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The 6-minute walking test (6WT) and the Timed Up and Go (TUG) test are two of the most commonly applied standardized measures of objective functional impairment that help support clinical decision-making for patients undergoing surgery for degenerative lumbar disorders. This study correlates smartphone-app-based 6WT and TUG results to evaluate their responsiveness.In a prospective study, 49 consecutive patients were assessed preoperatively and 6 weeks postoperatively using the 6WT, the TUG test, and commonly used patient-reported outcome measures. Raw values and standardized z-scores of both objective tests were correlated. An external criterion for treatment success was created based on the Zurich Claudication Questionnaire patient satisfaction subscale. Internal and external responsiveness for both functional tests was evaluated.The mean preoperative 6WT results improved from 401 m (SD 129 m), z-score -1.65 (SD 1.6) to 495 m (SD 129 m), z-score -0.71 (SD 1.6, p0.001). The mean preoperative TUG test results improved from 10.44 seconds (SD 4.37, z-score: -3.22) to 8.47 seconds (SD 3.38, z-score: -1.93, p0.001). The 6WT showed a strong negative correlation with TUG test results (r = -66, 95% CI 0.76-0.53, p0.001). The 6WT showed higher internal responsiveness (standardized responsive mean = 0.86) compared to the TUG test (standardized responsive mean = 0.67). Evaluation of external responsiveness revealed that the 6WT was capable of differentiating between patients who were satisfied and those who were unsatisfied with their treatment results (area under the curve = 0.70), whereas this was not evident for the TUG test ( area under the curve = 0.53).Both tests adequately quantified functional impairment in surgical candidates with degenerative lumbar disorders. The 6WT demonstrated better internal and external responsiveness compared with the TUG test. Clinical trial registration no.: NCT03977961 (clinicaltrials.gov).AUC = area under the curve; COMI = Core Outcome Measures Index; DLDs = degenerative lumbar disorders; LDH = lumbar disc herniation; LSS = lumbar spinal stenosis; PROM = patient-reported outcome measure; ROC = receiver operating characteristic; SRM = standardized responsive mean; TUG = Timed Up and Go; VAS = visual analog scale; 6WD = 6-minute walking distance; 6WT = 6-minute walking test; ZCQ = Zurich Claudication Questionnaire.

The worldwide spread of smartphone usage enables new possibilities for longitudinal monitoring of objective functional impairment (OFI) in patients undergoing surgery for lumbar degenerative disc disease (DDD).Three patients, undergoing elective surgery for lumbar DDD, self-assessed OFI using a recently validated 6-min walking test (6WT) smartphone application. Results are presented as raw 6-min walking distance (6WD) as well as in reference to age- and sex-specific healthy population reference values using standardized z-scores (number of standard deviations). In parallel, patient-reported outcome measures (PROMs), including numeric rating scale (NRS) leg-pain and Core Outcome Measures Index (COMI) were obtained before (pre) and 6 weeks (6 W) as well as 3 months (3 M) after surgery. Descriptive analyses were used to compare PROMs with repeated 6WT measurements over time. The feasibility and benefits of the longitudinal OFI measurements using the 6WT app are discussed.One patient presented a favorable outcome, reflected by a clinically meaningful improvement in PROMs. Correspondingly, the 6WT distance gradually improved above the normal population values ((pre 399 m (z-score - 1.96) vs. 6 W 494 m (- 0.85) vs. 3 M 557 m (- 0.1)). One patient experienced initial improvement at 6 W, followed by a decline in 6WD at 3 M which promoted further interventions with subsequent recovery ((358 m (z-score - 3.29) vs 440 m (- 2.2) vs 431 m (- 2.32) vs 471 m (- 1.78)). The last patient showed a lack of improvement in PROMs as well as in OFI (360 m (z-score 0.0) vs 401 m (0.30) vs 345 m (- 0.11)) resulting in secondary surgery.The longitudinal assessment of OFI using the 6WT app was feasible and provided the physician with a detailed history of patients' postoperative walking capacity complementing commonly used PROMs.

Epidural steroid injection (ESI) represents a popular treatment option in patients with lumbar degenerative disc disease (DDD). The main objective of the article was to determine whether the 6-minute walking test (6WT) could assist in the discrimination between ESI responders and nonresponders. We used a validated 6WT smartphone application to assess self-measured objective functional impairment (OFI) in 3 patients with DDD undergoing ESI. Patient-reported outcome measures (PROMs), including the Core Outcome Measures Index and the Oswestry Disability Index, were obtained at baseline and at the 3-, 7-, and 28-day follow-up. Descriptive analyses were used to compare PROMs with OFI over time. Two patients responded well to the ESI, illustrated by clinically meaningful improvements in PROMs. This improvement was accompanied by a substantial increase in the 6WT distance (case I: 358 m vs. 517 m and case II: 296 m vs. 625 m). One patient reported only moderate improvement in leg pain and conflicting results in the other PROMs. The 6WT demonstrated a persistent OFI (487 m vs. 488 m). This patient was considered a nonresponder and underwent surgical treatment. This case series illustrates the feasibility of the smartphone-based 6WT as a tool to assess OFI in patients undergoing ESI for lumbar DDD.

