. Citation Format: • Ender SA, Gradl G, Ender M et al. Osseofix® System for Percutaneous Stabilization of Osteoporotic and Tumorous Vertebral Compression Fractures – Clinical and Radiological Results After 12 Months. Fortschr Rontgenstr 2014; 186: 380 – 387

Die Behandlung von Fingerfrakturen ist nach wie vor eine Herausforderung fur den jeweiligen Behandler. Grundsatzlich gilt, dass die fruhzeitige Diagnosestellung und Behandlung von Fingerfrakturen Voraussetzungen fur ein gutes funktionelles Ergebnis sind. Aufgrund der verschiedenen Frakturformen und Frakturlokalisationen sowie der unmittelbaren Nahe zum komplexen Sehnenapparat und zu den Gefas-Nerven-Bundeln gibt es zahlreiche konservative und operative Behandlungsverfahren. Wahrend stabile nichtdislozierte Frakturen eine Domane der konservativen Bruchbehandlung darstellen, sind instabile dislozierte Frakturen der Phalangen operativ zu behandeln 4 8 33 . Bei der Wahl des Osteosyntheseverfahrens sollte nicht nur die Frakturform und -lokalisation, sondern insbesondere auch die funktionelle Anatomie der Finger berucksichtigt werden. Ziel einer jeden Osteosynthese sollte neben der anatomischen Reposition auch eine stabile Retention sein, welche eine fruhzeitige Mobilisation der Finger ermoglicht. Nur so kann in der ergo- und physiotherapeutischen Nachbehandlung, als weiterer zentraler Baustein in der Behandlung von Fingerfrakturen, ein gutes funktionelles Ergebnis erzielt werden 9 . Die Kirschner-Draht-Schrauben und die Plattenosteosynthese sind derzeit die bevorzugten Verfahren. Wahrend die Kirschner-Drahte sehr weichteilschonend eingebracht werden konnen, weisen sie aufgrund unzureichender kortikaler Verankerung haufig eine zu geringe Frakturstabilitat fur eine fruhfunktionelle Nachbehandlung auf. Platten- und Schraubenosteosynthesen dagegen fuhren insbesondere bei Frakturen ohne Knochenverlust zu einer sehr hohen Stabilitat. Allerdings ist die fur die Implantation zusatzlich notwendige Schadigung des vom Trauma selbst schon in Mitleidenschaft gezogenen Weichteilmantels ein nicht unerhebliches Problem, welches das funktionelle Ergebnis, insbesondere bei der Plattenosteosynthese, negativ beeinflussen kann. Es ist bisher nicht geklart, wie viel Stabilitat uberhaupt fur eine fruhfunktionelle Nachbehandlung notwendig ist. Obwohl Fingerfrakturen noch lange im Rontgenbild sichtbar sind, besteht im Allgemeinen schon nach 3 – 4 Wochen, unabhangig vom Behandlungsverfahren, eine ausreichende Ubungsstabilitat. Anhaltspunkt hierfur kann der Druckschmerz im Frakturbereich sein. Ist dieser verschwunden, kann man von einer ausreichenden Frakturstabilitat fur eine funktionelle Nachbehandlung ausgehen. Im Allgemeinen kann bei einfachen Frakturen ein gutes funktionelles Ergebnis erreicht werden. Bei Komplexverletzung dagegen, insbesondere mit Weichteilschadigungen, ist in der Regel mit einem schlechteren funktionellen Ergebnis zu rechnen.

The function of articular cartilage as an avascular tissue is mainly served by collagen type II and proteoglycan molecules. Within this matrix homeostasis between production and breakdown of the matrix is exceptionally sensitive. The current study was conducted to identify regional differences in specific alterations in cartilage composition during the osteoarthritic process of the human knee joint. Therefor the changes in the expression of the key molecules of the extracellular matrix were measured in dependence of the anatomical side (femoral vs tibial) and associated with immunohistochemistry and quantitative measurement. 60 serial osteochondral femoral condyle and the tibial plateau samples of patients undergoing implantation of total knee endoprosthesis of areas showing mild (Group A, macroscopically ICRS grade 1b) respectively advanced (Group B, macroscopically ICRS grade 3a/3b) (30 each) osteoarthritis according to the histological-histochemical grading system (HHGS) were compared with 20 healthy biopsies with immunohistochemistry and histology. We quantified our results on the gene expression of collagen type I and II and aggrecan with the help of real-time (RT)-PCR. Proteoglycan content was measured colorometrically. In group A slightly increased colour intensity was found for collagen II in deeper layers, suggesting a persisting but initially still intact repair process. But especially on the medial tibia plateau the initial Col II increase in gene expression is followed by a decrease leading to the lowest over all Col II expression on the medial plateau, here especially in the central part. There in late stage diseases the collagen type I expression was also more pronounced. Markedly decreased safranin O staining intensity was observed in the radial zone and less reduced intensity in the transitional zone with loss of zonal anatomy in 40% of the specimens in group A and all specimens in group B. Correlation between colorometrically analysed proteoglycan GAG content and aggrecan Real Time PCR is mainly weak. Tibial and femoral cartilage in contrast to patellar cartilage both are preferential exposed to compressive stresses, but presence of menisci affects the load distribution at the tibial side, which creates varying conditions for the different cartilage surfaces in the knee. As directly measured Poissons ratio in tibial cartilage is higher but Younǵs modulus is lower than in femoral cartilage, different resulting feedback amplification loops interact with proceeding cartilage damage. The initial loss of aggrecan may support Matrix metalloproteinases (Mmps) in the access to the collagen network and the considerably differing mechanical properties at both joint surfaces result in varying increased synthesis and release of matrix degrading enzymes. The present study has identified a selection of events which reflect the response of cartilage structure and composite, chondrocytes itself and their productivity to changes in mechanical stress depending on the anatomical site.

