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Zusammenfassung. Gelenkinfektionen stellen einen orthopädischen Notfall dar. Eine verzögerte Diagnose oder Behandlung kann zu schweren Schädigungen im betroffenen Gelenk führen. Zudem stellt die Abgrenzung zu anderen entzündlichen Arthritiden eine Herausforderung dar. Um sowohl eine Verzögerung der Therapie als auch eine Überbehandlung beziehungsweise vorschnelle Operation zu vermeiden, ist die frühzeitige, interdisziplinäre Kooperation zur Planung von Diagnostik und Therapie unerlässlich. Die rechtzeitige Zuweisung in ein Zentrum, welches auf muskuloskelettale Infektionen spezialisiert ist, ist zu empfehlen. Abstriche oder probatorische Antibiotikagabe verfälschen und verzögern die Diagnostik und sollten daher nicht durchgeführt werden.

Zusammenfassung. Die Diagnostik und Behandlung von Patienten mit Gelenkprotheseninfektionen ist eine interdisziplinäre Herausforderung. Der Schlüssel zur Sanierung der periprothetischen Infektion ist eine rasche und adäquate Behandlung in enger Zusammenarbeit des niedergelassenen Arztes mit dem orthopädischen Chirurgen sowie dem Infektiologen. Akute Gelenkprotheseninfektionen treten hauptsächlich in der peri- und früh-postoperativen Phase auf, können aber auch lebenslang nach Implantation als hämatogene oder lymphogene Infektionen auftreten. Beide Situationen stellen eine Notfallsituation dar, die direkt dem orthopädischen Chirurgen oder spezialisierten Zentrum zur Diagnostik und Behandlung zugewiesen werden sollten. Bei akuten Infektionen (d. h. < 4 Wochen postoperativ oder < 3 Wochen Symptome unabhängig vom Implantationszeitpunkt) hat die chirurgische Revision mit Prothesenerhalt (debridement, antibiotics and implant retention, DAIR) eine gute Prognose hinsichtlich der Sanierung der Infektion. Chronische Gelenkprotheseninfektionen benötigen hingegen immer eine aufwendige, interdisziplinäre Behandlung und sollten daher bereits zur Diagnostik, wenn immer möglich, in ein spezialisiertes interdisziplinäres Zentrum überwiesen werden. Ein kompletter Wechsel der Gelenkprothese zur Sanierung der Infektion ist hierbei unumgänglich. Die alleinige Operation ohne adäquate antibiotische Therapie sowie eine antibiotische Therapie ohne korrekte Operation sollte dringend verhindert warden, da sie nicht kurativ und häufig schädlich für den Patienten ist.

Background:Pelvic fractures in the elderly are associated with relevant morbidity and mortality. Both might be determined by fracture morphology and/or patient characteristics. The aim of this project is to investigate the prognostic value of specific fracture characteristics with respect to overall survival and to compare it with an established classification system. Methods:Retrospective analysis of patients ≥60 years, treated conservatively for a CT-scan verified, low-energy pelvic ring fracture between August 2006 and December 2018. Survival data was available from patients’ charts and cantonal or national registries. The prognostic value of fracture characteristic describing the anterior and posterior involvement of the pelvic ring was investigated. This analysis was repeated after patients were stratified into a high-risk vs a low-risk group according to patient characteristic (age, gender, comorbidities, mobility, living situation). This allowed to assess the impact of the different fracture morphologies on mortality in fit vs. frail senior patients separately Results:Overall, 428 patients (83.4% female) with a mean age of 83.7 years were included. Two thirds of patients were still living in their home and mobile without walking aid at baseline. In-hospital mortality was 0.7%, overall, one-year mortality 16.9%. An independent and significant association of age, gender and comorbidities to overall survival was found. Further, the occurrence of a horizontal sacral fracture as well as a ventral comminution or dislocation was associated with an increased mortality. The effect of a horizontal sacral fracture was more accentuated in low-risk patients while the ventral fracture components showed a larger effect on survival in high-risk patients.Conclusion:Specific fracture characteristics may indicate a higher risk of mortality in conservatively treated patients with a low-energy pelvic ring fracture. Hence, they should be taken into account in future treatment algorithms and decisions on patient management.

Background Pelvic fractures in older patients are associated with relevant morbidity and mortality. Both might be determined by fracture morphology and/or patient characteristics. The aim of this project is to investigate the prognostic value of specific fracture characteristics with respect to overall survival and to compare it with an established classification system. Methods Retrospective analysis of patients ≥ 60 years, treated conservatively for a CT-scan verified, low-energy pelvic ring fracture between August 2006 and December 2018. Survival data was available from patients’ charts and cantonal or national registries. The prognostic value of fracture characteristic describing the anterior and posterior involvement of the pelvic ring was investigated. This analysis was repeated after patients were stratified into a high-risk vs a low-risk group according to patient characteristic (age, gender, comorbidities, mobility, living situation). This allowed to assess the impact of the different fracture morphologies on mortality in fit vs. frail senior patients separately. Results Overall, 428 patients (83.4% female) with a mean age of 83.7 years were included. Two thirds of patients were still living in their home and mobile without walking aid at baseline. In-hospital mortality was 0.7%, overall, one-year mortality 16.9%. An independent and significant association of age, gender and comorbidities to overall survival was found. Further, the occurrence of a horizontal sacral fracture as well as a ventral comminution or dislocation was associated with an increased mortality. The effect of a horizontal sacral fracture was more accentuated in low-risk patients while the ventral fracture components showed a larger effect on survival in high-risk patients. Conclusion Specific fracture characteristics may indicate a higher risk of mortality in conservatively treated patients with a low-energy pelvic ring fracture. Hence, they should be taken into account in future treatment algorithms and decisions on patient management.

Objective Pelvic ring fractures in the elderly with osteoporotic bone are often caused by a minor trauma. A separate classification for these fragility fractures of the pelvis (FFP) has been proposed by Rommens. However, at our institution the management algorithm is rather based on patient profile, clinical course and the ability to mobilize than on the fracture category. We aimed to identify fracture characteristics that might better reflect clinical decision making and show an association with outcome. Methods Four fracture characteristics were investigated as potential variables: 1. Extent of the dorsal pelvic ring fracture (absent, unilateral, bilateral); 2. Extent of the ventral pelvic ring fracture (absent, unilateral, bilateral); 3. Ventral comminution/dislocation; 4. Presence of a horizontal sacral fracture. These four characteristics were assessed retrospectively in a series of 548 patients with a CT scan proven FFP. The association of the fracture morphology with the decision to perform surgery, failure of conservative treatment and the length of hospital stay (LOS) was determined. Results Three of the four evaluated characteristics showed an independent and significant association with clinical decision making and patient management. In particular the extent of the dorsal fractures was identified as an independent risk factor for the decision to perform surgery with a 7.3-fold increase per category (p Conclusion Three evaluated morphologic aspects of FFPs showed a clear and independent relation to current clinical decision making and patient management at our institution. Importantly, the ventral fracture component has been shown to have major impact on treatment decision and outcome, which has been underestimated in the current FFP classification system. These four easily distinguishable fracture characteristics have the potential to form the basis of an alternative classification system that matches clinical reality and captures prognostic aspects.