It is generally believed that radiological signs of lumbar degenerative disc disease (DDD) are associated with increased pain and functional impairment as well as lower health-related quality of life (HRQoL). Our aim was to assess the association of the Modic and Pfirrmann grading scales with established outcome questionnaires and the timed-up-and-go (TUG) test. METHODS: In a prospective two-center study with patients scheduled for lumbar spine surgery, visual analogue scale (VAS) for back and leg pain, Roland-Morris Disability Index, Oswestry Disability Index and HRQoL, as determined by the Short-Form (SF)-12 and the Euro-Qol, were recorded. Functional mobility was measured with the TUG test. Modic type (MOD) and Pfirrmann grade (PFI) of the affected lumbar segment were assessed with preoperative imaging. Uni- and multivariate logistic regression analysis was performed to estimate the effect size of the relationship between clinical and radiological findings. RESULTS: Two hundred eighty-four patients (mean age 58.5, 119 (42 %) females) were enrolled. None of the radiological grading scales were significantly associated with any of the subjective or objective clinical tests. There was a tendency for higher VAS back pain (3.48 vs. 4.14, p = 0.096) and lower SF-12 physical component scale (31.2 vs. 29.4, p = 0.065) in patients with high PFI (4-5) as compared to patients with low PFI (0-3). In the multivariate analysis, patients with MOD changes of the vertebral endplates were 100 % as likely as patients without changes to show an impaired TUG test performance (odds ratio (OR) 1.00, 95 % confidence interval (CI) 0.56-1.80, p = 0.982). Patients with high PFI were 145 % as likely as those with low PFI to show an impaired TUG test performance (OR 1.45, 95 % CI 0.79-2.66, p = 0.230). CONCLUSIONS: There was no association between established outcome questionnaires of symptom severity and two widely used radiological classifications in patients undergoing surgery for lumbar DDD

Although most patients with a mild traumatic brain injury (mTBI) recover within days to weeks, some experience persistent physical, cognitive and emotional symptoms, often described as post-concussion syndrome (PCS). The optimal recovery time including return-to-work (RTW) after mTBI is unclear. In this single-centre parallel-group trial, patients assigned three days (3D-group) or seven days (7D-group) sick leave were compared with a comprehensive neuropsychological test battery including the Post-Concussion Symptom Scale (PCSS) within one week, after three and 12 months post-injury. The influence of the effective time until RTW on post-concussional symptoms and cognitive performance was analysed. The 3D-group rated significantly higher mean scores in some PCSS symptoms, tended to fulfil diagnosis criteria of PCS more often and showed better cognitive performance in several neuropsychological test scores than the 7D-group at all three time-points of follow-up. Overall, patients returned to work 11.35 d post-injury, thus distinctly above both recommended sick leaves. There was a trend for longer sick leave in patients randomized into the 3D-group. Further analyses revealed that the group with an absolute RTW within one week showed lower symptom severity in fatigue at 3 and 12 months, less PCS and faster performance in fine motor speed at 12 months than the group with an absolute RTW after one week. Our data underline the heterogeneity of mTBI and show that acute and sub-acute symptoms are not prognostic factors for neuropsychological outcome at one year. Later, ability to work seems to be prognostic for long-term occurrence of PCS.

Zerebrale arteriovenöse Malformationen (AVM) sind kongenitale oder im frühen Entwicklungsalter entstehende vaskuläre Pathologien, bei welchen es zu direkten Gefässverbindungen zwischen Arterien und Venen ohne zwischengeschaltetem Kapillarbett und z.T. weiteren, komplizierenden Fehlbildungen kommt. Am häufigsten offenbaren sich AVM durch intrakranielle Blutungen in der 2. bis 4. Lebensdekade. Bei epileptischen Anfällen oder fokal-neurologischen Defiziten stellt die AVM besonders beim jungen Erwachsenen eine wichtige Differenzialdiagnose dar. Als kausale Therapie wird bei symptomatischen AVM in der Regel eine Ausschaltung durch chirurgische, endovaskuläre und radiotherapeutische Massnahmen, oder einer Kombination aus diesen empfohlen. Bei inzidentellen Befunden ist die Indikation zur Behandlung sorgfältig und stets individuell zu stellen. Dieser Übersichtsartikel gibt einen Überblick über aktuelle Empfehlungen zum Management von AVM beim erwachsenen Patienten.

