Search

A 17-year old soccer-player sustained a fracture and dislocation of the ulnar epicondyle combined with a bone bruises at the radial head and the capitellum. An open reduction and internal fixation was performed using two K-wires. Initial recovery was uneventful. After the operation he was discharged home and reviewed on a regular basis. When bony union had occurred the two K-wires were removed. However, on follow up he continued to complain of pain on the radial aspect of the joint and did not regain his normal range of movement. A further MRI was performed. Now a grade II osteochondritis dissecans not visible on the previous MRI taken 12 weeks earlier was clearly visualised. Treatment was continued conservatively with physiotherapy but avoiding aggressive mobilisation. On final review 6 months later he was able to move painfree with residual limitation of movement (ROM 0–5–130°). Another MRI taken now was assessed as normal. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the short and medium term efficacy and patient outcomes of DIAM spinal stabilization system on back pain, disability, leg pain and quality of life., Methods: 165 patients were enrolled; 146 patients with a single level disc herniation (L2 to L5) were randomized: 75 investigational (herniectomy and DIAM) and 71 control (herniectomy alone) treated and followed up for 24 months., Results: Significant improvements overtime (P < 0.001) in both groups but not significantly different between groups for visual analog scale (VAS) back pain at 6 months (investigational -3.97 ± 2.55 vs control-3.37 ± 3.15, P = 0.228) and Oswestry Disability Index (ODI) at 12 months (-38.55 ± 20.10 vs -37.19 ± 22.61, P = 0.719). For both outcomes, there was no statistically significant difference between the groups, at all postoperative time points. Although the enrolment ended before the intended sample size (308 patients) was reached, the number of patients reaching the VAS back pain minimally clinically important difference (MCID) of ≥2.2 at 6 months was higher in the investigational (79.4 % vs control 57.1 %, P = 0.008). These results were sustained throughout 24 months (82.8 vs 64.4 %, P < 0.05). In average, surgical duration (P < 0.001), blood loss (P = 0.029) and skin incision (P < 0.001) in the investigational were 10 min longer, 22.5 ml greater and 2.0 cm wider than control group (median values). Improved tertiary outcomes from BL to 24 mo in both groups (investigational vs control): VAS leg pain (mean decrease -6.41 ± 2.57 to -6.41 vs -5.61 ± to -3.30); improved quality of life (SF-36: 20.68 ± 9.44 vs 16.90 ± 10.74); pain medication reduction: 56.7 vs 47.9 %; return to work: 45.7 vs 38.0 %. Adverse event rates: 68.5 % investigational and 66.2 % control., Conclusions: This is the first randomized controlled trial to report equivalent efficacy and safety of herniectomy with or without DIAM spinal stabilizing device. Leg pain, back pain and the level of disability were not significantly different between groups; however, number of patients reaching the MCID for back pain was significantly higher in the investigational group at 6 through 24 months.

The DIAM (Device for Interspinous Assisted Motion) interspinous device offers the possibility of a viscoelastic supplementation of the lumbar motion segment with a small, reversible operation. It is intended as a restabilisation procedure after a discectomy to avoid facet joint overload and as a topping of procedure for the segment adjacent to a fusion. The device has been on the German market since 2004. There are several biomechanical studies available showing an effect mainly in extension and flexion, but hardly any in rotation and lateral inclination. Despite frequent clinical use, there have only been a few, mainly retrospective clinical studies indicating the success of the implant; however, sound scientific data are missing. Several prospective, randomised, controlled studies are now underway to fill that gap. Only then will it be possible to assess whether this implant is of true value to improve clinical results and to slow down the degenerative cascade or not.

Traditionally, radiographic assessment of the hip with anteroposterior and lateral views is the gold standard of diagnosis in SCFE. This paper evaluates the possible contributions of other methods of modern imaging to the early diagnosis and treatment. There is scientific evidence that ultrasound can diagnose the disease earlier than conventional radiography and also has the possibility to differentiate the classification between stable and unstable. MRI depicts marrow changes earlier than any other imaging method available and has a role in cases where the diagnosis is difficult to make as well as in assessing the risk of chondrolysis and avascular necrosis. To show the anatomic deformity, anteroposterior and lateral radiographs remain the mainstay of preoperative planning.