BACKGROUND A radical surgery of spine metastases is not possible in many cases, especially by elder multi morbid patients. The modern CAVITY/coblation method offers a very good therapeutic alternative for such patients. The goal of this paper was to evaluate and present the method as well as the results of the treatment of 302 patients with vertebral tumors/metastases. METHODS Patients with vertebral destructions of the spine caused by spinal tumors and metastases were treated. Diagnosis preoperatively: X-ray, MRT, CT, PET, histology. Tumor tissue resection was carried out by plasma field over the percutaneous transpedicular access and was followed by kyphoplasty. Follow-up with clinical and radiological examinations are in 2, 14 days, 3, 6, 12, 24, 36, 48, 60 months postoperatively. RESULTS Within 6 years (04/2008-05/2014) 302 patients (188 female, 114 male, age range of 31-92, average age of 65.4 years) were treated. It was shown by all patients: less blood loss, no seriously complications, pain reduction, increase in life quality. Postoperatively was possible: rapid mobilization, immediate radiation and chemotherapy for reduction of the local tumor recurrence rate. CONCLUSIONS CAVITY has shown itself to be a safe, minimal invasive procedure with good short and long term results, a low complication rate, blood loss and short surgery times. The total local recurrence rate was only 13.5%. Important are: comprehensive diagnostic including tumor staging, correct indication, prognostic assessment, precise surgical technique.

Background: Tumours and metastases of the spine are extremely stressful for patients. A radical surgery of metastases of the spine is not possible in many cases. Especially higher risk elder multimorbid patients are at risk. The therapeutic goals are always: small invasiveness, high efficiency of tumour removal, fracture repositioning, stabilisation, pain reduction, improving the patient’s life quality. The specialness and difficulties of the diagnosis and therapy with the Cavity/Coblation-method the operative technique, results of the treatment of more than 274 patients with vertebral body tumours/metastases is going to be presented. Materials and methods: Patients: Patients of every age with destruction were treated: with osteolysis, Fractures of the spine caused by spinal tumours and metastases. Diagnosis preoperatively was evaluated through X-Ray, MRT, CT, complete body PET, histology. Cavity/Coblation method: The tumour tissue resection in the vertebra was carried out by the plasma field (T 42C, cold energy) over the percutaneous transpedicular or extrapedicular access and was followed by vertebroplasty or balloon kyphoplasty with PMMA bone cement. This was followed up with clinical and radiological examinations, including data concerning pain and improvement of life quality after 2,14 days as well as 3, 6, 12, 24, 36, 48 and 60 months postoperatively. Results: Within 6 years (03/08-04/14) more than 274 patients (171 female, 103 male, age range of 31-92 y. old average age of 65.7) or 895 vertebral bodies with tumours or metastases were treated. In 61 cases of 274, dorsal percutaneous instrumentation und straightening was an additional treatment. A small amount of blood loss and a very low complication rate was recorded. Postoperatively was shown by all patients an obvious reduction of pain, increase in life quality, satisfaction with the operative result, rapid mobilization was possible as well as the immediate radiation and chemotherapy for reduction of the local tumour recurrence rate. The complications were as follows: in 39 cases of 274 a cement leakage occurred laterally or in the intervertebral disc space without clinical relevance. 194 patients (105 women, 89 men) are now deceased due to tumour manifestations. Conclusions: Coblation/Cavity has shown itself to be a safe, minimal invasive procedure with good short and long term results, a low complication rate, blood loss and short surgery times. The total local recurrence rate for all patients with spine metastases in the study was in 35 from 250 cases/patients with metastasen or only in 14.0%. Following things are important: a comprehensive diagnostic including tumour staging, correct indication, prognostic assessment and precise surgical technique. The method bears much promise for the future.

In recent years, decisions regarding the treatment of individual patients have increasingly been affected by economic considerations. The G-DRG system reimburses sledge endoprosthetic implantations at a much lower rate than surface replacements and at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, TKA produces higher gains. Taking only these revenues alone into consideration, however, does not provide the basis of an economically sound decision-making process. The target of this research was to present a comparison between variable costs of the two procedures.The mean cost and performance data of 28 Endo-Modell (Link company) sledge implantations (UKS) and of 85 NexGen CR surface replacement total knee arthroplasties (TKA; Zimmer company) were compared in 2007.From the perspective of the hospital, UKS treatment is of greater economic advantage when the medical indication is given. In preferring UKS marginal contribution can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of TKA. Based on the length of stay required for each procedure the average daily CW for UKS can be calculated as 0.1728, while being 0.1955 for TKA. The earlier release of the first patient results in another patient being admitted 1.5 days earlier and thus an increase in case mix. Meanwhile, the case-mix index and the costs of care per case decrease ceteris paribus.Assuming the correct medical indication, the hospital seeking to maximize its marginal contribution would be wise to select sledge endoprosthesis implantation. Considering the economic perspective of gains and costs, the assumption that TKA is advantageous could not be confirmed in the present study.