Intradurale spinale Tumoren werden in extra- und intramedulläre Tumoren unterteilt. Die häufigsten intradural-extramedullären Tumoren sind Meningeome und Neurinome, bei den intradural-intramedullären Tumoren überwiegen Ependymome und Astrozytome. Unabhängig von deren Ursprung manifestieren sich spinale Tumoren oft mit progressiven lokalen oder radikulären Schmerzen und neurologischen Defiziten. Die Therapie der Wahl bei den meisten intraduralen Tumoren ist eine möglichst komplette chirurgische Resektion. Bei ausgeprägtem infiltrativem Wachstum im intramedullären Bereich muss jedoch randständig Tumor belassen werden, um nicht zusätzlich bleibende neurologische Defizite zu riskieren. Grundsätzlich ist insbesondere beim Auftreten neurologischer Ausfälle eine möglichst rasche chirurgische Intervention indiziert, da die Prognose von der Schwere und der Dauer der vorbestehenden Defizite abhängt. Im Folgenden werden die klinische Präsentation und die massgebenden Therapieoptionen intraduraler spinaler Neoplasien praxisnah besprochen.

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.

Meningeome sind häufige intrakranielle Tumoren, die durch die Entartung von Zellen der Arachnoidea mater entstehen. Klinisch manifestieren sie sich in Form von Kopfschmerzen, fokalen oder generalisierten Krampfanfällen oder kompressionsbedingten neurologischen Ausfällen. Über 90% der in der Regel langsam wachsenden Meningeome sind benigne. Bei den meisten symptomatischen Patienten wird die Tumorresektion in kurativer oder zumindest symptomlindernder Intention angestrebt. Bei subtotaler Resektion besteht die Möglichkeit einer adjuvanten Bestrahlung. Eine stereotaktische Radiotherapie kann jedoch auch als Ersttherapie bei Patienten erfolgen, die sich durch hohes Alter oder Tumoren in eloquenten oder chirurgisch schlecht erreichbaren Arealen nicht für eine neuro-chirurgische Operation qualifizieren. Bei nicht resezierbaren Tumoren oder falls alle vorherigen Therapien keinen Erfolg gebracht haben, kann eine Hormon- oder Chemotherapie in Erwägung gezogen werden.

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

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.

Das Krankheitsbild Pott's puffy-Tumor beschreibt eine lokale Stirnbeinosteomyelitis, die meist durch einen äusseren Infekt mit konsekutiver sub­periostaler Abszedierung entsteht. Die klinische Manifestation entsteht schleichend und die sichtbare Erhebung ist oftmals indolent. Die Symptome sind vor allem Folgen komplizierender Sekundärmorbiditäten. Wir präsentieren einen komplizierten Verlauf mit intrakranieller Ausbreitung der initialen Sinusitis.

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.

Die Ursache ischämischer Hirninfarkte bei jungen Patienten (

Im klinischen Alltag besteht ein wesentlicher Teil der ärztlichen Tätigkeit darin, Patienten über medizinische Diagnosen und insbesondere über das Vorgehen operativer Eingriffe zu informieren. In diesen Gesprächen wird das Krankheitsbild, der Ablauf im Spital vor und nach der Operation sowie das Vorgehen während der Operation erklärt. Aus rechtlicher Sicht muss von ärztlicher Seite während des Gesprächs auf alle möglichen Risiken des Eingriffs hingewiesen werden. Um die Informationsvermittlung zu optimieren, werden während des Gesprächs Hilfsmittel wie Zeichnungen, Bilder, Röntgenbilder und Modelle verwendet. Nach einer rein mündlichen Aufklärung wird jedoch nur ein geringer Prozentsatz der Informationen vom Patienten aufgenommen. Damit die Patienten besser und frühzeitig über medizinische Details und interne Abläufe vor einer geplanten Operation informiert werden können, haben wir ein webbasiertes Informationsportal mit einer Kombination aus Bild, Text, Ton und Video über chirurgische Eingriffe entwickelt. Durch den Einsatz dieses Patienten-Informationssystems in der Aufklärungskaskade kann die Patientenzufriedenheit wesentlich verbessert werden. Zusätzlich kann der Einsatz des webbasierten multimedialen Informationsportals für das ärztliche Personal zu einer wesentlichen Zeitersparnis führen.

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.

Primary objective: The aetiology of the increased osteogenesis associated with severe traumatic brain injury (TBI) remains incompletely understood. The purpose of this article is to review the available evidence regarding the release of osteogenic humoral factors after TBI.Research design: This study is presented in the form of a literature review.Methods and procedures: To obtain suitable references, Pubmedwas searched using keywords ‘heterotopic ossification’, ‘brain’, ‘trauma’, ‘injury’, ‘aetiology’.Main outcomes and results: Evidence from both clinical and laboratory investigations points to centrally released osteogenic factor(s) that enter the systemic circulation following TBI.Conclusions: Further investigation into the identification of these putative osteogenic factor(s), using human tissues and new techniques, is indicated to better understand this phenomenon.