SUMMARY After intramedullary nailing of tibia shaft fractures, torsional malalignment greater than 10 degrees occur in up to 41% of operated legs. The reason is the difficult clinical assessment of rotation intraoperatively, the large variation in absolute torsion of the tibia, and the absence of established reliable methods to fluoroscopically evaluate tibial rotation and compare with the contralateral side. We present here a fast and low-tech intraoperative method on how to achieve identical tibial torsion of the operated and noninjured side. The method can be used for tibia shaft and metaphyseal fractures and only requires a normal C-arm fluoroscope with 2 monitors. First, a true lateral image of the knee on the noninjured side with the femoral condyles aligned is obtained. Second, with the leg and the C-arm rotation and tilt fixed, the fluoroscope is moved parallel to the patient axis and a lateral ankle image is obtained and saved. The fibula position relative to the tibia at the level of the Volkmann tubercle on the lateral view defines the torsion of the tibia. The sequence described above is repeated on the operated side after implantation of the nail before proximal locking. On the operated side, the fibula position relative to the tibia should be identical to the noninjured side before proximal locking takes place. Otherwise, a rotational malalignment is present and must be corrected. The comparison between operated and noninjured side is easy on a fluoroscope with 2 monitors. The complete examination takes a few minutes and has minor additional radiation exposure. We performed the intraoperative torsion control in 10 patients and performed a postoperative low-dose Computer Tomography-control of the torsion of both legs and found the rotational deformity to be less than 10 degrees in all patients.

Nonunion is known to occur in up to 10% of all bone fractures. Until recently, the treatment options considered in cases of delayed union and nonunion focused on revision surgery and improvement of local healing. Lately, teriparatide has been introduced as an osteoanabolic factor that induces fracture healing in cases with delayed or nonunions. We report on a series of five cases of delayed and nonunions treated with teriparatide: delayed unions of an atypical femoral fracture, of a multifragmentary clavicle fracture, and of a periprosthetic humeral fracture, nonunion of a tibial and fibular fracture, and infected nonunion of a tibial and fibular fracture. Based on this series, the indications and limits of application of teriparatide in cases of impaired fracture healing are discussed. Due to the &ldquo, off-label&rdquo, character of this application, informed consent, and cost coverage from the healthcare insurance must be obtained prior to treatment. In our experience and according to the limited existing literature, teriparatide is a safe feasible treatment in cases of delayed and nonunions with a reasonable need of resources. While adequate biomechanical stability remains the cornerstone of fracture healing, as well as healing of nonunions, teriparatide could help avoid repetitive surgeries, especially in atrophic delayed and nonunions, as well as in patients with impaired fracture healing undergoing bisphosphonate therapy. There is an urgent need for widely accepted definitions, standardized protocols, as well as further clinical trials in the field of impaired fracture healing.

Background The aims of this study were to assess and quantify hip abductor muscle strength deficits after total hip arthroplasty (THA) and to determine associations with external factors. Methods Studies reporting on hip abductor muscle strength before and/or after THA performed for osteoarthritis or atraumatic osteonecrosis of the hip were considered for inclusion. Data sources were Embase, Medline, and the Cochrane Central Register of Controlled Trials. Muscle strength on the affected side was compared with the healthy contralateral side or with control subjects. Study quality was assessed using a modified Newcastle-Ottawa Scale. Results Nineteen studies reporting on 875 subjects met the inclusion criteria. Patients scheduled for THA had a mean strength deficit of 18.6% (95% confidence interval (CI) [−33.9, −3.2%]) compared with control subjects. Abductor muscle strength then increased by 20.2% (CI [5.6, 34.8%]) at 4-6 months, 29.6% (CI [4.7, 54.4%]) at 9-12 months, and 49.8% (CI [−31.0, 130.6%]) at 18-24 months postoperatively compared with preoperative values. For unilateral THA, the mean torque ratio was 86.3% (CI [75.4, 97.2%]) and 93.4% (CI [75.1, 111.6%]) before and >24 months after THA, respectively. Study quality was low to moderate. Conclusion Hip abductor muscle strength deficits may gradually improve during 24 months after THA possibly without complete recovery. Cautious interpretation of these findings is warranted because high-quality evidence is largely missing.

Periprosthetic Joint Infections - An Overview

The purpose of this study was to determine the value of magnetic resonance imaging (MRI) for characterization of indeterminate spleen lesions in primary computed tomography (CT) of patients with blunt abdominal trauma. Twenty-five consecutive patients (8 female, 17 male, mean age 51.6 ± 22.4years) with an indeterminate spleen lesion diagnosed at CT after blunt abdominal trauma underwent MRI with T2- and T1-weighted images pre- and post-contrast material administration. MRI studies were reviewed by two radiologists. Age, gender, injury mechanism, injury severity score (ISS), management of patients, time interval between CT and MRI, and length of hospital stay were included into the analysis. Patient history, clinical history, imaging, and 2-month clinical outcome including review of medical records and telephone interviews served as reference standard. From the 25 indeterminate spleen lesions in CT, 11 (44%) were traumatic; nine (36%) were non-traumatic (pseudocysts, n = 5; hemangioma, n = 4) and five proven to represent artifacts in CT. The ISS (P 0.05). The MRI features ill-defined lesion borders, variable signal intensity on T1- and T2-weighted images depending on the age of the hematoma, focal contrast enhancement indicating traumatic pseudoaneurysm, perilesional contrast enhancement, and edema were most indicative for traumatic spleen lesions. As compared with CT (2/25), MRI (5/25) better depicted thin subcapsular hematomas as indicator of traumatic spleen injury. In conclusion, MRI shows value for characterizing indeterminate spleen lesions in primary CT after blunt abdominal trauma.

