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Die differenzialdiagnostische Beurteilung schmerzhafter funktioneller Storungen der lumbosakralen und lumbopelvinen Region, d. h. des „unspezifischen unteren Ruckenschmerzes“, ist sehr weit gespannt, wird jedoch haufig reduziert auf die Frage einer Chronifizierung. Die manualmedizinische Diagnostik kann hier einen wertvollen Beitrag in der Abgrenzung von struktureller und funktioneller Pathologie leisten. Fruhzeitige manualmedizinische therapeutische Masnahmen scheinen fur perakute Beschwerden effektiv zu sein. Die Mobilisation funktioneller Storungen der viszeralen Aufhangungen im kleinen Becken sollte dabei einbezogen werden. In einem ersten Beitrag wurde insbesondere auf das dorsale lumbosakrale Syndrom eingegangen. Der vorliegende Teil II befasst sich mit weiteren manualmedizinischen Syndromen, insbesondere mit dem lumbopelvinen Syndrom. Dies erleichtert sowohl die primare differenzialdiagnostische Beurteilung als auch die Therapieplanung. Die Kombination mit den osteopathischen Verfahren ist dabei sehr gewinnbringend. Eine notwendige facharztliche Differenzialdiagnostik bleibt unumganglich.

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

Background The G-DRG system reimburses sledge endoprosthetic implantations (UKA) at a much lower rate than surface replacements (TKA), at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, the complete endoprosthesis implantation produces higher gains. An orientation on these revenues alone, however, does not provide the basis for an economically sound decision-making process. The aim of this study is to present a comparison of the variable costs of the two procedures. Material and methods The mean cost and performance data of 28 Endo-Model UKA implantations and of 85 NexGen CR TKA replacements were compared with each other in 2007. Results From the perspective of the hospital, when the correct medical indication is present, UKA treatment is of greater economic advantage. In this way the total unit contribution margin can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of the TKA. Conclusion For the desired maximisation of the unit contribution margin, assuming that it is the proper medical indication, the recommendation for the hospital would be implantation of the UKA. Considered from the economic perspective of gains and costs, the assumption that a TKA would be advantageous could not be confirmed in the present study.

Objective.New bone formation of the spine is a typical feature of ankylosing spondylitis (AS). It is unknown whether new bone formation is part of a physiological repair process or a unique pathological entity of the disease.Methods.We analyzed zygapophyseal joints from patients with AS and osteoarthritis (OA) undergoing spinal surgery for rigid hyperkyphosis (AS) or radiculopathy caused by severe OA. In 17 patients with AS, 11 with OA, and 5 controls we performed immunohistochemical analysis of osteoprotegerin (OPG), nuclear factor-κB ligand (RANKL), and osteocalcin (OC) expression in osteoblasts and determined the trabecular thickness in AS and OA patients and controls. Osteoclasts were detected by tartrate-resistant alkaline phosphatase (TRAP) staining.Results.Trabecular thickness was significantly lower in patients with AS compared to OA (p = 0.01). The absolute number of CD56+ osteoblasts (p < 0.001) and OC+ (p = 0.002), OPG+ (p = 0.003), and RANKL+ osteoblasts (p = 0.03) in AS patients was also significantly lower than in OA patients. The percentages of OC+, OPG+, and RANKL+ osteoblasts did not differ between AS and OA (p > 0.05 in all cases). In controls, the percentages of OPG+ (p = 0.013) and OC+ (p = 0.034) but not RANKL+ (p > 0.05) osteoblasts were significantly lower compared to AS patients. The frequency of TRAP+ osteoclasts in AS patients was significantly lower compared to OA (p < 0.001), but higher compared to controls.Conclusion.Immunohistochemical analysis of zygapophyseal joints suggested that osteoblast activity is similar in AS and OA, indicating that new bone formation is possibly a physiological function of repair in both diseases.

Die sakroiliakale Dysfunktion (SD), d. h. der Schmerz, der vom Sakroiliakalgelenk und dessen periartikularen Strukturen ausgelost wird, ist in den zahlreichen Publikationen als Teil des tief sitzenden Ruckenschmerzes („low back pain“) angegeben. Die Diagnosestellung und Behandlung der SD werden jedoch kontrovers diskutiert und sind in der Literatur nicht standardisiert. Wie alle Verfahren der manuellen Medizin mussen sich diagnostische und therapeutische Techniken auch im Hinblick auf das Sakroiliakalgelenk nach wissenschaftlichen Kriterien bewerten lassen. Fur die Diagnostik der SD stehen Schmerzprovokationstests und Bewegungsprufungen bzw. Palpationstests zur Verfugung. Die Reliabilitat der Provokationstests ist deutlich hoher als die der Motilitatstest. Bei Anwendung mehrerer Schmerzprovokationstests wird eine gute Reliabilitat und Validitat erreicht. Die Wirksamkeit lokaler manualtherapeutischer Behandlungstechniken bei SD ist in verschiedenen Studien belegt. Dabei finden sich keine Unterschiede zwischen Manipulationen und Mobilisationen. Im vorliegenden Artikel werden neben anatomischen Besonderheiten und Angaben zu Epidemiologie, Atiologie, Pathogenese und Differenzialdiagnostik verschiedene Diagnostikverfahren und Behandlungsmoglichkeiten der SD unter Berucksichtigung des vorliegenden Evidenzgrades beschrieben.