Das isolierte Schädel-Hirn-Trauma (SHT) ist ein Hauptrisikofaktor für Morbidität und Mortalität nach einem Unfallereignis. Die Prognose ist sowohl von der primären, also der direkten Schädigung als auch von der sekundären Schädigung (posttraumatische Blutung, Ödem etc.), abhängig. Das in diesem Artikel beschriebene leichte SHT ist eine traumatisch bedingte, reversible Schädigung des Gehirns ohne morphologisch fassbare Veränderung, welches einem GCS von 13–15 zugeordnet wird. Gleich zu Beginn der Aufnahmeuntersuchung sollten Risikofaktoren für intrakranielle Pathologien identifiziert werden. Hierzu richtet sich die durchzuführende Diagnostik nach dem Schweregrad der Verletzungen. Besonders im Bereich der SHT ist dies nur ungenügend mit der herkömmlichen Nativradiologie zu gewährleisten. Im Folgenden werden praxisnah sowohl Algorithmen zum Vorgehen bei leichten SHT als auch der sinnvolle Einsatz einer frühen CT-Diagnostik besprochen.

Cerebral cavernomatous malformations (CCM) are a subgroup of low-pressure cerebral vascular malformation. They have an estimated prevalence of 0,1-4% of the population and account for 8-15% of all cerebral vascular malformations. Depending on their size and localization (supratentorial or infratentorial, brain stem), CCM may present with focal bleedings with or without neurological deficits, as epileptic seizures, or are diagnosed incidentally by MRI performed for unspecific symptoms (e.g. headache, vertigo), especially in younger patients (mostly in 2nd or 3rd decade). The decision-making in patients with CCM can be classified into four categories: surgical or conservative treatment of symptomatic or incidental lesions. The decision regarding the optimal therapy in the individual patient must be made in the knowledge of the natural history (risk for bleeding or epilepsy) on the one hand, and the surgical possibilities (accessibility of the lesion) including their estimated outcome on the other hand. Therefore, careful patient selection and appropriate experience of the centre is warranted in the management of CCM.Zerebrale kavernomatöse Malformationen (CCM) sind Gefässmissbildungen zwischen dem arteriellen und venösen Gefässsystem, die ausschliesslich aus Endothelzellen bestehen. Sie treten bei ungefähr 0,1–4% der Bevölkerung auf und präsentieren sich je nach Grösse und Lokalisation vor allem bei jüngeren Patienten durch epileptische Anfälle, fokale Hirnblutungen, neurologische Defizite oder werden aufgrund unspezifischer Beschwerden zufällig im MRI entdeckt. Im klinischen Alltag existieren bezüglich des Managements von Kavernompatienten vier Möglichkeiten: die chirurgische oder konservative Therapie von inzidentiellen oder symptomatischen Befunden. Die Entscheidungsfindung bezüglich der optimalen Therapie muss im Wissen um den natürlichen Verlauf der Pathologie sowie den chirurgischen Möglichkeiten mit dem zu erwartenden klinisch-funktionellen Ergebnis nach Operation erfolgen. Eine vorsichtige Patientenselektion und eine entsprechende Expertise des Zentrums sind somit beim Management der CCM entscheidend.Les malformations cérébrales caverneuses (CCM) sont un sous-groupe de cérébrales à basse pression malformations vasculaires. Elles ont une prévalence estimée à 0,1–4% de la population et représentent 8–15% de toutes les malformations vasculaires cérébrales. Selon leur taille et leur localisation (supratentorielle ou infratentorial, le tronc cérébral), les CCM peuvent provoquer un accident vasculaire cérébral hémorragique, des crises d'épilepsie, un déficit neurologique, en particulier chez les patients plus jeunes (surtout au cours de la 2ème ou 3ème décennie) ou sont diagnostiquées incidemment par IRM réalisée pour des symptômes non spécifiques (par exemple des maux de tête, des vertiges). En ce qui concerne la prise en charge clinique, les CCM peuvent être classées en quatre catégories: traitement chirurgical ou conservateur de lésions symptomatiques ou découvertes par hasard. La décision concernant la thérapie optimale pour un patient donné doit être effectuée en tenant compte de l'histoire naturelle, d'une part, et des possibilités chirurgicales, y compris leur résultat estimé, d'autre part. Par conséquent, la sélection des patients appropriée et l'expérience du centre sont justifiées dans la gestion de la CCM.