Zusammenfassung: Heterotope Ossifikationen werden als abnorme Bildung von Knochen in Weichteilgeweben definiert. Man unterscheidet die erworbene von den angeborenen Formen. Die erworbene Form, deren Pathogenese weitgehend ungeklärt ist, wird häufig bei Patienten mit Schädel-Hirn-Trauma, Rückenmarkverletzung, Trauma des Bewegungsapparats oder nach Verbrennungen beobachtet. Klinisch präsentieren sich die heterotopen Ossifikationen häufig symptomfrei, im Initialstadium mit unspezifischen Symptomen, ausgeprägte Formen können jedoch zu schwerwiegenden Funktionseinschränkungen führen. Zur Diagnosesicherung wird insbesondere die Knochenszintigraphie verwendet. Lokale Bestrahlung und nichtsteroidale Antiphlogistika bilden die klassischen Therapie- und Prophylaxeoptionen. In fortgeschrittenen Stadien kann eine chirurgische Resektion notwendig sein

Background. In the pathophysiology of implant failure, metal ions and inflammation-driven osteoclasts (OC) play a crucial role. The aim of this study was to investigate whether vanadium (V) ions induce differentiation of monocytic OC precursors into osteoresorptive multinucleated cells. In addition, the influence of V ions on the activation and function of in vitro generated OC was observed. Methods. Human monocytes and osteoclasts were isolated from peripheral blood monocytic cells (PBMCs). Exposition with increasing concentrations (0–3 μM) of V4+/V5+ ions for 7 days followed. Assessment of OC differentiation, cell viability, and resorptional ability was performed by standard colorimetric cell viability assay 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenil)-2H-tetrazolium (MTS), tartrate-resistant acid phosphatase (TRAP) expression, and functional resorption assays on bone slides during a period of 21 days. Results. No significant differences were noted between V4+/V5+ ions (p>0.05). MTS showed significant reduction in cellular viability by V concentrations above 3 μM (p<0.05). V concentrations above 0.5 μM showed negative effects on OC activation/differentiation. Higher V concentrations showed negative effects on resorptive function (all p<0.05) without affecting cell viability. V4+/V5+ concentrations below 3 μM have negative effects on OC differentiation/function without affecting cell survival. Conclusion. Vanadium-containing implants may reduce implant failure rate by influencing osteoclast activity at the bone-implant interface. V-ligand complexes might offer new treatment options by accumulating in the bone.

We present a 41-year-old man who underwent a cervical discarthroplasty (CDA) C5-6 procedure with an increase of the segmental range of motion from 2.8° to 6.9° and an increase in disc height from 5.8mm preoperatively to 10.4mm postoperatively with an unfavorable long-term clinical outcome. Both anterior cervical discectomy with fusion (ACDF), as well as CDA have been proven to be successful procedures in the management of cervical radiculopathy with good to excellent outcomes and low complication rates. The rationale for CDA over ACDF highlights the preservation of segmental motion and reduction of the incidence of adjacent segment disease. This case report suggests that a hypermobility syndrome and also an overcorrection of the cervical range of motion may be responsible for an unfavorable outcome after CDA.

Hypersensitivity reactions to titanium (Ti) are very rare. Thus, we assessed the proinflammatory response and also potential tolerance favoringin vitroreactivity of human blood lymphocytes and monocytes (PBMC) to Ti in healthy individuals (14 without, 6 with complication-free dental Ti implants). The proliferation index (SI) in lymphocyte transformation test (LTT) and production of cytokines linked to innate immune response (IL-1β, IL-6, and TNFα) or immune regulation (IL-10) were assessed in response to TiO2particles or Ti discs. In both groups, the Ti-LTT reactivity was not enhanced (e.g.,SI<3). The control antigen tetanus toxoid (TT) gave adequate reactivity (median SI individuals without/with implant:20.6±5.97/19.58±2.99). Individuals without implant showed higher cytokine response to Ti materials than individuals with symptom-free implants; for example, TiO2rutile particle induced increase of IL-1β70.27-fold/8.49-fold versus control medium culture. PBMC of 5 of the 6 individuals with complication-free Ti implants showed anex vivoongoing production of IL-10 (mean4.18±2.98 pg/mL)-but none of the 14 controls showed such IL-10 production. Thusin vitroIL-1β-, IL-6-, and TNF-αproduction reflects “normal” unspecific immune response to Ti. This might be reduced by production of tolerogenic IL-10 in individuals with symptom-free Ti dental implants.

OBJECTIVE: : This study was designed to investigate the specific type and incidence of implant failure in patients with a proximal femur fracture treated with a proximal femoral nail antirotation. This device has a helical-shaped blade as a neck-head holding device, instead of the lag screw used in other intramedullary nails. The advantage of the blade is believed to originate from bone impaction and a larger bone-implant interface in comparison with the lag screw design, with consequential greater mechanical resistance to torsion in the cancellous bone. PATIENTS AND METHODS: : This is a retrospective cohort study conducted at the state hospital of Winterthur, Switzerland. From December 2006 until November 2008, 210 consecutive patients were treated with a pertrochanteric femur fracture (OTA type 31-A1, 31-A2, and 31-A3) using a proximal femoral nail antirotation. One hundred and twelve patients were followed up clinically for a minimum of 12 months after discharge. Clinical and radiologic assessment of fracture healing and/or implant failure was investigated. RESULTS: : We report 7 cases of implant failure with a "Cut Through," defined as a postoperative central perforation of the spiral blade into the hip joint, without any displacement of the neck-head fragment. CONCLUSIONS: : Cut through needs to be distinguished from the well-known anterocranial perforation combined with a varus displacement of the neck-head fragment, known as "Cut Out," seen with intramedullary nails utilizing lag screws. LEVEL OF EVIDENCE: : Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Die klassische Zervikobrachialgie entsteht meist akut durch eine bandscheibenbedingte Nervenwurzelkompression oder subakut durch progressive spondylotische Veränderungen der Wirbelsäule. Klinisch präsentiert sich in der Regel ein schmerzhaftes Lokalsyndrom mit oder ohne radikuläre Schmerzenund sensomotorische Defizite. Die exakte Diagnostik erfordert neben Anamnese und zielgerichteter klinischer Untersuchung den bestätigenden Einsatz bildgebender Verfahren. Sofern keine absoluten Operationsindikationen gegeben sind, sollte initial eine konservative Therapie erfolgen. Der Therapieerfolg kann sich interindividuell stark unterscheiden und eine Chronifizierung der Beschwerden kann sowohl nach konservativer als auch nach operativer Therapie auftreten.