Konzepte zur Behandlung von Ruckenschmerzen sind in den letzten Jahren unter dem Einfluss der Erkenntnisse zur Schmerzchronifizierung verstarkt in die Diskussion gekommen. Jede Art der Therapie setzt in jedem Falle eine moglichst exakte Diagnose voraus. Die Zuordnung klinischer Befunde zu bestehenden strukturellen Pathologien ist bei lumbalem Ruckenschmerz jedoch nicht immer einfach. Die stationare Stufendiagnostik im hier vorgestellten Konzept erfasst eine abgestufte strukturelle und funktionelle Diagnostik bei Ruckenschmerzpatienten. Neben den spezifischen (klassifizierbaren) Faktoren der Schmerzverursachung (z. B. Wurzelkompression, facettenassoziierte Schmerzsyndrome, sakroiliakale Dysfunktion, segmentale Instabilitat) sind auch unspezifische (nicht klassifizierbare) Krankheitsursachen und begleitende, die Krankheit beeinflussende oder sogar wesentlich bestimmende Faktoren der biopsychosozialen Ebenen zu differenzieren. Ziel dieses Beitrages ist es, den Wert und das Vorgehen stationarer Stufendiagnostik vorzustellen. Es werden verschieden Verfahren aufgezeigt und deren Wert fur bestimmte Indikationen beschrieben.

Most osteoporotic sintering fractures are treated conservatively. However, persistent pain and consecutive spinal deformity may require certain cement-augmenting interventions. These procedures have proven their intermediate-term efficacy in pain reduction, prevention of progressive sintering and improvement of the overall quality of life in the majority of patients. In fractures with relevant spinal stenosis, persisting instability, gross deformity and trauma-associated osteoporotic fractures with or without neurological deficits, the therapeutic options may call for more extensive surgical procedures. In this regard, poor bone quality, age and respective comorbidities of the individual patient must be considered during preoperative planning and management. This article provides an overview of the diverse problem-solving strategies discussed in today's literature. It is generally acknowledged that any decision to perform surgery on an osteoporotic fracture is strongly case-dependent. Treating physicians must therefore master the complete therapeutic spectrum in order to meet this complex orthopedic challenge appropriately.

Background Little is known about the loads acting on a vertebral body replacement within the first month postoperatively. Among other things, such data are required for choosing the optimal rehabilitation program for a patient and for evaluating the efficacy of aids like crutches and braces. Methods Telemeterized vertebral body replacements were implanted into three patients, replacing parts of their fractured vertebral body L1. Six load components were measured for several exercises in upright and lying positions within the first postoperative month. The fractured vertebra was additionally stabilized with an internal spinal fixation device. Findings The highest force component acted in the direction defined by a line connecting the centres of the adjacent vertebral bodies. The resultant force was always less than 100 N in a lying position. Standing and sitting caused forces between about 150 and 450 N. Support with the arms or hands reduced the force considerably. Flexion of the upper body caused resultant forces higher than 420 N in all three patients. Elevation of both arms in the sagittal plane to about 90° also led to high resultant forces, especially when carrying an additional weight in the hands or when working against the resistance of a physiotherapist. In the latter case, forces higher than 700 N were measured. The force direction was close to the axial direction of the treated spinal segment in upright body positions and varied only slightly for most exercises. The highest resultant bending and torsional moments measured were less than 4 Nm. For most exercises the resultant moment was below 2 Nm. Interpretation High loads act on a vertebral body replacement during several exercises already in the first month postoperatively. These activities should be avoided, especially in patients with osteoporotic vertebrae in order to prevent implant subsidence. Using e.g. a wheeled invalid walker or supporting the upper body by hands when sitting was found to reduce implant loads.

Patients with ankylosing spondylitis are endangered suffering from cervical spine fractures following falls caused by kyphosis, stiffness and osteoporotic bone quality of the spine. Risk sustaining neurological deficits is higher than average. We present a patient with ankylosing spondylitis, who was admitted to our hospital with a complex fracture pattern of the cervical spine after a fall from a racing cycle. In spite of early operative treatment the patient died in the follow up because of severe hypoxic brain damage. We discuss the area of conflict between the recommendation for sport activities in patients with ankylosing spondylitis and the resulting risks for the diseased spine.

Die sonographische Diagnostik der Huftdysplasie (DDH) nach Graf und die sonographiegestutzte Therapie stellen einen Meilenstein in der Erkennung und Behandlung dieser Erkrankung dar. Die Ultraschalluntersuchung ermoglicht eine Diagnosestellung und damit eine Therapieeinleitung ab dem ersten Lebenstag. Neben methodenspezifischen Vorteilen der Sonographie (Wiederholbarkeit, Strahlenersparnis, Kosten, Verfugbarkeit) ist die Moglichkeit der Fruhesttherapie als entscheidender Gewinn anzusehen. Nach dem Entwickler und Erstbeschreiber der Methode – Reinhard Graf – unterscheidet man funf Haupttypen (I, II, D, III und IV), die in zwolf verschiedene Subtypen differenziert werden. Hierbei entspricht ein Typ I (Ia oder Ib) immer einem gesunden Gelenk, das nicht behandelt werden muss. Gelenke des Typs D, III (IIIa oder IIIb) oder IV sind dezentrierte, also kranke Gelenke, die immer behandelt werden mussen. Alle Huften des Typs II sind „borderline cases“, die – je nach Alter und Befund – krank oder gesund sein konnen. Die Diagnosestellung basiert auf einer exakten sonographischen Abbildung, einer deskriptiven Befundbeschreibung und einer Uberprufung der Deskription durch die Bestimmung eines Knochenwinkels „Alpha“ als Mas der Dysplasie und eines Knorpelwinkels „Beta“ als Mas der Instabilitat. Fur jedes Gelenk werden zwei Bilder erstellt, von denen eines vermessen wird. Bei fruhestmoglichem Behandlungsbeginn in den ersten Lebenstagen mit Spreizhose, Overhead-Extension, Pavlik-Bandage oder Gips sind auch bei schwer dysplastischen Gelenken Ausheilungsraten von weit uber 90% erreichbar. Operative Behandlungen stellen die Ausnahme dar und sind dann zumeist einer verzogerten Diagnosestellung zuzuschreiben. Als Mas der Gesundung eines Huftgelenkes dient das Erreichen einer guten knochernen Pfannenformgebung und ein damit korrespondierender Knochenwinkel von >60°. Nur diese sichert eine ausreichende Gelenkkongruenz und ist Voraussetzung fur eine physiologische Gelenkfunktion. Seit 1995 ist die sonographische Untersuchung der Sauglingshufte in das Screeningprogramm zur Fruherkennung vermeidbarer Erkrankungen im Rahmen der U3 aufgenommen. Dies ermoglicht zwar erstmals eine luckenlose Untersuchung der Sauglinge, fuhrt jedoch im Falle einer Pathologie zu einem verspateten Behandlungsbeginn nach der U3 in der 4. bis 5. Lebenswoche. Nur eine breite, exakte und zeitgerechte Anwendung der Methode der sonographischen Dysplasiediagnostik sichert maximale Erfolge in Diagnostik und Behandlung der Huftgelenkdysplasie im Interesse der kleinen Patienten.