Low-grade gliomas (LGG) are brain tumors with a low or intermediate biological aggressiveness. According to histopathological features, they are further specified as grade I or II by WHO criteria. Diffuse astrocytomas, oligodendrogliomas, and mixed gliomas are the most common LGG. They mainly affect young patients in their 3rd to 5th decade and often manifest with epileptic seizures. A macroscopically complete or near-complete tumor resection that does not induce additional neurological deficits, is recommended as first line therapy in surgically accessible tumors, as a significant benefit for overall survival has been demonstrated. The indication for adjuvant chemo- or radiotherapy must be discussed interdisciplinary in each case. MGMT promotor methylation, LOH 1p/19q, as well as the status of somatic mutations within IDH1/2 gene constitute biomarkers that may predict response to adjuvant therapy and may correlate to overall survival. These and other biomarkers could be of benefit in future managing plans to offer patients with LGG an individually tailored, optimal treatment.Niedrig-gradige Gliome (NGG) sind zellbiologisch betrachtet niedrig bis mässig maligne, primäre Hirntumore, die nach der Weltgesundheitsorganisation (WHO) als Grad I und II eingestuft werden. Diffuse Astrozytome, Oligodendrogliome und Mischgliome stellen häufige Untergruppen dar. NGG kommen hauptsächlich bei jüngeren Patienten vor und manifestieren sich häufig mit einem epileptischen Anfall. Eine möglichst vollständige Tumorresektion unter Erhalt neurologischer Funktionen gilt als Erstlinientherapie, da sich hierdurch signifikante Vorteile für das Gesamtüberleben ergeben. Die Indikation einer adjuvanten Strahlen- oder Chemotherapie muss interdisziplinär und fallspezifisch diskutiert werden. Biomarker wie MGMT-Methylierung, LOH 1p/19q und IDH1/2-Mutationsstatus können bezüglich des Therapieansprechens und des Gesamtüberlebens nützlich sein. Zukünftig könnten diese und weitere Marker genutzt werden, um betroffenen Patienten eine individuell angepasste, und damit personalisierte Tumortherapie mit einem optimalen Therapieergebnis anzubieten.Les gliomes de bas grade (GBG) sont des lésions tumorales cérébrales primaires considérées à potentiel malin faible à modéré; l'Organisation Mondiale de la Santé les a classés de grades I et II. Les astrocytomes, les oligodendrogliomes et les gliomes mixtes constituent des sous-groupes. Les GBG sont principalement retrouvés chez les jeunes patients et se manifestent souvent par des crises épileptiques. La résection tumorale complète, dans la mesure où elle ne cause pas de dysfonction neurologique, est considérée comme le traitement de première ligne, car elle améliore significativement la survie globale. L'indication à une radiothérapie et/ou une chimiothérapie adjuvantes doit être discutée au cas par cas à la consultation multidisciplinaire. La connaissance de biomarqueurs tels que le MGMT (et de son éventuelle méthylation), et le status, muté ou non, de 1p/19q et IDH1/2- peuvent être utiles en raison de la répercussion sur le traitement et la survie globale. À l'avenir, ces marqueurs (et d'autres encore) pourraient être utilisés pour fournir un traitement personnalisé, par conséquent avec un résultat thérapeutique optimal pour les patients atteints de GBG.

Lumbar spine surgery has been performed for decades using the so-called «dorsal open approach». Although established as a safe and effective procedure, it is associated to some extent with extensive collateral damage in the area of the operative field. For over ten years, minimal-invasive spine surgery (MISS) techniques, which are considerably less destructive and less traumatic, have earned their place as valuable and at times superior to the established dorsal open approach. Advantages include smaller skin incisions, less soft tissue and muscle damage, less peri-operative blood loss, lower infection rates, earlier postoperative return to function or work as well as shorter hospital stays. All these advantages, however, have to be carefully balanced against the potential disadvantages of MISS techniques, notably reduced orientation, steep learning curves, and increased radiation exposure from repeated imaging for guidance. This article gives an overview about the evolution and current role of MISS in lumbar spine surgery.Die lumbale Wirbelsäulenchirurgie ist seit Jahrzehnten von sogenannten «offenen dorsalen Zugängen» geprägt, die – obwohl etabliert – mit z.T. erheblichen Kollateralschäden im Bereich des operativen Zugangsweges assoziiert sind. Seit über zehn Jahren gibt es zunehmend minimal-invasive spinale Operationsmethoden (minimal invasive spine surgery, MISS), die deutlich weniger destruktiv und weniger traumatisch sind. Zu den Vorteilen zählen unteren anderem kleinere Hautinzisionen, geringeres Weichteil- und Muskeltrauma, geringerer perioperativer Blutverlust, erniedrigte Infektionsrate, raschere Mobilisierung, kürzerer Spitalaufenthalt und raschere postoperative Arbeitsfähigkeit. Diese Vorteile müssen jedoch gegenüber potenziellen Nachteilen abgewogen werden, zu welchen unter anderem eine erschwerte Orientierung für den Chirurgen, steilere Lernkurve sowie eine vermehrte Strahlenbelastung gehören. Dieser Artikel gibt einen Überblick über die Evolution und die aktuellen Möglichkeiten der MISS.Depuis des décennies, la chirurgie du rachis lombaire est réputée invasive et les complications liées aux abords ouverts qu'elle impose sont désormais bien établies. Depuis plus de dix ans, des techniques minimalement invasives (MISS, minimal invasive spine surgery) – nettement moins délabrantes – ont été développées. Elles ont l'avantage de permettre une incision cutanée minime, un traumatisme musculaire moindre, une perte sanguine fortement diminuée, une réduction du taux d'infections opératoires, une mobilisation plus rapide, un séjour hospitalier raccourci et un retour à la vie active accéléré. Ces avantages sont à mettre en balance avec les techniques opératoires parfois plus compliquées, un apprentissage chirurgicale difficile et l'exposition accrue des patients aux rayons de radioscopies peropératoires. Cet article de synthèse fournit un aperçu de l'évolution et les possibilités actuelles de MISS.