Prospective study of the patients with degenerative spinal central stenosis, operated bilateral in a full-endoscopic unilateral technique.The objective of this prospective study was to examine the technical possibilities of full-endoscopic interlaminar bilateral technique with unilateral approach in degenerative lumbar central spinal stenosis and predominant leg symptoms using new designed endoscopes and instruments.Extensive decompression with laminectomy where appropriate, is often still described as the method of choice in the operation of degenerative lumbar spinal stenosis. Nonetheless, tissue-sparing procedures are becoming more common. Endoscopic techniques have become the standard in many areas because of the advantages they offer in surgical technique and in rehabilitation. At the spine, 1 essential point was the developing of the instruments for sufficient bone resection under continuous visual control. This enabled the use in the operation of spinal canal stenoses.A total of 72 patients with lumbar central spinal stenosis full-endoscopic unilateral decompression were followed for 2 years. In addition to general and specific parameters, these measuring instruments were used: VAS, German version North American Spine Society Instrument, Oswestry Low-back Pain Disability Questionnaire.The results show that 70.8% no longer have leg pain or it was nearly completely reduced and 22.2% have occasional pain. The decompression results were equal to those of conventional procedures. The complication rate was low. The full-endoscopic techniques brought advantages in these areas: operation, complications, traumatization, and rehabilitation.The recorded results show that the full-endoscopic interlaminar bilateral decompression with unilateral approach is a sufficient and safe supplement and alternative to conventional procedures when the indication criteria are fulfilled. At the same time, it offers the advantages of a minimally invasive intervention.

A case of late dislocation of a disc spacer L5/S1 with perforation of the sigmoid colon and transanal passage 4 years after implantation is reported. The objective is to describe an uncommon complication of anterior endoscopic spondylodesis L5/S1. To our knowledge, this is the first report on this rare complication. A 39-year-old patient suffering from a spondylolisthesis L5/S1 (Meyerding grade 2) with bilateral lysis L5 was operated with posterior instrumentation L5/S1 and anterior endoscopic insertion of two disc spacers. 4 years after surgery the patient noticed one of the spacers in the toilet. Radiographic examination of the colon with contrast dye revealed a perforation at the distal sigmoid colon. At the lumbosacral junction there was a bony defect at the site of the absent spacer and an anterior dislocation of the second spacer. A partial resection of the colon at the perforation site with end-to-end anastomosis was performed. The second spacer was removed, and the defect was packed with autologous cancellous bone and local antibiotics. The further course was uneventful. 2 weeks postoperatively the patient was discharged without signs of infection. The radiographic examination after 6 months showed healing of the bone graft with bony fusion L5/S1. In case of incomplete or absent bony fusion the dislocation of intradiscal spacers may arise even years after the primary surgery. In consequence periodical radiographic examinations of spinal instrumentations are recommended until complete bony fusion occurred. Unclear abdominal symptoms following anterior spine surgery require immediate examination.

Retrospective case-referent study.To assess whether the new sedimentation sign discriminates between nonspecific low back pain (LBP) and symptomatic lumbar spinal stenosis (LSS).In the diagnosis of LSS, radiologic findings do not always correlate with clinical symptoms, and additional diagnostic signs are needed. In patients without LSS, we observe the sedimentation of lumbar nerve roots to the dorsal part of the dural sac on supine magnetic resonance image scans. In patients with symptomatic and morphologic central LSS, this sedimentation is rarely seen. We named this phenomenon "sedimentation sign" and defined the absence of sedimenting nerve roots as positive sedimentation sign for the diagnosis of LSS.This study included 200 patients. Patients in the LSS group (n = 100) showed claudication with or without LBP and leg pain, a cross-sectional area80 mm, and a walking distance200 m; patients in the LBP group (n = 100) had LBP, no leg pain, no claudication, a cross-sectional area of the dural sac120 mm, and a walking distance1000 m. The frequency of a positive sedimentation sign was compared between the 2 groups, and intraobserver and interobserver reliability were assessed in a random subsample (n = 20).A positive sedimentation sign was identified in 94 patients in the LSS group (94%; 95% confidence interval, 90%-99%) but none in the LBP group (0%; 95% confidence interval, 0%-4%). Reliability was kappa = 1.0 (intraobserver) and kappa = 0.93 (interobserver), respectively. There was no difference in the detection of the sign between segmental levels L1-L5 in the LSS group.A positive sedimentation sign exclusively and reliably occurs in patients with LSS, suggesting its usefulness in clinical practice. Future accuracy studies will address its sensitivity and specificity. If they confirm the sign's high specificity, a positive sedimentation sign can rule in LSS, and, with a high sensitivity, a negative sedimentation sign can rule out LSS.

Object Extensive decompression with laminectomy where appropriate is often still described as the method of choice in surgery for lateral recess stenosis. Nonetheless, tissue-sparing procedures are becoming more common. Endoscopic techniques have become the standard in many areas because of the advantages they offer in surgical technique and in rehabilitation. Transforaminal and interlaminar access provide 2 full-endoscopic (FE) techniques for lumbar spine surgery. The goal of this prospective randomized controlled study was to compare the surgical results for the FE technique via the interlaminar approach with those of the conventional microsurgical technique in patients with degenerative lateral recess stenosis. Methods A total of 161 patients with FE or microsurgical decompression underwent follow-up for 2 years. In addition to general and specific parameters, the following measuring instruments were used: visual analog scale, German version of the North American Spine Society instrument, and the Oswestry low-back pain disability questionnaire. Results The results show that 74.5% of patients reported no longer having leg pain, and 20.5% had only occasional pain. The clinical results were the same in both groups. The rate of complications and revisions was significantly reduced in the FE group. The FE techniques brought advantages in the following areas: operation, complications, traumatization, and rehabilitation. Conclusions The clinical results of the FE interlaminar technique are equal to those of the microsurgical technique. At the same time, there are advantages in the operation technique, such as reduced traumatization. The FE interlaminar spinal decompression procedure is a sufficient and safe supplement and alternative to microsurgical procedures.