Die Ultraschalluntersuchung des Huftgelenkes hat eine grose Bedeutung in der differenzialdiagnostischen Abklarung des schmerzhaften Huftgelenkes. Insbesondere im Kindesalter kommt der Untersuchung eine richtungweisende Bedeutung zu. Das Leitsymptom der sonographischen Beurteilung ist der Nachweis einer intraartikularen Ergussbildung, da alle akuten Erkrankungen und Verletzungen des Huftgelenkes mit einer intraartikularen Volumenzunahme einhergehen. Diese ist in einer konvexen Abhebung der Gelenkkapsel erkennbar. Altersentsprechende Normwerte dafur gibt es nicht, ein Seitenunterschied von mehr als 2,5 mm spricht fur eine Ergussbildung im Huftgelenk.

Die Implantation einer Hufttotalendoprothese (Huft-TEP) gehort zu den erfolgreichsten Operationen der orthopadischen Chirurgie. Mit herkommlichen Implantaten und Operationstechniken sind Standzeiten von 95% und mehr nach zehn Jahren erreicht worden. Trotzdem wurde immer wieder versucht, weitere Optimierungen zu erreichen. Hierzu wurden robotergestutzte Verfahren, Computernavigation, neue Implantate und in jungster Vergangenheit die minimalinvasive Implantationstechnik favorisiert. Die robotergesteuerten Verfahren wurden bereits verlassen. Die Navigation der Pfannen- und Schaftimplantation wird insbesondere wegen der Notwendigkeit der Erstellung eines praoperativen Computertomogramms und wegen der nicht geringen Anschaffungskosten unverandert kontrovers diskutiert. Die zur Verfugung stehenden minimalisierten Implantate (Oberflachenersatz) sind teilweise mit einem ausgedehnteren Zuggangstrauma verbunden als herkommliche Implantate oder Kurzschaftprothesen. Der wesentliche Vorteil der minimalinvasiven Huftchirurgie zur Implantation einer Huft-TEP wird im verringerten Zugangstrauma und der damit assoziierten schnelleren Mobilisierbarkeit des endoprothetisch versorgten Patienten gesehen. Dieser Vorteil hat ganz wesentlich mit erhaltenen myofaszialen Strukturen und Regelkreisen zu tun. Im folgenden Artikel werden die verschiedenen Methoden der Implantationstechnik einer Huft-TEP unter besonderer Berucksichtigung des Zugangsweges und der affektierten myofaszialen Strukturen beschrieben. Ziel der Arbeit ist es weiterhin, dem Nachbehandler eine Orientierung in die Hand zu geben, welche myofaszialen Strukturen nach welchem Operationsverfahren einer manualtherapeutischen Behandlung uberhaupt zuganglich sind und welche nicht.

Purpose: The objective of our study was to evaluate whether preoperative ultrasound-guided marking of calcium deposits has a positive effect on the efficiency and speed of localization of calcium deposits during surgery, and whether this technique is a factor that increases the probability of good clinical results. Methods: Twenty-four patients who required surgery for calcific tendinitis in the years 2001 and 2002 were divided into 2 groups of 12 patients by week. Before undergoing surgery, those in group 1 (weeks 1, 3, 5, etc.) were given a standard ultrasound examination, along with preoperative ultrasound-guided marking (pre-USM) of calcium deposits, whereas group 2 (weeks 2, 4, 6, etc.) received the standard ultrasound examination without pre-USM. In both groups, arthroscopic removal of calcium deposits was carried out and the postoperative treatment plan was identical. The clinical result was evaluated by the Constant-Murley score. Results: At the 6-week and 2-year follow-up visits, the clinical result was significantly better ( P v 70 points and 80 v 74 points, respectively). After 12 weeks, the clinical outcomes of both groups showed an approaching significance, with better results seen in the pre-USM group (79 v 74 points; P = .052). The time required for intraoperative localization of calcium deposits was 16 versus 22 minutes. The difference showed an approaching significance ( P = .057). Removal of calcium was possible in 12 versus 10 cases; complete removal was possible in 8 versus 6 cases, respectively. However, none of these variables had a statistically significant influence on our results. Conclusions: Preoperative ultrasound-guided marking of calcific deposits is a procedure that statistically significantly improves the clinical results of arthroscopic surgery as seen at 6 weeks and 2 years; statistical significance of .052 was approached only at 12 weeks, as we have shown here for calcifying tendinitis of the shoulder joint. Level of Evidence: Level III, development of diagnostic criteria with nonconsecutive patients.