A lumbar disc herniation is a frequent pathology. The incidence of a postoperative recurrence is between 1-18%. According to the current literature, a large anular defect and a limited perioperative microdiscectomy leads to an increased risk of recurrence. In contrast, a generous perioperative microdiscectomy comes along with an accelerated postoperative disc height loss and a progressive degenerative disc disease. The present work discusses the position of an anular-closure-device in respect of the problem risk of recurrence versus postoperative degenerative disc disease.Die lumbale Diskushernie (LDH) ist ein Krankheitsbild mit hoher Prävalenz. Das grösste Risiko während des postoperativen Verlaufes ist das Risiko eines Diskushernienrezidivs mit einer Inzidenz, je nach Literaturangabe, von 1–18%. Aus der aktuellen Literatur geht hervor, dass ein grosser Anulus-Defekt und eine limitierte perioperative Bandscheibenfachausräumung zu einem erhöhten Risiko eines Diskushernienrezidivs führen. Im Gegensatz dazu ist eine grosszügige perioperative Ausräumung des Bandscheibenfachs mit einem beschleunigten postoperativen Verlust der Bandscheibenhöhe und damit mit einer zunehmenden Bandscheibendegeneration vergesellschaftet. Der Wirbelsäulenchirurg ist perioperativ bei jeder LDH-Operation mit dieser Problematik konfrontiert. Seit einiger Zeit wurden sogenannte Anulus-Verschluss-Produkte (engl. anular closure devices) mit dem Ziel entwickelt, das postoperative Rezidivrisiko zu senken. Die vorliegende Arbeit diskutiert anhand einer aktuellen Patientengeschichte die Position einer Anulus-Verschluss-Prothese in Bezug auf die Problematik Rezidivrisiko vs. postoperative Bandscheibendegeneration.La hernie discale lombaire (HDL) est une pathologie à haute prévalence. Le risque le plus important après une chirurgie dédiée à cette pathologie est celui d'une récidive herniaire, dont l'incidence est estimée, selon divers auteurs, entre 1 et 18%. La littérature actuelle suggère qu'une interruption de continuité de l'anneau fibreux associée à une microdiscectomie chirurgicale incomplète expose le patient à un risque de récidive herniaire. Cependant, une discectomie étendue est associée à une perte de hauteur discale et par conséquent à une dégénérescence discale post-opératoire accélérée. Le chirurgien du rachis est donc confronté à un dilemme lors de chaque opération pour une HDL. Depuis quelques temps, des systèmes nommés «dispositifs de fermeture de l'anneau fibreux» sont apparus dans le but de réduire le risque de récidive herniaire post-opératoire. Ce document, en exposant la situation réelle d'un patient, discute la possibilité de recours à un dispositif de fermeture de l'anneau fibreux en tenant compte de la problématique du risque de récidive ainsi que de celui de dégénérescence discale.

The Guillain-Barre syndrome (GBS) is a reactive, self-limited, autoimmune disease frequently triggered by a preceding bacterial or viral infection. In its typical form, GBS presents with a gait disturbance and clinical features of pain, weakness and areflexia. A careful history, physical examination and routine laboratory tests are necessary to make the clinical diagnosis and to exclude other disorders that cause a similar presentation. GBS following surgery is rare and may either be secondary to anaesthesia or due to metabolic changes induced by the surgical procedure itself (e.g. gastrectomy, thymectomy, and transplantation). Diagnosis of GBS under these circumstances is often delayed, which may lead to an increase in morbidity. In this article, we present the first described case of a patient who developed GBS after surgical fixation of multiple pelvic injuries and a fracture of the fourth lumbar vertebral body sustained in a motorcycle accident.