Der lumbale Bandscheibenvorfall stellt durch seine hohe Prävalenz und sozialmedizinische Bedeutung ein wichtiges Krankheitsbild dar. Klinisch imponiert er durch Rückenschmerzen mit radikulärer Schmerzausstrahlung; gegebenenfalls auch Sensibilitätsausfällen oder Paresen. Die klinische Verdachtsdiagnose sollte durch eine geeignete Bildgebung überprüft werden, sofern eine Operation in Erwägung gezogen wird. Eine hohe Remissionsrate rechtfertigt in vielen Fällen eine initial konservative Therapie mit adäquater Analgesie und Physiotherapie. Führt dieses Vorgehen in 5 bis 8 Wochen nicht zu einer signifikanten Beschwerdelinderung, ist gegebenenfalls eine Operation indiziert, um das Risiko chronischer Nervenschädigungen zu reduzieren. Das Standardverfahren ist hierbei die posteriore interlaminäre Fensterung in mikrochirurgischer Technik. Nach Monaten bis Jahren kommt es in bis zu 10% der Fälle zu einem lokalen Rezidivvorfall, was bei entsprechender Symptomatik meist eine nochmalige Operation erfordert.

Intrazerebrale Blutungen (ICB) sind für 10-17% aller Schlaganfälle verantwortlich und gehen mit einer hohen Mortalität und Morbidität einher. Von den primären ICB sind über 50% mit einer arteriellen Hypertonie und bis 30% mit einer zerebralen Amyloidose assoziiert. Da mehrere Studien bei Patienten mit supratentoriellen ICB keinen Benefit einer chirurgischen Hämatomevakuation zeigten, ist meist eine primär konservative Therapie indiziert. Bei Patienten mit neurologischen Defiziten und infratentoriellen ICB hingegen kann eine neurochirurgische Evakuation die Prognose deutlich verbessern. Moderne Therapieregime und aktuelle Forschungsbemühungen zielen auf eine frühe Hämostase, ein verbessertes intensivmedizinisches Management und weniger auf invasive chirurgische Interventionen ab, um eine Reduktion sekundärer Gehirnschäden zu erreichen. Im Folgenden wird ein Überblick über die klinische Präsentation, Diagnostik sowie die zur Verfügung stehenden Therapieoptionen gegeben.

Die Syringomyelie umfasst Spaltbildungen im Rückenmark, welche sich beim adulten Patienten meist auf Grundlage einer Chiari-Malformation vom Typ I oder nach einem schweren Wirbelsäulentrauma entwickeln. Das klinische Bild präsentiert sich in der Regel vielfältig, beeinhaltet aber meistens Schmerzen und progrediente neurologische Ausfälle. Im weiteren Verlauf kann es zu muskulärer Atrophie und Aufhebung der Schmerz- und Temperaturempfindung der betroffenen Extremität kommen. Mittels Magnetresonanztomographie kann die Syringomyelie häufig bereits in frühen Stadien diagnostiziert werden. Die interdisziplinäre Therapie umfasst neben einer adäquaten Analgesie und Physiotherapie in ausgewählten Fällen zusätzlich eine operative Behandlungsoption. Insbesondere bei symptomatischen Patienten ist in der Regel eine chirurgische Therapie indiziert, da sonst progressive neurologische Ausfälle, Querschnittsyndrome und chronische neuropathische Schmerzen resultieren können.

Die tiefe Hirnstimulation (THS) ist inzwischen ein etabliertes Verfahren mit zum Teil beeindruckenden Behandlungserfolgen. So kann zum Beispiel eine Stimulation des Nucleus ventralis intermedius den mit dem essentiellen Tremor und idiopathischen Parkinson-Syndrom vergesellschafteten Tremor deutlich verbessern. Auf eine ähnliche Art kann die Stimulation des Nucleus subthalamicus und des Globus pallidus internus zu einer deutlichen Verminderung von Bradykinese, Rigidität und Tremor sowie zu einer Verbesserung der L-Dopa induzierten Dyskinesien bei Patienten mit idiopathischem Parkinson-Syndrom führen. In letzter Zeit wurde die THS auch bei anderen neurologischen und psychiatrischen Erkrankungen eingesetzt. Der genaue Wirkmechanismus auf neuronaler Ebene ist dabei bis heute nicht vollständig geklärt. Unabhängig von der zugrunde liegenden Erkrankung und der chirurgischen Elektrodenplatzierung sind die sorgfältige Patientenselektion sowie die Indikationsstellung für den Erfolg von entscheidender Bedeutung.

Das Kraniopharyngeom (KP) ist ein seltener dysontogenetischer Tumor, der seinen Ursprung entweder von versprengten Ductus-craniopharyngeus-Inseln nimmt oder sich metaplastisch von adenohypophysaren Parenchymzellen herleitet. Trotz Klassifizierung als WHO-Klasse-I-Tumor kann sich das histologisch benigne KP hierbei zuweilen sehr aggressiv verhalten. Das KP wird meist vor dem 20. Lebensjahr manifest. Patienten klagen oft uber Kopfschmerzen, je nach Lokalisation kann auch ein Chiasmasyndrom auftreten. Eine begleitende Hypophysenvorderlappeninsuffizienz manifestiert sich bei Kindern in der Regel in Form einer Wachstumsverzogerung. Zusatzlich kann bei Kompression des Hypophysenhinterlappens ein Diabetes insipidus oder bei Infiltration des Hypothalamus eine Adipositas auftreten. Therapeutisch kommt sowohl die radikale chirurgische Entfernung als auch die Teilresektion mit adjuvanter Radiotherapie zum Einsatz, bei zystischen Tumoren evtl. auch eine stereotaktische Zystendrainage mit erganzender Bestrahlung. Die Prognose hangt massgebend von der fruhzeitigen Diagnosestellung ab. ABSTRACT: The craniopharyngioma is a rare dysontogenetic tumour that originates from either scattered cells of the craniopharyngeal duct or from metaplastically mutated anterior pituitary parenchyma cells. Despite being classified as a WHO-Class-I tumour, the histologically benign craniopharyngioma may display an aggressive behaviour. Like other congenital tumours, it usually becomes manifest within the first two decades of life. Patients typically complain of headache and a chiasma syndrome with bitemporal hemianopsy may develop depending on tumour localisation. In children, anterior pituitary insufficiency often manifests as growth restriction. Additionally, diabetes insipidus and other hormonal disturbances may develop. Therapeutically either radical total removal or subtotal resection in combination with postoperative radiation is recommended. In cystic tumors, stereotactic cyst drainage and adjuvant radiation may be a possible alternative. The prognosis is best in patients who are diagnosed early.