Osteoporotische Frakturen der Brustwirbelsaule konnen zu Deformierungen und Fehlstellungen mit Auswirkungen auf den gesamten Stutz- und Bewegungsapparat fuhren. Die Therapie ist in der Mehrzahl der Falle konservativ. Die Therapiekonzepte mussen interdisziplinar und individuell erstellt werden. Feste Bestandteile des therapeutischen Konzepts sind eine antiosteoporotische Medikation, eine suffiziente Schmerztherapie und eine umfassende Trainingstherapie. Persistierende Beschwerden mit der Gefahr der Chronifizierung oder schwerwiegende Frakturmuster konnen Anlass zu zusatzlichen operativ-stabilisierenden Masnahmen sein. Bei den typischen osteoporotischen Sinterungsfrakturen haben sich die Vertebroplastie und Kyphoplastie als Zement augmentierende Verfahren etabliert. Instabile Frakturen, Stenosen und vorliegende neurologische Defizite erfordern konventionelle operative Masnahmen unter besonderer Berucksichtung der Eigenschaften des osteoporotischen Knochens.

Verletzungen im Bereich der Brustwirbelsaule und des Thorax betreffen vor allem die knocherne Wirbelsaule selbst und die Rippen. Verletzungen der thorakalen Wirbelsaule gehen mit folgenden Gefahren fur den Patienten einher: neurologische Defizite, verbleibende Deformitat, resultierende Instabilitat und chronische Schmerzen. Je nach Ausmas der Gefahrdung stehen operative und nichtoperative Therapieverfahren zur Verfugung. Entscheidet man sich zur operativen Stabilisierung und Dekompression, ist heute die dorsoventrale Spondylodese das Verfahren der Wahl. Hiermit sind im Hinblick auf die oben genannten Kriterien hervorragende Ergebnisse zu erreichen. Trotz immer weiterer Verfeinerung der Operationstechniken und einer Minimierung der Zugangswege spielt im Bereich der Brustwirbelsaule das Zugangstrauma in der funktionellen Nachbehandlung eine wesentliche Rolle. Der Begriff „Postthorakotomiesyndrom“ beschreibt diesen Komplex nur unzureichend. Die an sich zumeist harmlosen Rippenverletzungen werden vor allem durch viszerale Komplikationen wie Hamato- und/oder Pneumothorax mit resultierender Drainagenotwendigkeit und bleibenden pleuralen Verklebungen klinisch bedeutsam. Hieraus resultieren ebenfalls teilweise langwierige Behandlungsverlaufe. Fur jeden funktionsmedizinisch arbeitenden Behandler ist die Kenntnis der operativen Ablaufe von Interesse. Ebenso finden funktionelle Aspekte in der Operationsplanung und Behandlungsstrategie Beachtung.

Case report.To present an unusual traumatic neurologic pathology caused by gunshot injury.Spine unit of Department of Trauma and Orthopaedic Surgery, University Medical School, Charité - Campus Benjamin Franklin, Berlin, Germany.A 35-year-old male sustained a gunshot injury from a machine gun. The projectile caused a fracture of the left pedicle of Th10. The spinal cord was indirectly damaged by cavitation that caused a Brown-Séquard syndrome (BSS). After a microscopically assisted posterior revision at T9/10 with removal of bullet and bone fragments from the spinal canal and debridement of the bullet cavity via extended fenestrectomy the patient gained his motor function back. The sensory deficit remained unchanged.BSS can be caused by bullet-related injury of the spinal canal with no direct damage of neural structures. The initial treatment is always based on the total injury pattern. Possible spinal cord injuries are only clarified after restitution of vital functions. Decompression of neural structures in shotgun injury is indicated in incomplete paraplegia, injury of intra-abdominal hollow organs or high velocity bullet wounds. Through debridement and decompression of neural structures and chronic damage caused by foreign body granulomas can be prevented. Secondary destabilization of the spine should be avoided.

Background: Odontoid fractures, often in combination with C1 fractures, are a common fracture of the cervical spine in geriatric patients. The optimal treatment of this fracture in this patient population is often controversial. We report the surgical outcome of unstable type II odontoid fractures in the elderly. Method: 8 patients (median age, 80.5 years; range, 72-93) with unstable type II odontoid fractures according to the Anderson and d'Alonzo classification were included in this prospective study. 2 patients sustained a C1 fracture (1 had an unstable type III fracture according to the Gehweiler classification, and 1 had a stable type III fracture). There were no neurological complications. All patients were classified as ASA class III. 7 patients were treated with anterior odontoid double-screw compression osteosynthesis followed by a firm neck support for 6 weeks. 1 patient with an unstable C1 and C2 fracture was treated with an occipital cervical (C2) fusion in combination with a C1-C2 fusion acco...

Unstable ankle fractures are demanding injuries to treat. Open reduction and internal fixation are accepted as standard care, however, in patients with severe soft tissue damage or serious medical conditions, this approach may not always be advisable. Closed reduction with temporary fixation using vertical transarticular pins is one method to maintain joint alignment until an open technique is possible. Fourteen patients (median age: 59.5 years) with unstable ankle fractures, including three type-2 open fractures, were included in the study. Open reduction and fixation was delayed because of severe soft tissue damage, and a temporary transarticular pin fixation using two Kirschner wires was performed. After a median of 8.4 days, an open reduction and internal fixation was carried out in all patients. No complications related to the temporary arthrodesis were observed during the acute phase, and follow-up at 24 months revealed no damage to the articular surface attributable to the pin insertion. The median Olerud-score was 33.43, but three patients showed signs of early post-traumatic arthritis which we felt were due to the initial fracture. We conclude that closed reduction and temporary fixation using vertical transarticular pins of unstable ankle fractures is a safe method of maintaining joint alignment until a definitive open approach is feasible.