Anterior cervical decompression and fusion (ACDF) is the standard for cervical discectomies. With the full-endoscopic anterior cervical discectomy (FACD) a minimally invasive procedure is available. The objective of this prospective, randomised, controlled study was to compare the results of FACD with those of ACDF in mediolateral soft disc herniations. A total of 103 patients with ACDF or FACD were followed up for two years. In addition to general parameters specific measuring instruments were used. Postoperatively 85.9% of the patients no longer had arm pain, and 10.1% had occasional pain. There were no significant clinical differences between the decompression with or without fusion. The full-endoscopic technique afforded advantages in operation technique, rehabilitation and soft tissue injury. The recorded results show that FACD is a sufficient and safe alternative to conventional procedures when the indication criteria are fulfilled. At the same time, it offers the advantages of a minimally invasive intervention.

AIM This prospective report evaluates the clinical outcome of titanium arthroplasty in the management of hallux metatarsophalangeal joints. PATIENTS AND METHODS Eigthy joints in 78 patients were treated surgically with the titanium implant for hallux metatarsophalangeal joints between January 2000 and April 2007. There were 56 women and 22 men. The mean age was 58 (range: 34 - 80) years, and the mean follow-up was 56 (range: 6 - 87) months. The pathological indications were hallux rigidus (85.5 %), metatarsalhead necrosis (8.5 %), revision of Keller-Brandes (3.6 %) and 2 cases were done as a revision of silastic to titanium prosthesis and a revision of pseudarthrosis after arthrodesis (2.4 %). The patients were subsequently examined by means of clinical and radiological assessments. The clinical function was classified using the score of Kitaoka et al. RESULTS The mean time taken to get back to normal activities is 35.2 (range: 21 - 76) days. The average Kitaoka score improved to 75 points (p < 0.05) at 3 months postoperatively and to 85 points (p < 0.05) at 6 months postoperatively. The mean range of motion achieved was 38.6 degrees (range ex 21.5 degrees /flex 17.1 degrees ). CONCLUSION The clinical results of titanium arthroplasty were good. The advantages of this procedure are preservation of joint movement and good pain relief with an early mobilisation.

Lumbar spinal stenosis is a frequent indication for spinal surgery. The predictive quality of treadmill testing and MRI for diagnostic verification is not yet clearly defined. Aim of the current study was to assess correlations between treadmill testing and MRI findings in the lumbar spine. Twenty-five patients with lumbar spinal stenosis were prospectively examined. Treadmill tests were performed and the area of the dural sac and neuroforamina was examined with MRI for the narrowest spinal segment. VAS and ODI were used for clinical assessment. The median age of the patients was 67 years. In the narrowest spinal segment the median area of the dural sac was 91 mm(2). The median ODI was 66 per cent. The median walking distance in the treadmill test was 70 m. The distance reached in the treadmill test correlated with the area of the dural sac (Spearman's rho = 0.53) and ODI (rho = -0.51), but not with the area of the neuroforamina and VAS. The distance reached in the treadmill test predicts the grade of stenosis in MRI but has a limited diagnostic importance for the level of clinical symptoms in lumbar spinal stenosis.

Study design Case report on resection of a hemivertebra at the craniocervical junction. Objective To describe technique and result of a hemivertebra resection within the craniocervical junction (axis). Summary of background data To our knowledge, this is the first report on a transoral and posterior hemivertebra resection at C2. Methods A 42-year-old patient presented with coronal imbalance due to a hemivertebra at C2. Correction was performed by a combined anterior (transoral) and posterior approach with hemivertebra resection and compression instrumentation. Results The postoperative course was uneventful. The radiographs showed a complete correction of the deformity with a perfect clinical result. Conclusion Hemivertebra resection at the craniocervical junction can be performed safely with good clinical and radiographical outcome. Level of evidence 4.

ObjectEven with good results, conventional disc operations may result in subsequent damage due to trauma. Endoscopic techniques have become the standard in many areas because of the advantages they offer intraoperatively and postoperatively in rehabilitation. The goal of this prospective study was to examine the expanded technical possibilities of full-endoscopic transforaminal and interlaminar resection of herniated lumbar discs in which the authors used newly developed optics and instruments. The focus was on questions of achieving sufficient decompression, as well as the advantages and disadvantages of the minimally invasive procedure.MethodsTwo hundred thirty-two patients underwent follow up for 2 years after undergoing surgery. In addition to general and specific parameters, the following measuring instruments were used: a visual analog scale, the German version of the North American Spine Society instrument, and the Oswestry Disability Index of low-back pain disability.Postoperatively 84% of the patients no longer had leg pain, and 12% had only occasional pain. The results of decompression were equivalent to those of conventional procedures. The incidence of traumatization was reduced. Epidural scarring was minimized. The recurrence rate was 6.0%. No serious surgical complications were observed. Resection of the herniated disc was technically possible in all cases in which the new instruments were used.ConclusionsThe authors view the aforedescribed techniques, which offer the advantages of a truly minimally invasive procedure, as a sufficient and safe supplementation and alternative to conventional procedures, when the appropriate indication criteria are heeded. The new endoscope with its 4.2-mm working channel and corresponding instruments significantly reduced the technical problems.