Positional plagiocephaly in the newborn corresponds to a posterior flattening and asymetry of the head. Its incidence has significantly increased since the "back to sleep" campain in the nineteen nineties to prevent sudden infant death syndrome. The posterior deformation usually worsens during the first six months of life when the skull is susceptible to posterior constant pressure which induces the deformation. Spontaneous outcome can be favorable. Treatment is always conservative and consists in positionnal exercise, physiotherapy and osteopathy. In some cases treatment with a helmet is recommended for a period of three months usually. Posterior positionnal plagiocephaly has no consequences on the brain's developement an is considered as an esthetic issue. In most cases good results are obtained after management with a custom fitted helmet when needed.Als lagebedingter Plagiocephalus wird eine Asymmetrie der Kopfform im Säuglingsalter bezeichnet. International propagierte Empfehlungen «Kinder nicht mehr in Bauchlage schlafen zu lassen», um dem plötzlichen Kindstod vorzubeugen, haben zu einem deutlichen Anstieg der Inzidenz geführt. Ein lagebedingter Plagiocephalus ist nach Ausschluss einer unter Umständen operativ zu behandelnden Kraniosynostose, ein rein kosmetisches Problem. Auch ohne Therapie ist die weitere Entwicklung meistens positiv. Mittlere und auch ausgeprägte Kopfdeformitäten können, bei rechtzeitiger Erkennung und Therapiebeginn, in der Regel immer mittels konservativer Therapie, bestehend aus Positionsbehandlung, physiotherapeutischer und/oder osteopathischer Therapie, sowie gegebenenfalls einer Helmbehandlung zufriedenstellend behandelt werden.La palagiocéphalie positionnelle du nourisson se traduit le plus souvent par une asymétrie postérieure de la forme de la tête. L'incidence de la plagiocéphalie positionnelle a augmenté de manière significative depuis les années nonantes avec les campagnes menées pour prévenir la mort subite du nourisson en préconisant une position stricte sur le dos dans le berceau jusqu'à l'âge de six mois. La déformation postérieure visible s'aggrave en général au cours des six premiers mois de la vie, car le crâne est sensible à cet âge aux phénomènes de pressions constantes. L'évolution spontannée peut être favorable. Le traitement toujours conservateur peut consister en des manoeuvres de positionnement régulières, de l'ostéopathie ou du port d'un casque selon la sévérité de la déformation. C'est un problème esthétique sans conséquence sur le développement cérébrale. En général le traitement par casque sur mesure conduit à de bons résultats.

This case report discusses a case of aseptic osteonecrosis in a cranioplasty bone flap after decompressive craniectomy, which is a known, but rare complication after autologous cranioplasty. We suggest that the pathophysiology of cranial bone flap necrosis may have a similar pathophysiology to free flap necrosis/failure. The key suggested problem causing the osteonecrosis is vessel thrombosis within the smaller vessels of the bone flap due to the prothrombotic effects of the factors released during drilling of the bone flap. Suspicious local findings like wound dehiscence or fluid leakage should lead to a head computed tomography in order to discuss a prophylactic artificial second cranioplasty if necessary.Wir berichten über einen Fall von aseptischer Osteonekrose einer Kranioplastie nach dekompressiver Kraniektomie, die eine bekannte, jedoch seltene Komplikation einer autologen Kranioplastie darstellt. Wir nehmen an, dass eine aseptische Osteonekrose nach autologer Kranioplastie auf ähnlichen pathophysiologischen Grundlagen basiert, wie die Nekrose der Lappenplastik in der ästhetischen Chirurgie. Hauptverursacher der aseptischen Knochennekrose sind prothrombotisch wirksame Gewebsfaktoren, die zu einer venösen Gefässthrombose des autologen Knocheninterponats mit nachfolgender Ischämie führen. Auffällige Lokalbefunde wie eine Wunddehiszenz oder -sekretion sollten Anlass zu einer kranialen Computertomographie geben um, basierend auf der klinisch-radiologischen Befundkonstellation, die Indikation für eine prophylaktische artifizielle Zweitkranioplastie zu diskutieren.