Verletzungen des Ellenbogens sind bei traumatologischen Patienten eher selten. Aufgrund des meist komplexen Verletzungsmusters sind sie jedoch oft schwer und fur die Betroffenen mit einem nicht immer befriedigenden Behandlungsergebnis verbunden. Eine notwendige Ruhigstellung des Ellenbogengelenkes sollte auf ein Minimum begrenzt bleiben, um posttraumatische Kontrakturen zu vermeiden, zumal die operativen Moglichkeiten einer Therapie verbleibender Restfunktionsstorungen (Arthrolyse) begrenzt sind. Nur eine enge Zusammenarbeit zwischen behandelnden Arzten und betreuenden Physiotherapeuten sichert ein optimales Ergebnis der Behandlung.

Die sinnvolle bildgebende Beurteilung des Ellenbogengelenkes nach der klinischen Untersuchung stellt ein relevantes Problem im klinischen Alltag dar. Lassen sich knocherne Prozesse relativ gut radiologisch darstellen, ist die Mehrzahl der klinischen Befunde mit Veranderungen des periartikularen Weichteilgewebes bzw. mit intraartikularer Flussigkeitsansammlung verbunden. Zur Darstellung derartiger Pathologien ist die Ultraschalluntersuchung sehr gut geeignet. Die standardisierte Untersuchungstechnik der Sonographie des Ellenbogengelenkes soll hier vorgestellt werden.

Cervical spine spondylodiscitis is a rare, but serious manifestation of spinal infection. We present a retrospective study of 20 consecutive patients between 01/1994 and 12/1999 treated because of cervical spondylodiscitis. Mean age at the time of treatment was 59.7 (range 34-81) years, nine of them female. In all cases, diagnosis had been established with a delay. All patients in this series underwent surgery such as radical debridement, decompression if necessary, autologous bone grafting and instrumentation. Surgery was indicated if a neurological deficit, symptoms of sepsis, epidural abscess formation with consecutive stenosis, instability or severe deformity were present. Postoperative antibiotic therapy was carried out for 8-12 weeks. Follow-up examinations were performed a mean of 37 (range 24-63) months after surgery. Healing of the inflammation was confirmed in all cases by laboratory, clinical and radiological parameters. Spondylodesis was controlled radiologically and could be achieved in all cases. One case showed a 15 degrees kyphotic angle in the proximal adjacent segment. Spontaneous bony bridging of the proximal adjacent segment was observed in one patient. In the other cases the adjacent segments radiologically showed neither fusion nor infection related changes. Preoperative neurological deficits improved in all cases. Residual neurological deficits persisted in three of eight cases. The results indicate that spondylodiscitis in cervical spine should be treated early and aggressive to avoid local and systemic complications.

Die Verletzungen der oberen Halswirbelsaule (HWS) von C0–C2 spielen bei der operativen Behandlung der Traumafolgen der gesamten HWS eine besondere Rolle. Obgleich die Zahl derartiger Versorgungen in den letzten Jahren zugenommen hat, liegen klare Behandlungsempfehlungen fur die meisten Verletzungsformen nicht vor. Da das Spektrum der in Frage kommenden Verletzungen breit und die Zahl der Behandlungsalternativen entsprechend gros ist, wird fur diese Ubersichtsarbeit besonders auf folgende Verletzungen eingegangen: C0-Fakturen [Frakturen der Hinterhauptkondylen (OKF)], atlantookzipitale Dislokationen (AOD), Atlasfrakturen, atlantoaxiale Instabilitaten (AAD) und Axisfrakturen. Es werden besondere Aspekte des Unfallmechanismus, der klinischen Symptomatik, sowie diagnostische Ablaufe und Behandlungsoptionen erlautert. Hierbei wird besonders auf die Darstellung alternativer Behandlungsmethoden im Literaturvergleich Wert gelegt. Eine zusammenfassende Tabelle am Ende eines jeden Kapitels erleichtert die schnelle Orientierung.

Mit einem Befall der Halswirbelsaule (HWS) beim Rheumatiker ist im Langzeitverlauf in >50% der Falle zu rechnen. Primar kommt es zu einer Manifestation des rheumatischen Geschehens an der oberen HWS. Der initiale Befall des Segments C1/C2 fuhrt zu einer horizontalen Instabilitat, bei fortschreitender Destruktion kann es zu einer sog. vertikalen Instabilitat kommen. Diese ist durch ein relatives Hohertreten des Dens gekennzeichnet. Daraus resultiert die Gefahr einer Myelonkompression mit der Ausbildung der prognostisch ungunstigsten Komplikation der rheumatischen Arthritis an der HWS, der zervikalen Myelopathie.

OBJECTIVES The objective of the present study was to assess the validity of ultrasound diagnosis of shoulder disorders in relation to examiner experience. METHODS A total of 239 patients referred to us for shoulder arthroscopy from October 2001 to June 2004 were prospectively studied by ultrasound. The following ultrasound diagnoses were evaluated: total and partial rotator cuff tears, calcific tendinitis, biceps tendon injuries and subacromial bursitis. Examiner A established the ultrasound diagnoses and examiner B performed the surgery during week A, whereas examiner B did the examinations and examiner A operated in week B. The surgeon was blinded to the ultrasound results. Examiner A conducts ultrasound training seminars for DEGUM, the German Society of Ultrasound in Medicine, and has performed over 10,000 ultrasound examinations, with an average of roughly 150 examinations per year. Examiner B completed his ultrasound training some years ago and has performed roughly 1500 examinations (50 per year). The results were analysed in a time-independent and blinded manner by the co-author (H), who neither operated nor examined the patients. RESULTS Ultrasound correctly identified 103 of 104 complete rotator cuff tears (sensitivity: 0.99--specificity: 0.99--accuracy: 98.7%). Both examiners achieved comparable results. Moreover, 41 of 52 partial rotator cuff tears were detected preoperatively (sensitivity: 0.79--specificity: 0.91--accuracy: 88.7%). Examiner A achieved a sensitivity of 0.92, a specificity of 0.95, and an accuracy of 94.7%. The corresponding rates for examiner B were: sensitivity 0.68, specificity 0.86, and accuracy 81.3%. 16 of 23 injuries of the long biceps tendon were identified correctly (4 of 8 dislocations and 12 of 15 tears: sensitivity 0.53; specificity 0.9; accuracy 95.3%). Examiner A achieved: sensitivity 0.58; specificity 0.99; accuracy 91.7% compared to examiner B: sensitivity 0.33; specificity 0.97; accuracy 95.3%. Both examiners correctly identified all 32 cases of calcific tendinitis (sensitivity 1.0; specificity 0.98; accuracy 98.3 % examiner A: 1.0--1.0--100% examiner B: 1.0--0.96--96.2%). 22 of 28 cases of subacromial bursitis were correctly diagnosed (sensitivity 0.79; specificity 0.98; accuracy 95.8% examiner A: 0.92--0.99--98.5% examiner B: 0.69--0.97--92.5%). CONCLUSIONS Preoperative ultrasound examination of the shoulder permits a reliable diagnosis of complete rotator cuff tears and calcium deposits (calcific tendinitis). The method is less sensitive but sufficiently reliable for the diagnosis of partial rotator cuff tears and pathology of the long biceps tendon. Examiner experience plays an important role in these special cases. Permanent continuous training in the field of ultrasound diagnosis is a prerequisite for sufficient reliability of ultrasound diagnosis of shoulder disorders.