Ziel der prospektiven Studie war es zu untersuchen, ob SaluCartilage-Hydrogelzylinder eine mogliche Alternative bei der Behandlung von schweren Knorpelschaden sind. Die prospektive Studie wurde klinisch, rontgenologisch sowie magnetresonanztomographisch bei 18 Patienten mit Grad-IV-Knorpelschaden, bei denen im Zeitraum von Oktober 2002 bis Juli 2003 49 Hydrogelzylinder implantiert wurden, durchgefuhrt. Die klinische Beurteilung erfolgte mit dem Score nach McDermott. Nach 3 Monaten postoperativ wurde eine signifikante Verbesserung des McDermott-Scores auf 75 Punkte (p

BACKGROUND: Congenital scoliosis due to hemivertebrae usually progresses during further growth and leads to severe deformities. Early correction in young children is therefore required. PATIENTS: Thirty-six hemivertebrae in 33 children aged 1 to 6 years (average 3 years 5 months) underwent surgical intervention. Mean follow-up was 4.5 years (2 months to 13 years). METHODS: The hemivertebra was resected by a posterior approach. The gap after resection was closed by compression via a transpedicular instrumentation, thus correcting the scoliotic deformity. RESULTS: Mean Cobb angle of the main curve was 45.9 degrees preoperatively, 11.9 degrees postoperatively, and 9.9 degrees at latest follow-up. The compensatory cranial curve improved spontaneously from 18.4 degrees preoperatively to 5.0 degrees postoperatively and 3.7 degrees at latest follow-up. The compensatory caudal curve improved from 21.3 degrees to 6.7 and 5.4 degrees. The angle of kyphosis was 22.8 degrees preoperatively, 8.9 degrees postoperatively, and 6.8 degrees at latest follow-up. There was one infection, 2 pedicle fractures, and 3 implant failures. In 3 patients additional operations were performed due to new developing deformities. CONCLUSION: Correction surgery of congenital scoliosis should be performed early before the development of severe local deformities and secondary structural changes. Posterior resection of the hemivertebrae with transpedicular instrumentation allows for early intervention in very young children. Excellent correction in both the frontal and sagittal planes, and a short segment of fusion allow for normal growth in the unaffected parts of the spine.

INTRODUCTION Developmental spondylolisthesis leads to lumbosacral kyphosis with retroversion of the sacrum and lumbar hyperlordosis. The overall sagittal profile of the spine is affected. The deformity is progressive during growth. This retrospective study describes a technique for complete reduction with clinical and radiological evaluation. PATIENTS Thirty-four patients (mean age 16 years 3 months, 10 males, 24 females) with severe developmental spondylolisthesis L5/S1 (Meyerding grades 3 to 5) were operated on between February 1997 and July 2002. METHOD Reduction was achieved by temporary transpedicular instrumentation of L4. These screws were removed at the end of the operation or 12 weeks later. RESULTS Mean slippage was corrected from 76 % preoperatively to 10 % postoperatively. Segmental kyphosis L5/S1 improved from + 21 degrees preoperatively to - 7 degrees postoperatively. Sacral inclination was 34 degrees preoperatively, 43 degrees postoperatively, and 47 degrees at latest follow-up. 76 % of the patients were pain free at the latest follow-up. In 4 patients a fusion at L4/5 was performed due to subsequent decompensation. CONCLUSION The technique described allows for a nearly anatomic reduction with correction of slippage as well as segmental kyphosis. Correction of the local deformity with monosegmental fusion L5/S1 improves dramatically the overall sagittal profile of the spine. Fusion of the primarily healthy segment L4/5 can be avoided.

AIM The following study describes a technique for preoperative planning and computer-assisted correction osteotomy in the treatment of ankylosing spondylitis. The effect on the overall sagittal profile is evaluated. METHOD Kyphosis was corrected by a posterior closing wedge osteotomy. Angle and localisation of the wedge were exactly planned preoperatively and transferred to a navigation system. The osteotomy was then performed along the premarked lines with image-guided tools. Nine patients aged 40 to 61 years (average 46 years) were operated on. Follow-up time averaged 12 months (1 to 33 months). RESULTS The planned angle of the wedge osteotomy was an average of 30 degrees (range 24 degrees to 40 degrees ) preoperatively. Postoperatively, the angle averaged 30 degrees as well (range 22 degrees to 41 degrees ). The individual difference between real and planned angle was an average of 2.7 degrees (range 1 degrees to 6 degrees ). Sacral inclination was 23 degrees preoperatively (range-- 6 degrees to 40 degrees ) and was corrected to 40 degrees (range 27 degrees to 49 degrees ). Anterior displacement of the gravity line averaged 112 mm preoperatively (range 47 to 196 mm) and was corrected to 31 mm (range--7 to 135 mm) postoperatively and 38 mm (range-- 21 to 137 mm) at latest follow-up. CONCLUSION Precise preoperative planning and correction osteotomy exactly according to this planning allow for an excellent correction of the sagittal profile even in severe ankylosing spondylitis. Pelvic tilt and gravity line are normalised, the patient is able to adopt an ergonomic upright position. Navigation facilitates the intraoperative transfer of the preoperative planning.