Aim: To examine the quality and usefulness of time-of-flight MR-angiography and duplex-doppler sonography, respectively, in assessment of the extracranial arteries before cervical spine operations., Methods: Patients scheduled for operations of the cervical spine had an MRI plus TOF as well as a duplex and Doppler scan. At the time of the examination the radiologist and the neurologist in charge were blinded for the study. Endpoints were not only the accuracy of the procedures but more so which method improved the preoperative process most., Results: Twenty patients were examined so far. Only in one case did the result differ when a complete occlusion diagnosed sonographically was judged as a severe stenosis on MRA. One patient did not tolerate the MRA for the extra 5 minutes necessary, therefore a contrast-enhanced MRA was performed. MRA eased the preoperative process as imaging of the pathology and the carotids were realised in one step. The costs were slightly higher for MRA than for duplex-doppler sonography., Conclusion: TOF-MRA can replace the duplex-doppler examination in the preoperative assessment of the carotids and has the potential to streamline the preoperative time schedule. Similar to duplex and doppler, in order to be accurate enough the method requires a high degree of expertise from the radiologist.

Magnetic resonance imaging (MRI) is the leading diagnostic procedure for disk pathology and has overtaken other imaging modalities in frequency of use. However, one must be cautious not to overinterpret small abnormalities that are also frequent in asymptomatic subjects. There is conflicting evidence about the correlation of high-intensity zones with clinical symptoms. Bulging disks and protrusions are a common finding in asymptomatic individuals, whilst extrusions are almost always accompanied by back pain and sciatica. In patients with back pain or sciatica, MRI is indicated after failure of conservative management or neurological deterioration. Contrast-enhanced MRI is well suited to differentiate a recurrent disk extrusion from epidural fibrosis. In all cases suspicious of tumor or infection, MRI is indicated as a first-line investigation. The indications and pitfalls of the state of the art of MRI are delineated in this article.

Aim: To prospectively investigate the outcome efficacy of whole spine MRI for diagnosis and treatment in patients with suspected metastases of the spine., Methods: All patients older than 50 years with newly diagnosed back pain and/or newly diagnosed spine-related neurological symptoms without a diagnosis by other imaging modalities were accepted in this study. A whole spine MRI and a detailed MRI per spine region with suspicious lesions were performed using a Siemens Magnetom Expert 1.0 Tesla machine. Outcome efficacy was determined by assessing further therapy and result for the patient., Results: In all 15 patients of the year 1999 whole spine MRI allowed us to determine the definite diagnosis and treatment. Plain X-ray and 99mTc bone scanning gave a diagnostic suspicion but no definite diagnosis or therapeutic consequence., Conclusions: MRI of the spine including whole spine images allows clear cut decision making in diagnosis and treatment of cases suspicious for metastatic disease of the spine. Careful history taking and clinical examination provide enough information to opt for whole spine MRI as the first choice investigation. This will provide maximum benefit to the patient and avoid examination cascades.

The purpose of this study was to determine the current position of diagnostic ultrasound imaging in the day to day orthopaedic practice. A questionnaire was sent to all the 387 conservative and operative orthopaedic hospitals and orthopaedic university departments in Germany. 167 of these hospitals completed the forms and provided the basis for this evaluation (response rate 43.2%). Screening of the fetal hip for CDH was by far the most common indication, the shoulder was ranking second, the knee and the hip joint in children and adults rank third and fourth. Other frequent indications were injuries of the achilles tendon, the menisci of the knee, the knee in rheumatoid arthritis and muscle injuries. Ultrasound imaging is clearly established as a diagnostic tool at least in the named areas. It is therefore of importance to include ultrasound examination techniques in the curriculum of the orthopaedic training scheme.

In a prospective trial we evaluated the diagnostic value of ultrasound imaging in the diagnosis of injuries to the anterior syndesmosis of the ankle joint. In an initial series of 20 patients using a basic standard ultrasound machine (Siemens Sonoline SL 1 with a 7.5 MHz piece) and a simple dynamic testing protocol as described in this article we found a significant difference between the ultrasound result for the ruptured syndesmosis versus non rupture and a specificity similar to that of arthrography. We conclude that ultrasound imaging is a useful tool in the diagnosis of syndesmotic rupture. Given the statistical significance of these results we feel confident that-despite the small amount of patients of this series and after an individual learning curve-ultrasound will eventually replace arthrography as the standard of investigation for this type of injury.

We retrospectively reviewed 93 patients (118 knees) treated by arthroscopic excision of painful medial plica. A scoring scale 0-100 was used to evaluate the symptoms. After an average of 2 (1-4) years, 109 of 118 knees had little, if any, pain and the average improvement in the score was 41 points. Thus arthroscopic excision of a painful medial plica can provide lasting and satisfactory relief of symptoms.