Aim: The goal of intraoperative nerve root monitoring on the lumbosacral spine is to minimize the risk of nerve root injuries during surgery by reducing the incidence of misplaced pedicle screws. In this study we hypothesized that the INS-1 device (Nuvasive®) may provide more accurate information about screw placement. Method: The INS-1 device provides a means for intraoperative EMG stimulation through the inside of the pedicles or the implanted screws. The readings from relevant muscles serve as a monitoring technique to detect perforated pedicles and thus can be used to prevent or detect misplaced pedicle screws and reduce the risk of nerve root injuries. We controlled 58 patients with 334 implanted pedicle screws. Results: Our first experience with 334 pedicle screws shows that nerve root injuries can be avoided by reducing the number of misplaced pedicle screws through additional intraoperative information gained by the INS-1 device. Thus we corrected 3.9% of screws intraoperatively in cases without relevant information from flouroscopic control. Conclusion: The INS-1 device is a helpful tool to obtain additional information on misplaced pedicle drill holes or already implanted screws in the lumbosacral spine.

Spondylitis is a rare disease in childhood and atypical symptoms frequently retard the diagnosis. From 1968 to 1988, 25 children with a diagnosis of spondylitis were treated in our orthopedic hospital. Anamneses, clinical symptoms, roentgenograms, and differential diagnoses are described for these cases. Spondylodiskitis represents a mild course of the disease in childhood. Tuberculous spondylitis was not present in any of the cases. The prognosis of childhood spondylitis is favorable, and surgical interventions were not necessary in our patients. Spondylitis healed with an ankylosis of one segment of the spine without essential disturbance of spinal function.

This retrospective study was made to illustrate the rare occurrence of neurologic deficits resulting from intervertebral disc calcification (IDC) in a child. Most authors agree that juvenile IDC is usually a benign, self-limiting disease with excellent prognosis. The symptoms subside spontaneously in 95% of patients. Conservative treatment is therefore usually sufficient. Reviewing the English-speaking literature, only two further cases of operated juvenile IDC with myelopathy have been published. In the current report, we describe a case of permanent thoracic myelopathy resulting from juvenile IDC treated by urgent decompressive thoracic laminectomy. At the 3-year follow-up examination, the patient had not recovered fully. Persisting deficits in motor and sensory function were observed.

SUMMARY Aims This study analysed the effects of specially manufactured insoles on foot pressures in diabetic patients during a 1-year prospective observation period. Methods We studied 81 type 2 diabetic patients without foot lesions. Using pedobarography three different regions of interest were examined: maximum peak pressure (MPP) of the total foot area, heel region and head of metatarsal bone I-III. Eighteen patients with high risk pressure (MPP of total foot 474 ± 183 kPa; heel region 278 ± 147 kPa, metatarsal 389 ± 222 kPa) received optimal insole support. Sixty-three patients as a control group (MMP of total foot 367.7 ± 157 kPa; heel 263.1 ± 127 kPa, metatarsal 339.9 ± 171 kPa) received conventional footwear. Results After insole support a 30% pressure reduction of total foot MMP (474 ± 183 kPa vs. 290 ± 106 kPa) was achieved in the treatment group. After 6 months (324 ± 127 kPa) and 1 year (380 ± 190 kPa) a pressure reduction was found. Between the 6- and 12-month controls plantar pressures again increased. In the control group a significant increase of all peak pressures occurred. Conclusions Early insole support is successful in reducing plantar pressure. A repeated adjustment should be performed every 6 months to prevent foot pressure increases. The comparison of foot pressure development between the two groups showed constant levels in the treatment group. In the control group a marked increase of the pressure values was found. Identification and subsequent support of patients with high ulceration risk may help to reduce the high amputation rate.

BACKGROUND A real congenital dislocation of the hip joint is very rare. Because of the severeness of the disease an immediate diagnosis and begin of treatment is required. PATIENTS Between 1984 and 1995 clinical and sonographic screening examinations at 4177 newborns were performed at our hospital. METHODS We analyzed our patients retrospectively and found out all cases of congenital dislocation of the hip joint. All these cases were classified and the results of treatment were determined. The clinical success of our strategy of treatment was described. RESULTS Among the 4177 observed newborns 39 cases of congenital dislocation of the hip joint in 27 children were found. We diagnosed the hip type IIIa, IIIb and IV according to Graf in 28.2 and 9 cases respectively. After 12 month a complete healing rate of 95 percent was exhibited with the functional management strategy. Five percent of the affected joints showed a residual dysplasia. The rate of residual dysplasias was 2.5%. CONCLUSIONS The good prognosis after our early treatment strategy severe congenital dislocation of the hip joint underlines the use of earliest therapy together with a hip screening program.