AIM: To correlate findings of hip ultrasound on day 4-10 of life with sex, intrauterine position and a positive family history for congenital hip anomalies. METHODS: The SNiP-study ( Survey of Neonates In Pommerania) registered 2256 neonates (2030 term, 226 preterm) between May 2002 and March 2004. Hip ultrasound results of 1043 term and since October 2003 33 preterm neonates were analysed. Time of ultrasound was day 4-10 after birth. Preterm neonates were examined when reaching their corrected term gestational age. Ultrasound was applied with a 7.5 MHz linear scanner and results were classified according to Graf. Chi-square and Fishers exact test were used for statistical analysis. RESULTS: 4.9 % of the screened hips were classified as IIc or higher, 3.1 % were unilateral and 1.7 % bilateral. Incidence was significantly higher (p < 0.023) in females (6.6 %) than in males (3.2 %). There was no significant difference in intrauterine position or positive family history for hip anomalies with 3.7 % for mothers, 1.2 % of fathers and 2.4 % of siblings positive. There was a higher incidence for congenital hip dysplasia in preterms with 6.1 %, which is not significant due to the limited number. DISCUSSION: Current screening methods miss up to 18 % of newborns with severe hip dysplasia. We were able to demonstrate that screening for congenital hip dysplasia with ultrasound is a diagnostic tool even during the first days of life. There is a significantly higher incidence of congenital hip dysplasia in females, but in contrast to other studies we found no significant difference in intrauterine position or familial history. Earlier diagnosis and therapy on the base of relevant risk factors might correspond with an improved prognosis and outcome. Further studies are warranted to evaluate the significance in preterm neonates.

AIM Adenoviral gene transfer remains a powerful tool for basic research purposes. We hypothesize that adenoviral transduction of human mesenchymal stem cells (hMSC) in vitro can be improved by refined use of experimental parameters. METHODS hMSCs were transduced by adenoviral vectors encoding Luciferase or BMP-2 at a selection of multiplicities of infection (MOI) and exposure times. Transgene production and total protein content were measured. To determine practical relevance, expression of the bone marker genes Runx2 and Type I collagen was analyzed by quantitative PCR. As a phenotypic marker alkaline phosphatase was assessed. ANOVA and post hoc statistical analyses were used to determine differences among data (p < 0.05). RESULTS Prolonged exposure led to a decrease in transgene production and total protein content. Increasing MOI at exposure of up to 4 hours resulted in a higher production of the transgene. Transfer of the hBMP-2 gene promoted an enhanced lineage progression to the osteoblast phenotype indicating biological activity. CONCLUSION Time of exposure is of major importance for toxicity in vitro and should not exceed 4 hours for hMSC. While increase in exposure time leads to cell death, surviving cells, up to a certain limit, seem to compensate by increasing production of the transgene indicating that transduction efficiency cannot be positively measured in a binary yes-or-no scheme.

AIM Mesenchymal stem cells (MSC) of various species appear to require different cues to differentiate towards the osteoblastic lineage. For MSC of human origin, recombinant hBMP-2 is reported to be not sufficient but dexamethasone seems to be essential. The aim of this study was to analyse changes in genotype and phenotype of hMSC after adenoviral transfer of the BMP-2 gene in the absence of dexamethasone. METHODS We employed hMSC and analysed changes in expression of the Runx2, Osterix and type I collagen gene by quantitative PCR after adenoviral transfer of the human BMP-2 gene in the absence of dexamethasone. As a phenotypic marker alkaline phosphatase activity was assessed. ANOVA and post hoc statistical analyses were used to determine differences among data (p < 0.05). RESULTS Transfer of the hBMP-2 gene and consecutive production of transgenic BMP-2 up-regulated bone marker gene expression and increased alkaline phosphatase activity and thus promoted an enhanced lineage progression to the osteoblast phenotype without the addition of dexamethasone. CONCLUSION These findings are noteworthy in the light of a possible superiority of endogenous transgenic proteins compared to exogenous recombinant proteins.

Background Type 1 diabetes mellitus (DM) has been shown to alter the properties of bone and impair fracture healing in both humans and animals. The objective of this study was to examine changes in the histomorphometrical, histological and mechanical parameters of bone and remodeling during fracture healing, depending on the diabetic metabolic state in spontaneously diabetic BB/O(ttawa)K(arlsburg) rats, a rat strain that represents a close homology to DM in man. Methods On the basis of blood glucose values at the time of surgery, postoperative blood glucose course and postoperative insulin requirements, 90 spontaneously diabetic BB/OK rats were divided into groups with well-compensated or poorly compensated metabolic state. Forty-five LEW.1A rats served as the normoglycemic controls. The femurs were fractured in a standardized procedure and then allowed to heal for 2, 4 and 6 weeks. Results Our study showed that, in terms of bone histomorphometry, within the first 4 weeks after fracture, severe mineralization disorders occurred exclusively in the rats with poorly compensated diabetic metabolic states with a significant decrease of all fluorochrome-based parameters of mineralization, apposition, formation and timing of mineralization, as well as a delay in cellular differentiation and significantly decreased values of biomechanical properties in comparison to the spontaneously diabetic rats with well-compensated metabolic states and to the control rats. Conclusions With a controlled insulin therapy and a resulting well-compensated diabetic metabolic state, mineralization and cellular differentiation disorders, as well as the decreased values of biomechanical properties in the fracture repair in the poorly compensated diabetic metabolic state with very severe hyperglycemia can be avoided. Copyright © 2005 John Wiley & Sons, Ltd.