Symptomatic lumbar (LDH) and cervical disc herniations (CDH) are highly prevalent diseases that neurosurgeons and orthopaedic surgeons face every day. If symptom control cannot be achieved by nonsurgical means or in cases with severe or progressive neurological deficits, a surgical therapy is generally recommended. Nevertheless, the majority of patients will improve significantly or even completely without surgery over weeks until months after symptom onset. Still, when a recommendation is to be made concerning the further treatment in affected patients, it has to be kept in mind that the nonsurgical therapy may be associated with disabling pain and persisting neurological deficits with influence on the functional capacity, quality of life and ability to work for a variable period. Today, it is almost impossible to predict which patient will profit from nonsurgical therapy and which patient will require surgery during the clinical course because of incomplete alleviation. In this work, we present two current cases of patients with spontaneous regression of a LDH and a CDH.Lumbale (LDH) und zervikale Diskushernien (CDH) sind prävalente Krankheitsbilder. Falls es unter Ausschöpfung konservativer Therapiemassnahmen nur zu einer unzureichenden Befundverbesserung kommt oder eine eindeutige Operationsindikation besteht, wird in der Regel eine operative Intervention empfohlen. Bei der Mehrzahl der Patienten kommt es jedoch ebenfalls nach Wochen bis Monaten unter konservativer Therapie zu einer deutlichen Beschwerderegredienz. Zu bedenken gilt jedoch, dass betroffene Patienten während einem variablen Zeitraum z. T. an invalidisierenden Schmerzen und/oder sensomotorischen Defiziten leiden, was einen negativen Einfluss auf die funktionelle Kapazität, Lebensqualität und Arbeitsfähigkeit hat. Die vorliegende Arbeit zeigt zwei aktuelle Patientengeschichten mit einer klinischen und radiologischen Spontanregression einer LDH und einer CDH.

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.

Purpose. To compare early functional outcomes, complications, and mortality in elderly patients treated with the less costly, cemented Thompson prosthesis or the cemented bipolar prosthesis in order to identify factors affecting outcomes. Methods. Records of 303 patients with femoral neck fractures treated with the cemented Thompson monoblock prosthesis (n=206) or the cemented bipolar prosthesis (n=97) were reviewed. The choice of prosthesis was solely determined by surgeon's preference. Data relating to patient demographics, clinical and residential status, mobility, mental function, mortality, and complications during hospitalisation and rehabilitation were collected. Results. After adjusting for confounding variables, independent postoperative indoor mobility was associated with preoperative indoor mobility (p=0.002) and mental function (p=0.001), whereas postoperative outdoor mobility was associated with preoperative outdoor mobility (p=0.003), daily living activity (p=0.02), and mental function (p=0.02). Mortality within 6 months was only associated with poor mental function (p=0.009). At 6-month follow-up, there was no significant difference between the 2 types of prosthesis in terms of functional outcomes, mortality and complication rates. Conclusion. In elderly patients with limited mobility, treatment with the bipolar prosthesis was not associated with better short-term outcomes than those receiving the Thompson prosthesis.

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.

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.

Normal pressure hydrocephalus (NPH) is characterized by a classic triad of symptoms including gait disturbance, urinary incontinence, and dementia. NPH is associated with a radiological verifiable ventriculomegaly in the absence of elevated cerebrospinal fluid (CSF) pressure. Because many patients do not present with classical clinical and radiological findings, its diagnosis and management represents a challenge for the treating doctor. Various supplemental preoperative tests, including lumbar CSF tap test or CSF outflow resistance determination, can improve the accuracy of predicting a response to surgical intervention. CSF shunt results in significant reduction of the symptoms in the majority of appropriately evaluated patients.

In the current climate of increasing awareness, patients are demanding more knowledge about forthcoming operations. The patient information accounts for a considerable part of the physician’s daily clinical routine. Unfortunately, only a small percentage of the information is understood by the patient after solely verbal elucidation. To optimise information delivery, different auxiliary materials are used. In a prospective study, 52 consecutive stationary patients, scheduled for an elective lumbar disc operation were asked to use a web-based audiovisual patient information system. A combination of pictures, text, tone and video about the planned surgical intervention is installed on a tablet personal computer presented the day before surgery. All patients were asked to complete a questionnaire. Eighty-four percent of all participants found that the audiovisual patient information system lead to a better understanding of the forthcoming operation. Eighty-two percent found that the information system was a very helpful preparation before the pre-surgical interview with the surgeon. Ninety percent of all participants considered it meaningful to provide this kind of preoperative education also to patients planned to undergo other surgical interventions. Eighty-four percent were altogether “very content” with the audiovisual patient information system and 86% would recommend the system to others. This new approach of patient information had a positive impact on patient education as is evident from high satisfaction scores. Because patient satisfaction with the informed consent process and understanding of the presented information improved substantially, the audiovisual patient information system clearly benefits both surgeons and patients.

Osteopetrosis (OP) is a rare heterogeneous group of inherited skeletal dysplasias characterised by osteoclast dysfunction, impaired bone resorption and poor bone remodelling. Three groups can be categorised on the basis of clinical findings. These include neurological symptoms, haematological abnormalities and renal tubular acidosis in the first group. Increased bone density, osteomyelitis and frequent fractures are the clinical findings in the second group, and the third group have normal life expectancy but may develop cranial nerve compression and osteomyelitis. Fractures in patients with OP are common and require appropriate pre-, peri- and postoperative management. The long bones are most frequently affected, fractures of the femoral neck and proximal (upper third) shaft being particularly common. This case report proposes possible operative fracture treatment in a patient with OP and highlights the potential perioperative pitfalls in this rare surgical population.

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.

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.