Aseptic loosening is one of the most common intermediate and long-term complications after total hip replacement (THR). These complications cause suffering and require expensive revision surgery. Little concrete data on direct costs are available from the hospital’s, moreover operating department’s perspective. We here provide a detailed analysis of the costs of THR revision and relate them to reimbursement underlying the German diagnosis-related groups (DRG) system. Major cost parameters were identified using for orientation the cost matrix of the German Institute for Hospital Reimbursement (InEK GmbH). We then retrospectively analysed the major direct costs of aseptic revision THR in terms of contribution margins I and II. The analysis included a total of 114 patients who underwent aseptic revision from 1 January 2009 to 31 March 2012. Data were retrieved from the hospital information system and patient records. All costs of surgery, diagnostic tests, and other treatments were calculated as purchase prices in EUR. The comparative analysis of direct costs and reimbursements was done for DRG I46A and I46B from the hospital’s, especially treating department’s rather than the society or healthcare insurance’s perspective. The average direct cost incurred by the hospital for a THR revision was €4,380.0. The largest share was accounted for surgical costs (62.7 % of total). Implant and staff costs were identified as the most important factors that can be influenced. The proportion of the daily contribution margin that was left to cover the hospital’s indirect cost decreased with the relative cost weight of the DRG to which a patient was assigned. Our study for the first time provides a detailed analysis of the major direct case costs of THR revision for aseptic loosening from the provider’s perspective. Our findings suggest that these revision operations could be performed cost-beneficially by the operating unit. From an economic perspective, cases with higher cost weights are more favorable for a hospital. These results need to be confirmed in multicenter studies.

STUDY DESIGNA prospective consecutive cohort study (follow-up study).OBJECTIVEOur study investigated whether implantation of an expandable titanium mesh cage (Osseofix®) is a successful and safe minimally invasive therapy for osteoporotic vertebral compression fractures (VCF). Our experiences, clinical and radiological findings after 12 months follow-up are presented. Kypho- and vertebroplasty are well-established minimally invasive procedures for the treatment of osteoporotic VCF. The main complications associated with both procedures are uncontrolled bone cement leakage. Therefore a suitable alternative has been investigated.METHODSDuring June 2010 to May 2011 24 patients were included with 32 osteoporotic VCF (T6 to L4). All of them were stabilized with the Osseofix® system. Preinterventionally we performed X-ray, MRI, and bone density measurements (DXA). Clinical and radiological results were evaluated preop., postop. and after 12 months postop. based on the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS), X-ray (Beck Index, Cobb-angle) and CT.RESULTSThere was a significant improvement in the mean ODI (70,6% to 30,1%) as well as a significant reduction in pain intensity (VAS) (7,7 to 1,4) after 12 month. The mean kyphotic angle according to Cobb showed significant improvements (11,7° to 10,4°) after 12 months. Postinterventional imaging showed only one case of loss of height in a stabilized vertebral body (3.1%). We saw no changes in posterior vertebral wall or adjacent fractures. Except for one pronounced postoperative hematoma we saw no surgical complications including no cement leakage.CONCLUSIONSStabilization of symptomatic osteoporotic VCF with Osseofix® system is a safe and effective procedure, even in fractures with posterior wall involvement. The clinical mid-term results are good at a very low complication rate. The Osseofix® system is an interesting alternative to the established procedures of cement augmentation.

Unter »physiotherapeutischer Therapie« wird die gezielte Behandlung von Funktionsstorungen des arthroneuromuskularen Systems mit aktiven und passiven Therapieformen verstanden.

The use of metal implants in large defects caused by spinal infection to support the anterior column is controversial, and relatively few results have been published to date. Despite the fact that there is bacterial adhesion to metal implants, the strong immunity of the highly vascularized spine because of rich muscle covering is unique. This possibly allows the use of metal implants, which have the advantage of high stability and reduced loss of correction. This is a retrospective study of patients with spondylodiscitis treated with metal implants.We retrospectively analyzed the outcome in 22 consecutive patients (mean age 69 (43-82) years, 15 men) with spondylodiscitis (20 lumbar and 12 thoracic discs) who had received an anterior titanium cage implantation. In 13 cases, the pathogen could be identified. Antibiotic treatment was continued for at least 12 weeks postoperatively.The mean follow-up was 36 (32-47) months. Healing of inflammation was confirmed by clinical, radiographic, and laboratory parameters. The mean VAS improved from 9.1 (6-10) preoperatively to 2.6 (0-6) at the final follow-up, and the mean Oswestry disability index was 17 (0-76) at the final follow-up.Our findings highlight the high healing rate and stability when titanium implants are used. Prerequisites are a radical debridement, correction of deformity, and additional bony fusion by bone grafting. The increased stability, with facilitated patient mobilization, and the relatively little loss of correction using anterior and posterior implants are of considerable advantage in the treatment of the patients with multiple co-morbidities.

Patients with ankylosing spondylitis are at significant risk for sustaining cervical spine injuries following trauma predisposed by kyphosis, stiffness and osteoporotic bone quality of the spine. The risk of sustaining neurological deficits in this patient population is higher than average. The present review article provides an outline on the specific injury patterns in the cervical spine, diagnostic algorithms and specific treatment modalities dictated by the underlying disease in patients with ankylosing spondylitis. An emphasis is placed on the risks and complication patterns in the treatment of these rare, but challenging injuries.