Aim The objective of this study was to examine changes in the histomorphometrical and mechanical parameters of bone during fracture healing in dependence on the diabetic metabolic state in spontaneously diabetic BB/O(ttawa)K(arlsburg) rats. Methods Based on blood glucose values at the time of surgery, postoperative blood glucose course and postoperative insulin requirements, 90 spontaneously diabetic BB/OK rats were divided into groups with well compensated or poorly compensated metabolic states. Forty-five LEW.1A rats served as the normoglycemic controls. The femurs were fractured in a standardized procedure and then allowed to heal for 2, 4 and 6 weeks. Results In terms of bone histomorphometry, our study showed that, within the first four weeks after fracture, severe mineralization disorders occurred exclusively in the rats with poorly compensated diabetic metabolic states, with a significant decrease of all fluorochrome- based parameters of mineralization, apposition, formation and a significantly prolonged timing of mineralization, as well as significantly decreased values of biomechanical properties in comparison to the spontaneously diabetic rats with well compensated metabolic states and to the control rats. Conclusion With a strictly controlled insulin therapy and a resulting well compensated diabetic metabolic state, severe mineralization disorders and the decreased values of biomechanical properties in the fracture repair in the poorly compensated diabetic metabolic state of the experimental animal can be avoided.

Ziel der Studie war die histomorphometrische und biomechanische Abschatzung des Einflusses der diabetischen Stoffwechsellage auf die Knochendefektheilung in Abhangigkeit von der Defektgrose bei spontandiabetischen BB/OK-Ratten. Anhand der Blutglukosespiegel und des Insulinbedarfs postoperativ wurden 120 spontandiabetische BB/OK-Ratten mit guter und schlechter diabetischer Stoffwechselfuhrung gruppiert. 60 LEW.1A-Ratten dienten als normoglykamische Kontrolltiere. Knochendefekte unterschiedlicher Grose im distalen Femur wurden nach 2, 4 und 6 Wochen Heilung untersucht. Ausschlieslich bei den Ratten mit schlechter diabetischer Stoffwechsellage zeigte sich bei einer Defektgrose ab 0,8 mm eine signifikante Abnahme struktureller Kalkulationen und bei einer Defektgrose ab 1,2 mm signifikant verringerte fluorochromabhangige Parameter fur die Mineralisation, sowie eine signifikante Abnahme der biomechanischen Eigenschaften im Vergleich zu den Ratten mit guter diabetischer Stoffwechselfuhrung und den Kontrollratten. Die Knochendefektheilung kleiner Defekte ist unabhangig von der diabetischen Stoffwechsellage spontandiabetischer BB/OK-Ratten. Mit kontrollierter Insulintherapie und resultierender guter diabetischer Stoffwechsellage konnen die schweren histomorphometrischen und biomechanischen Storungen bei der Knochendefektheilung groserer Defekte mit schlechter diabetischer Stoffwechsellage verhindert werden.

Insulin-dependent type 1 diabetes mellitus (IDDM) has been shown to alter the properties of bone and to impair fracture-healing in both humans and animals. The objective of this study was to examine changes in the histomorphometric and mechanical parameters of bone and remodeling during bone-defect healing, depending on the diabetic metabolic state in spontaneously diabetic BB/O(ttawa)K(arlsburg) rats, a rat strain that represents a close homology to IDDM in humans. A standardized bone-defect model was chosen and based on blood-glucose values at the time of surgery (mg%), postoperative blood-glucose course (mg%), and postoperative insulin requirements (IU/kg). A total of 120 spontaneously diabetic BB/OK rats were divided into groups with a well-compensated (n = 60; 169 +/- 102 mg%; 230 +/- 126 mg%; and 2.2 +/- 1.1 IU/ kg) or poorly compensated (n = 60; 380 +/- 159 mg%; 359 +/- 89 mg%; and 5.4 +/- 1.1 IU/kg) metabolic state. Sixty LEW.1A rats served as the normoglycemic controls (93 +/- 19 mg%). Fifteen animals from each group were killed on postoperative days 7, 14, 24, and 42, and specimens were processed undecalcified for quantitative bone histomorphometry and for biomechanical testing. Our study showed in terms of bone histomorphometry, within the first 14 days, that severe mineralization disorders occurred exclusively in the rats with a poorly compensated diabetic metabolic state with a highly significant (P < 0.001) or significant (P < 0.01) decrease of all fluorochrome-based parameters of mineralization, apposition, formation and timing of mineralization, as well as significantly decreased values of biomechanical properties (P < 0.05) in comparison to the spontaneously diabetic rats with a well-compensated metabolic state and to the control rats. Bone-defect healing in spontaneously diabetic BB/ OK rats is retarded exclusively in a poorly compensated diabetic metabolic state. This study suggests that strictly controlled insulin treatment resulting in a well-compensated diabetic metabolic state will ameliorate the impaired early and late parameters of IDDM bone-defect healing.

Neurilemomas are benign tumours arising from peripheral nerves with a Schwann cell sheath. They are normally painless and slowly growing, rarely causing motor disturbances. Neurilemomas are most common in the cranial nerves, in the trunk, the upper and lower extremities, but may appear anywhere. Especially rare are neurilemomas of the lateral peroneal nerve in the region of the fibular head and in the foot. We present the first detailed report of a neurilemoma localized between the Achilles tendon and the flexor digitorum longus muscle with separation of the tumour from the tibial nerve.