Background: An enhanced fracture healing response has been reported in patients with traumatic brain injury (TBI). This has been attributed to circulating humoral factors that are thought to be proteins produced and released by the injured brain. However, these factors remain unknown. The aim of this study was to identify osteogenic factors in serum and cerebrospinal fluid (CSF) from TBI patients. This was carried out using in vitro proliferation assays with the human foetal osteoblastic 1.19 cell line (hFOB) combined with a novel proteomic approach. Methods: Serum was collected from brain-injured (n = 12) and non-brain-injured (n = 9) patients with a comorbid femur shaft fracture. Similarly, CSF was obtained from TBI (n = 7) and non-TBI (n = 9) patients. The osteoinductive potential of these samples was determined by measuring the in vitro proliferation rate of hFOB cells. Highly osteogenic serum and CSF samples of TBI patients were chosen for protein analysis and were compared to those of non-brain-injured patients. A new hFOB cell-based method was used to enrich the proteins in these samples, which had a functional affinity for these osteoprogenitor cells. These enriched protein fractions were mapped using two-dimensional gel electrophoresis and protein imaging methods displaying serum and CSF proteins of brain-injured and control subjects that had an affinity for human osteoprogenitor cells. Results: Serum and CSF derived from brain-injured patients demonstrated a greater osteoinductive potential (P Language: en

Patients who undergo surgery to the esophagus and lungs are in jeopardy of recurrent laryngeal nerve (RLN) damage during the procedure. This study was designed to investigate the feasibility of intraoperative monitoring of the RLN for single-lung ventilation esophagus and lung surgery.Twelve consecutive patients booked for esophagus or lung surgery were included in this prospective, observational study. Six patients underwent transthoracic esophagectomy for carcinoma of the esophagogastric junction or lower esophagus, five had a lobectomy, and one underwent a pneumonectomy for lung carcinoma. Intraoperative, noninvasive RLN identification and monitoring was performed unilaterally (n = 8) or bilaterally (n = 4) using a handheld stimulator and a laryngeal surface electrode. The correct functioning of the nerve monitoring system was tested directly at the vagus nerve. Diagnosis of postoperative RLN paralysis was performed using indirect laryngoscopy.During the surgical procedures, we monitored a nerve signal in all 12 patients. In one patient with lower esophagus carcinoma, a nerve signal could be detected only on one side. Postoperative indirect laryngoscopy showed normal vocal cord movement in all patients.Intraoperative RLN identification and monitoring during single-lung ventilation surgery is technically feasible, easy, and reliable. The introduction of standardized RLN monitoring during this type of surgery may reduce the incidence of permanent RLN paralysis.

Das Leitsymptom der aneurysmatischen Subarachnoidalblutung (aSAB) ist der so genannte «Vernichtungskopfschmerz», welcher von Nackensteifigkeit, Bewusstseinsstörungen sowie vegetativen Symptomen begleitet sein kann. Bei klinischer Verdachtsdiagnose wird initial eine native Computertomographie (CT) durchgeführt. Die Lokalisation und Morphologie des Aneurysmas wird mit Hilfe einer CT-Angiographie und/oder konventionellen Panangiographie dargestellt. Bis zur definitiven Aneurysmaausschaltung mittels mikrochirurgischen Clippings oder endovaskulären Coilings sollte eine Nachblutung unbedingt verhindert werden. Die post-operative Phase ist insbesondere bei Patienten mit höhergradiger aSAB mit dem Auftreten krankheitsspezifischer Komplikationen (zerebrale Vasospasmen, intrakranielle Hypertension, Krampfanfälle, Hydrozephalus) und konsekutiv erhöhtem Risiko für sekundäre Hirnschäden geprägt. Zusätzlich präsentieren viele Patienten systemische Komplikationen wie z.B. Elektrolytstörungen und kardiale Dysfunktionen. Durch rechtzeitiges Erkennen der zerebralen und systemischen Komplikationen können entsprechende Gegenmassnahmen getroffen werden, um den klinisch-funktionellen Outcome zu verbessern.

The management of patients with aneurysmal subarachnoid hemorrhage (SAH) requires a fundamental knowledge of the disease, its therapeutic options and possible complications. The preoperative goal is to prevent rebleeding by controlling blood pressure and treating pain and anxiety as well as stabilizing cardiopulmonary functions. An acute hydrocephalus has to be treated immediately. Microsurgical clipping or endovascular coiling are the therapeutic options available. The postoperative goal aims at securing cardiopulmonary functions as well as recognizing and treating cerebral (cerebral vasospasm, hydrocephalus, epilepsy) and systemic complications (electrolyte disorder, cardiac dysfunction). This article provides an overview about the pre-, peri- and postoperative management of patients with SAH.

Metal implants are essential therapeutic tools for the treatment of bone fractures and joint replacements. The metals and metal alloys used in contemporary orthopedic and trauma surgery are well tolerated by the majority of patients. However, complications resulting from inflammatory and immune reactions to metal implants have been well documented. This review briefly discusses the different mechanisms of metal implant corrosion in the human body, which lead to the release of significant levels of metal ions into the peri-implant tissues and the systemic blood circulation. Additionally, this article reviews the effects of the released ions on bone metabolism and the immune system and discusses their involvement in the pathophysiological mechanisms of aseptic loosening and metal hypersensitivity in patients with metal implants.

There is increasing evidence that titanium ions are released from orthopedic implants by biocorrosion. The aim of this study was to investigate titanium uptake by human T-lymphocytes and its effects on phenotype and proliferation. Freshly isolated human nonadherent peripheral blood mononuclear cells (NA-PBMC), were exposed to TiCl4 [Ti(IV)]. Bioavailability and distribution of Ti(IV) in T-lymphocytes was determined by energy-filtered electron microscopy (EFTEM). The effects of Ti(IV) challenge on nonactivated and PHA-activated cells were assessed by flow cytometric analysis of surface markers, RANK-L production, and proliferation assays. EFTEM colocalized Ti(IV) with phosphorus in the nucleus, ribosomes, cytoplasmic membranes, and the surface membrane of T-lymphocytes. Ti(IV) increased significantly the expression of CD69, CCR4, and RANK-L in a concentration-dependent manner. Titanium enters T-lymphocytes through a currently unknown mechanism and binds to phosphorus-rich cell structures. Titanium influences phenotype and function of T-lymphocytes, resulting in activation of a CD69+ and CCR4+ T-lymphocyte population and secretion of RANK-L. These results strongly suggest the involvement of titanium ions challenged T-lymphocytes in the complex pathophysiological mechanisms of aseptic loosening of orthopedic implants.