The purpose of our examinations is to determine whether mechanized functional diagnostics can provide evidence of functional deficits in patients after operative treatment of calcaneal fractures, and whether measurable parameters for rehabilitation result. This retrospective study reports on 30 patients with fractures of the calcaneus who were treated between May 1993 and November 1996 with closed and ‘semi-open' repositioning of the fragments and subsequent percutaneous Kirschner wire osteosynthesis according to the ‘AOFAS Ankle-Hindfoot Scale,' followed by isokinetic and gait analytical postoperative examination. Prior to beginning deficit-oriented therapy, the AOFAS Ankle-Hindfoot Scale showed that after operative treatment of calcaneal fractures, 63.3% of the patients had a good to very good outcome. Gait analysis indicated significant deficits in functional mobility during the swing phase, manifesting as a diminishment of the active heel lift. At the time of the final assessment, the findings from gait analysis demonstrated that these deficits were no longer evident to any significant extent. The AOFAS Ankle-Hindfoot Scale from the final assessment yielded an increase in good and very good results to a total of 80.0%. Mechanized functional diagnostics is suited to both the detection of functional deficits following reconstructive surgery on the musculoskeletal system and to devising individual, patient-oriented rehabilitation plans.

The purpose of our examinations was to determine whether gait analysis can provide evidence of functional deficits in patients with surgically treated ruptures of the Achilles tendon, and whether measurable parameters for rehabilitation result. In a retrospective study, we examined 30 patients with traumatic Achilles tendon rupture who had been surgically treated immediately posttraumatically with direct tendon suturing between May 1996 and November 1999. We used gait analysis and applied the Hannover Achilles tendon score with regard to occupational and athletic disability. The average follow-up examination interval was 24 (range 18-28) months. After processing results and placing patients in deficit-oriented therapy, a final assessment was conducted using the score mentioned above and a gait analysis. Prior to beginning deficit-oriented therapy, the 100-point score showed that, after an Achilles tendon rupture, 66.7% of the patients had a good to very good outcome. Gait analysis indicated significant deficits in functional mobility during the swing phase, manifesting as a diminishment of the active heel lift. At the time of the final assessment, the findings from gait analysis demonstrated that these deficits were no longer evident to any significant extent. The 100-point score from the final assessment yielded an increase in good and very good results to a total of 80.0%. Gait analysis is suited to both the detection of functional deficits following reconstructive surgery on the musculoskeletal system and to devising individual, patient-oriented rehabilitation plans.

Cartilage degeneration of the knee joint is considered to be a largely mechanically driven process. We conducted a microstructural and histomorphometric analysis of subchondral bone samples of intact cartilage and in samples with early and higher- grade arthritic degeneration to compare the different states and correlate the findings with the condition of hyaline cartilage. These findings will enable us to evaluate changes in biomechanical properties of subchondral bone during the evolution of arthritic degeneration, for which bone density alone is an insufficient parameter. From a continuous series of 80 patients undergoing implantation of total knee endoprosthesis 30 osteochondral samples with lesions macroscopically classified as ICRS grade 1b (group A) and 30 samples with ICRS grade 3a or 3b lesions (group B) were taken. The bone samples were assessed by 2D histomorphometry (semiautomatic image analysis system) and 3D microstructural analysis (high-resolution micro-CT system). The cartilage was examined using the semiquantitative real-time PCR gene expression of collagen type I and II and aggrecan. Both histomorphometry and microstructural and biomechanical analysis of subchondral bone in groups A and B consistently revealed progressive changes of both bone and cartilage compared with healthy controls. The severity of cartilage degeneration as assessed by RT PCR was significantly correlated with BV/TV (Bone Volume Fraction), Tb.Th (Trabecular Thickness) showed a slight increase. Tb.N (Trabecular Number), Tb.Sp (Trabecular separation) SMI (Structure Model Index), Conn.D (Connectivity Density) and DA (Degree of Anisotropy) were inversely correlated. We saw sclerotic transformation and phagocytic reticulum cells. Bone volume fraction decreased with an increasing distance from the cartilage with the differences compared with healthy controls becoming greater in more advanced cartilage damage. The density of subchondral bone alone is considered an unreliable parameter for classifying changes evolving over time. The progressive damage of subchondral bone seen in the present study correlates well with cartilage changes. Trabecular orientation is also impaired, which explains the changes in biomechanical parameters and the inadequate load transfer and excessive loading of cartilage. Besides subchondral bone density, which in turn correlates with cartilage thickness, other parameters such as structure model index and grade of anisotropy best reflect mechanical properties such as Young modulus, compressive strength, tensile stress, and failure energy. However, it remains unclear whether the mechanical interaction of the mineralized subchondral tissues with articular cartilage works vice versa. The possibility of a biochemical signalling from the degenerating cartilage via the synovial fluid and bone- cartilage crosstalks via subchondral pores may indeed explain a certain depth-dependency of subchondral bone changes.

In appropriate situations, extensive decompression with laminectomy often continues to be described as the method of choice for operations involving lumbar zygoapophyseal joint (z-joint) cysts. Tissue-sparing procedures are nevertheless becoming more common. Endoscopic techniques have become the standard procedures in many areas because of the advantages they offer in terms of surgical technique and in rehabilitation. One key aspect in spinal surgery was the development of instruments for sufficient bone resection carried out under continuous visual control. This enabled endoscopes to be used when operating on z-joint cysts. The objective of this prospective study was to examine the technical possibilities for the full-endoscopic interlaminar and transforaminal technique in lumbar z-joint cysts. A total of 74 patients were followed up for 2 years. The results show that 85% of the patients no longer have any leg pain or that the pain had been almost completely eliminated, and 11 % experience occasional pain. The complication rate was low. The full-endoscopic techniques brought advantages in the following areas: operation, complications, traumatization, and rehabilitation. The recorded results show that full-endoscopic resection of a z-joint cyst using an interlaminar and transforaminal approach provides an adequate and safe supplement, and is an alternative to conventional procedures when the indication criteria are fulfilled. It also offers the advantages of a minimally invasive intervention.