Normaldruckhydrozephalus (NPH = normal pressure hydrocephalus) ist ein Syndrom, welches durch die Symptomen-Trias Gangstörungen, Urininkontinenz und demenzielle Entwicklung charakterisiert ist, wobei die Gangstörung das Kardinalsymptom darstellt. Der NPH ist mit einer radiologisch verifizierbaren Ventrikelerweiterung ohne wesentlich erhöhten intrakraniellen Druck vergesellschaftet. Da sich viele Patienten nicht mit den klassischen klinischen und bildgebenden Befunden eines NPH präsentieren, stellt die Diagnosestellung und das Management der fortschreitenden Erkrankung eine Herausforderung für die behandelnden Hausärzte, Neurologen und Neurochirurgen dar. Eine Reihe von ergänzenden präoperativen Untersuchungen wie zum Beispiel die lumbale Liquorpunktion oder der Liquorinfusionstest liefern Hinweise auf das Ansprechen einer chirurgischen Intervention. Eine permanente Liquorableitung über einen Shunt führt bei der Mehrzahl eines vorsichtig ausgewählten Patientenkollektives zu einer signifikanten klinischen Verbesserung. Im Folgenden werden sowohl die klinischen Aspekte und die Diagnostik und die aktuellsten Therapieoptionen des NPH praxisnah besprochen.

Maligne Gliome, darunter das Glioblastoma multiforme, sind die häufigsten Tumoren des Gehirns. Das Glioblastom stellt dabei den ungünstigsten Tumor dar. In der Schweiz erkranken jedes Jahr ca. 450 Menschen an einem Glioblastoma multiforme. Die mediane Überlebenszeit liegt unter 12 Monaten, die Prognose ist also trotz Kombinationstherapie düster. Die chirurgische Resektion bildet den Hauptbestandteil des Managements von Patienten mit einem Glioblastom. Postoperative Radio- und Chemotherapie haben einen günstigen Einfluss auf die Überlebenszeit sowie auf die Lebensqualität. Glioblastome sind aufgrund ihres infiltrativen Wachstums operativ nur schwer zu entfernen und das angestrebte Resektionsausmass kann meist nur zum Teil ausgeschöpft werden. Seit einiger Zeit wird nun an der Neurochirurgischen Klinik des Kantonsspitals St. Gallen eine neue, in Deutschland entwickelte Methode angewendet: Die 5-ALA-gestützte mikrochirurgische Operationstechnik erlaubt eine zielgesteuerte und sichere operative Entfernung der Tumoranteile. Eine präoperativ verabreichte Substanz färbt den Tumor ein und macht ihn damit für den Neurochirurgen leichter erkennbar. Somit kann das gesunde Hirngewebe besser vom Tumorgewebe abgegrenzt werden. Dies erlaubt nicht nur eine weitestgehende chirurgische Resektion des Tumorgewebes, sondern minimiert auch die Resektion gesunden Gewebes.

Cerebral microdialysis (CMD) is a minimal-invasive monitoring technique for patients with subarachnoidal haemorrhage or severe traumatic brain injury, which allows the investigation of a wide spectrum of compounds in the brain tissue. The aim is a precocious identification of cerebral ischemia and secondary brain damage. The method was introduced in the early 1970s. By using commercial equipment it is nowadays possible to conduct on-line analysis at the bedside in the intensive care unit. The following article discusses the principles of CMD, the most commonly used biomarkers and the options during neurointensive care.

Bei bis zu 10% der Patienten mit «Low Back Pain» kommt es zu chronischen Kreuzschmerzen, welche per definitionem über einen Zeitraum von mindestens drei Monaten bestehen. Dieses Krankheitsbild hat gravierende Auswirkungen auf die psycho-soziale und physische Integrität der betroffenen Personen. Schmerzsyndrome der Lendenwirbelsäule verursachen jährlich direkte und indirekte Kosten von 150–250 Milliarden Schweizer Franken. Trotz intensiver Behandlung bleiben einige Patienten symptomatisch. Daraus resultiert eine beschwerdebedingte funktionelle Unterbelastung, welche zu einer Verminderung der Leistungsfähigkeit und einer verstärkten Inaktivität führt – der Beginn eines Teufelskreislaufs. Ein multimodales Behandlungskonzept mit physio- und psychotherapeutischer Behandlung, welches von einer gezielten medikamentösen Therapie unterstützt wird, verbessert die körperlichen Funktionen und bewirkt eine deutliche Beschwerdereduktion. Bei länger andauernder Therapieresistenz ist es sinnvoll, frühzeitig minimal-invasive oder invasive Therapieoptionen in Erwägung zu ziehen.

Background: Scientific evidence is mounting for an association between traumatic brain injury and enhanced osteogenesis. The aim of this study was to correlate the in vitro osteoinductive potential of serum with the features of fracture-healing and the extent of brain damage in patients with severe traumatic brain injury and bone fracture. Methods: Patients with a long-bone fracture and a traumatic brain injury (seventeen patients) or without a brain injury (twenty-four patients) were recruited. The Glasgow Coma Scale score was determined on admission. Radiographs of the fracture were made before surgery, at six weeks, and at three, six, and twelve months after surgery. The time to union was estimated clinically and radiographically, and the callus ratio to shaft diameter was calculated. Serum samples were collected at six, twenty-four, seventy-two, and 168 hours after injury, and their osteogenic potential was determined by measurement of the in vitro proliferation rate of the human fetal osteoblastic cell line hFOB1.19. Results: Patients with a traumatic brain injury had a twofold shorter time to union (p = 0.01), a 37% to 50% increased callus ratio (p < 0.01), and their sera induced a higher proliferation rate in hFOB cells (p < 0.05). A linear relationship was revealed between hFOB cell proliferation rates and the amount of callus formed (p < 0.05). The Glasgow Coma Scale score was correlated with the callus ratio on both radiographic projections (p < 0.05), time to union (p = 0.04), and the proliferation rate of hFOB cells at six hours after injury (p = 0.03). Conclusions: Patients with a severe brain injury release unknown humoral factors into the blood circulation that enhance and accelerate fracture-healing.

Most metals in contact with biological systems undergo corrosion by an electrochemical process. This study investigated whether human osteoclasts (OC) are able to grow on stainless steel (SS) and directly corrode the metal alloy leading to the formation of corresponding metal ions, which may cause inflammatory reactions and activate the immune system. Scanning electron microscopy analysis demonstrated long-term viable OC cultures and evident resorption features on the surface of SS discs on which OC were cultured for 21 days. The findings were confirmed by atomic emission spectrometry investigations showing significantly increased levels of chromium, nickel, and manganese in the supernatant of OC cultures. Furthermore, significant levels of pro-inflammatory cytokines IL-1beta, IL-6, and TNF-alpha, which are considered to be major mediators of osteolysis, were revealed in the same cultures by cytometric bead array analysis. Within the present study, it was shown that human osteoclast precursors are able to grow and differentiate towards mature OC on SS. The mature cells are able to directly corrode the metal surface and release corresponding metal ions, which induce the secretion of pro-inflammatory cytokines that are known to enhance osteoclast differentiation, activation, and survival. Enhanced corrosion and the subsequently released metal ions may therefore result in enhanced osteolytic lesions in the peri-prosthetic bone, contributing to the aseptic loosening of the implant.

Die lumbale Spinalkanalstenose (SKS) ist als Einengung des Spinalkanals mitsamt neuralen und vaskulären Strukturen durch das umgebende Knochen- und Weichteilgewebe definiert. Bei Patienten über 65 Jahren gehört die SKS zu den häufigsten Ursachen von Kreuzschmerzen, mit oder ohne Schmerzausstrahlung in die Beine. Die Prävalenz wird aufgrund der steigenden Lebenserwartung zunehmen. Leitsymptom ist die Claudicatio spinalis, mit lumboglutealen oder ischialgieformen Schmerzen, die beim Gehen auftreten und zu einer Einschränkung der Gehstrecke führen. Die typische Symptomkonstellation von Claudicatio spinalis mit subjektiver Beinschwäche führt zur Verdachtsdiagnose. Das bildgebende Verfahren der Wahl zur Diagnosestellung ist heutzutage die Magnetresonanztomographie. Eine konservative Therapie ist initial in den meisten Fällen ausreichend. Die Operationsindikation ist gegeben, wenn die Schmerzen und die Einschränkung der Gehstrecke nicht mehr toleriert werden. Eine zusätzliche Fusion muss bei degenerativer Spondylolisthese und anderen pathomorphologischen Veränderungen, die zu einer Instabilität führen, in Betracht gezogen werden. Konservative und operative Behandlungsziele beinhalten primär neben der Schmerzlinderung die Verbesserung der körperlichen Funktionalität, Mobilität und allgemeinen Lebensqualität.

Akute Rückenschmerzen gehören zu einem der häufigsten Gründe für einen Hausarzt- oder Notarztbesuch. Bis zu 90% der Erwachsenen leiden im Laufe ihres Lebens an mindestens einer Rückenschmerzepisode.Obwohl es sich bei den meisten Patienten um ein unkompliziertes, gutartiges Krankheitsbild handelt und es bei 80–90% der Betroffenen innerhalb von 4 bis 6 Wochen zu einer Beschwerdebesserung kommt, liegen bei einem kleinen Anteil schwerwiegende Krankheitsbilder zugrunde. Zu diesen gehören unter anderem eine Aortendissektion, ein rupturiertes Aortenaneurysma, eine vertebrale Osteomyelitis, ein spinaler epiduraler Abszess und das Caudaequina- Syndrom (CES). Letzteres beinhaltet die akute Komprimierung der Nervenwurzeln der Cauda equina. Die Patienten präsentieren sich häufig posttraumatisch mit Rückenschmerzen und der klinischen Trias: Reithosenanästhesie, Blasen- oder Mastdarmfunktionsstörungen und muskuläre Schwäche der unteren Extremitäten. Eine verzögerte Diagnose und Behandlung kann zu einer signifikant erhöhten Morbidität führen. Deshalb sind eine frühzeitige Diagnose und die Einleitung der notwendigen therapeutischen Schritte essentiell. Ausführliche Patientenanamnese und körperliche Untersuchung führen zur Verdachtsdiagnose. Im Folgenden werden klinische Präsentation, Diagnostik und massgebende Therapie des CES praxisnah besprochen.

Akute Kreuzschmerzen sind ein sehr häufiges Symptom. Bis zu 90% der Erwachsenen leiden im Laufe ihres Lebens mindestens einmal an einer Kreuzschmerz-Episode. Meistens handelt es sich dabei um mechanische Lumbalgien. Diese sind, mit oder ohne Schmerzausstrahlung in die Beine, normalerweise selbstlimitierend, haben keine schwerwiegende zugrunde liegende Pathologie und klingen bei 80–90% der Betroffenen innerhalb von 6 Wochen ab. Im Zentrum der therapeutischen Bemühungen stehen neben der medikamentösen und physiotherapeutischen Behandlung die eingehende Aufklärung des Betroffenen über den grundsätzlich benignen Charakter und die günstige Prognose seiner Beschwerden. Eine genauere Untersuchung ist bei gewissen Patienten mit Warnzeichen, sogenannten „red flags”, erforderlich, da diese mit einem erhöhten Risiko eines Caudaequina- Syndroms, eines Tumors, einer Infektion oder einer Fraktur vergesellschaftet sein können. Diese Patienten benötigen ebenfalls eine engmaschigere Nachbetreuung und in seltenen Fällen sogar eine notfallmässige chirurgische Intervention. Bei Patienten mit unspezifischen mechanischen Kreuzschmerzen kann die bildgebende Diagnostik für mindestens vier bis sechs Wochen verzögert werden. Dies führt normalerweise von selbst zu einem Beschwerderückgang. Therapeutisch gesehen gibt es genügend Evidenz für die Wirksamkeit von Paracetamol, nichtsteroidalen antiinflammatorischen Medikamenten, Muskelrelaxantien, Wärmeapplikation, Physiotherapie und den Ratschlag „aktiv” zu bleiben. Eine vollständige Entlastung und Schonung stellen ein überholtes Konzept dar, weil dadurch die Dekonditionierung gefördert und die Rückkehr an den Arbeitsplatz unnötig verzögert wird. Die manualmedizinische Behandlung kann bei gewissen Patienten zu einer kurzzeitigen Beschwerdelinderung führen. In einem multimodalen Behandlungskonzept sollte sich die Patientenschulung auf den natürlichen Verlauf des Rückenschmerzes, die insgesamt gute Prognose und Vorschläge für eine effektive Therapie konzentrieren.

Background aims. Fractures with a critical size bone defect (e.g., open fracture with segmental bone loss) are associated with high rates of delayed union and non-union. The prevention and treatment of these complications remain a serious issue in trauma and orthopaedic surgery. Autologous cancellous bone grafting is a well-established and widely used technique. However, it has drawbacks related to availability, increased morbidity and insufficient efficacy. Mesenchymal stromal cells can potentially be used to improve fracture healing. In particular, human fat tissue has been identified as a good source of multilineage adipose-derived stem cells, which can be differentiated into osteoblasts. The main issue is that mesenchymal stromal cells are a heterogeneous population of progenitors and lineage-committed cells harboring a broad range of regenerative properties. This heterogeneity is also mirrored in the differentiation potential of these cells. In the present study, we sought to test the possibility to enrich defined subpopulations of stem/progenitor cells for direct therapeutic application without requiring an in vitro expansion. Methods. We enriched a CD146+NG2+CD45– population of pericytes from freshly isolated stromal vascular fraction from mouse fat tissue and tested their osteogenic differentiation capacity in vitro and in vivo in a mouse model for critical size bone injury. Results. Our results confirm the ability of enriched CD146+NG2+CD45– cells to efficiently generate osteoblasts in vitro , to colonize cancellous bone scaffolds and to successfully contribute to regeneration of large bone defects in vivo . Conclusions. This study represents proof of principle for the direct use of enriched populations of cells with stem/progenitor identity for therapeutic applications.

In vitro studies suggest that human osteoclasts (OC) are able to corrode surgical stainless steel 316L (SS). The aim of this study was to investigate whether osteoclastic biocorrosion can be blocked pharmacologically. Human OCs were generated in vitro from peripheral blood monocytic cells (PBMCs) in the presence of OC differentiation cytokines. The osteoclastic viability, differentiation, and resorptive function (on both bone and SS) were assessed using standard colorimetric cell viability assay 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenil)-2H-tetrazolium, inner salt (MTS), fluorescence microscopy, tartrate-resistant acid phosphatase expression (flow cytometry), and scanning electron microscopy. OCs cultured on SS were exposed to nontoxic concentrations of bafilomycin A1, amiloride hydrochloride, or zoledronic acid. The extent of biocorrosion was quantified using atomic emission spectrometry (to measure the concentration of metal ions released into the supernatant) and scanning electron microscopy. PBMCs differentiated into mature and functional OC in the presence of all the drugs used. Osteoclastic resorption of SS was noted with differences in the resorption pattern for all drug treatments. Under the drug treatments, single areas of osteoclastic resorption were larger in size but less abundant when compared with positive controls. None of the drugs used were able to inhibit osteoclastic biocorrosion of SS.

Extensive space occupying strokes occur in about 1-10% of all ischaemic supratentorial infarctions. Both the high mortality and morbidity primarily result from secondary brain damage due to an accompanying brain edema. Therefore, the primary therapeutic target in patients with space occupying strokes is the control of the brain edema and the consecutively elevated intracranial pressure. If intracranial pressure cannot be controlled by conservative treatment methods, a decompressive craniectomy (DC) is a possible treatment option in selected patients to reduce intracranial pressure. In this review recommendations from the surgeon's perspective are given concerning the indication and timing of DC in patients with space occupying supra- and infratentorial cerebral infarctions.

Background: There is mounting evidence to suggest the involvement of the immune system by means of activation by metal ions released via biocorrosion, in the pathophysiologic mechanisms of aseptic loosening of orthopedic implants. However, the detailed mechanisms of how metal ions become antigenic and are presented to T-lymphocytes, in addition to how the local inflammatory response is driven, remain to be investigated. Methods: Human T-lymphocytes were cultured in the presence of a variety of metal ions before investigating functional and phenotypic changes using flow cytometric analysis. Additionally, human monocyte-derived dendritic cells (mDC) loaded with metal ions were used as antigen-presenting cells and incubated with naive T-lymphocytes with the aim of generating titanium-specific T-lymphocytes. Results: Using an autologous in vitro model, with mDC treated with Titanium (IV), we were able to induce Titanium (IV)-specific T-lymphocytes. These T-lymphocytes responded in a dose-related manner to Titanium (IV), while they did not cross-react with Titanium (III) or other metal ions, indicating that the new antigenic peptide complexes formed by Titanium (IV) are highly specific. Conclusion: This study showed that mDC exposed to Titanium (IV) are able to induce the generation of Titanium (IV)-specific T-lymphocytes, demonstrating the strong and specific antigenicity of Titanium (IV) ions released by biocorrosion.

Spinal cordectomy has been described as an effective treatment option in paraplegic patients for the treatment of syringomyelia to manage spasticity, pain and ascending neurological dysfunction. The objective of this study was to investigate the long-term health-related quality of life (HRQoL) after cordectomy in patients with intractable symptoms caused by syringomyelia. Seventeen patients underwent spinal cordectomy for syringomyelia between February 2000 and July 2009. The etiology of syringomyelia was traumatic in 16 patients and spinal ependymoma in one patient. The mean follow-up was 3.8 years (range, 0.9–10.3). The HRQoL was assessed pre- and postoperatively using the EuroQol (EQ; degree of discomfort: 1 = none, 2 = moderate and 3 = extreme) and the short-form SF-36 quality of life score (SF-36). All patients underwent a telephone interview. The mean pre- and postoperative EuroQol-levels for mobility were 1.8 and 1.5; for self-care, 1.9 and 1.5; for usual activities, 2.1 and 1.5; for pain/discomfort, 2.3 and 2.0; and for anxiety/depression, 1.7 and 1.5, respectively. The mean overall EQ visual analogue scale improved postoperatively from 42 points (range, 15–80) to 67 points (range, 10–95) (p = 0.006). The component summary measure for mental health (SF-36) significantly improved postoperatively (p = 0.01). A telephone interview revealed a high subjective patient satisfactory (94.1%) in terms of postoperative sequelae. Following the intervention, 58.8% of all patients were employed full or part-time. Spinal cordectomy may increase the quality of life and can be considered as an ultimo ratio therapy in a selective group of patients with intractable symptoms caused by syringomyelia.

An enhanced fracture healing response has been reported in patients with traumatic brain injury (TBI). This has been attributed to circulating humoral factors that are thought to be proteins produced and released by the injured brain. However, these factors remain unknown. The aim of this study was to identify osteogenic factors in serum and cerebrospinal fluid (CSF) from TBI patients. This was carried out using in vitro proliferation assays with the human foetal osteoblastic 1.19 cell line (hFOB) combined with a novel proteomic approach.Serum was collected from brain-injured (n = 12) and non-brain-injured (n = 9) patients with a comorbid femur shaft fracture. Similarly, CSF was obtained from TBI (n = 7) and non-TBI (n = 9) patients. The osteoinductive potential of these samples was determined by measuring the in vitro proliferation rate of hFOB cells. Highly osteogenic serum and CSF samples of TBI patients were chosen for protein analysis and were compared to those of non-brain-injured patients. A new hFOB cell-based method was used to enrich the proteins in these samples, which had a functional affinity for these osteoprogenitor cells. These enriched protein fractions were mapped using two-dimensional gel electrophoresis and protein imaging methods displaying serum and CSF proteins of brain-injured and control subjects that had an affinity for human osteoprogenitor cells.Serum and CSF derived from brain-injured patients demonstrated a greater osteoinductive potential (P0.05) than their non-brain-injured counterparts. Clear-cut differences in the pattern of proteins in two-dimensional gels were detected between TBI and control patients. Fourteen proteins were exclusively present in the serum of TBI patients, while other proteins were either up- or downregulated in samples collected from TBI patients (P0.05).Osteoinductive factors are present in the serum and CSF of brain-injured patients. These may include one or more of those proteins identified as having an affinity for osteoprogenitor cells that are either exclusively present or up- or downregulated in the serum and CSF of brain-injured patients.