Kopfschmerzen sind eine der haufigsten krankhaften Storungen in Mitteleuropa. Die Klassifikation der International Headache Society ist sehr detailliert, berucksichtigt jedoch Kopf- und Gesichtsschmerzen im Zusammenhang mit funktionellen Storungen des Bewegungssystems nicht ausreichend. Im vorliegenden Beitrag werden zwei manualmedizinische Kopf- und Gesichtsschmerzsyndrome vorgestellt: das orbitotemporale (OTS) und das orofaziale Syndrom (OFS). Weitere manualmedizinische Kopfschmerzsyndrome wie das nasopharyngeale (NPS) und das laryngomediastinale Syndrom (LMS) werden in der nachsten Ausgabe dieser Zeitschrift beschrieben, dann auch mit der differenzialdiagnostischen Abgrenzung zur Migrane, dem Spannungskopfschmerz und den trigeminoautonomen Kopfschmerzen. In diesen Beitragen werden spezifische manualmedizinische Funktionsstorungen im Zusammenhang mit typischen Beschwerdeschilderungen von Kopfschmerzpatienten herausgearbeitet, sie stellen also den Versuch einer manualmedizinischen Syndrombildung in Bezug auf die Kopf- und Gesichtsschmerzen dar. Der manualmedizinische Untersuchungsgang und die Behandlungssequenz werden syndromspezifisch beschrieben. Auf die Prognose und die Prophylaxe der einzelnen Syndrome wird ebenfalls eingegangen.

STUDY DESIGN The loads acting on a vertebral body replacement (VBR) were measured in vivo. OBJECTIVE To measure the implant loads for different activities within the first 6 months after surgery. SUMMARY OF BACKGROUND DATA Mathematical models exist for predicting spinal loads for various activities. The intradiscal pressure has been measured in vivo for many activities. Loads on internal spinal fixation devices have been measured in 10 patients. However, only little information exists regarding the loads acting on a VBR. METHODS Telemeterized VBRs were implanted into 2 patients with a fractured L1 vertebral body. The implant allows the in vivo measurement of 3 force and 3 moment components acting on the implant. For several activities, implant loads were measured in the first 6 months after surgery. RESULTS One month after surgery, the resultant force during standing was about 270 N in 1 patient and 300 N in the other. When the patients were lying in relaxed positions, resultant forces were less than 30% of the values during standing. In one patient, implant loads were slightly lower during sitting than during standing whereas in the other patient higher loads were measured during sitting. In both patients, flexion of the upper body and walking upstairs caused implant loads, which were more than twice as high as those during standing. Force direction varied only slightly for forces higher than 100 N. CONCLUSION High forces may act on a VBR especially in the first postoperative month. Flexion of the upper body and going upstairs cause high implant loads and should be avoided in the first few months after stabilizing the spine.

The purpose of this study was to investigate the outcome of expandable titanium cage implantation in large defects caused by acute vertebral osteomyelitis. Twenty-five patients with acute single or multilevel spondylodiscitis were treated after radical debridement and posterior instrumentation with an anterior expandable titanium cage and bone grafting. Clinical, laboratory and radiological follow-up continued for 36 months. Within the postoperative course there was no recurrence of spinal infection. The final radiological examination showed successful fusion in all cases without implant loosening or failure. At the final follow-up after 36 months the Oswestry Disability Index was 23 +/- 14 and the pain visual analogue scale 2.1 +/- 1.7. This study reveals healing and improved function after expandable titanium cage implantation in all patients. Prerequisites for optimal healing include radical debridement, provision of stability for weight-bearing, adequate bone grafting and correction of deformity using rigid implants.

Postoperative spinal infections are relatively rare. They can become life-threatening.A 56-year-old man developed multisegmental spinal infection with methicillin-resistant Staphylococcus aureus after discectomy at L3/4. A staged ventrodorsoventral intervention was needed for radical debridement and stabilization. After femoral head necrosis developed as a result of the infection, a Girdlestone hip was maintained until the joint was aseptic and a hip prosthesis could be implanted. Two years postoperatively, the patient remained free of infection recurrence.Radical debridement and a tightly controlled antibiotic regimen are necessary for the management of postoperative spinal infections. This should include staged interventions until recovery from infection is possible. Early intervention can prevent systemic sepsis caused by widespread bacterial dissemination.

Due to the increase in patients with multiple co-morbidities and immigration from developing countries the incidence of thoracic spondylodiscitis has not decreased. The diagnosis of thoracic spondylodiscitis is based on clinical findings, laboratory diagnostics and radiological imaging, including X-ray and MRI. Surgical therapy includes radical debridement, correction of deformity and adequate stabilisation, even though the use of titanium implants is discussed controversially. Additionally antibiotic therapy according to the resistance spectrum is necessary. Early diagnosis and therapy enable healing without severe complications.

Because of its unique anatomy, specific diseases and lesions arise in the upper cervical spine, which differ widely from the rest of the spine. During the last two decades standardised diagnostic and therapeutic algorithms have been defined for most of the craniocervical pathologies often occurring in combination with an underlying disease requiring surgical intervention as well. On the other hand there are some very rare phathological alterations: about 20% of the patients suffering from neurofibromatosis type I develop spinal deformities. These are mostly found in the thoracic and lumbar spine (dystrophic/non-dystrophic type). In rare cases the dystrophic neurofibromatosis type I involves the upper cervical spine leading to bizarre deformities endangering the spinal cord. An aggressive, timely and combined operative therapy is necessary. Patients with Down syndrome should be investigated regularly for affections of the upper cervical spine. Though only in about 1% of all patients with Down syndrome do instabilities require surgical intervention, the upper cervical spine should be screened on a regular basis, since neurological changes due to the pathognomy of the underlying disease often remain undetected for a long time. The operative therapy of the instable os odontoideum in Down syndrome follows the general principles of this pathoanatomical variation. Even though the Klippel-Feil syndrome is generally not linked with neuropathological findings, rare associated deformities of the upper cervical spine should be excluded by proper diagnostic procedures.

Objectives:The aim of this study was to determine whether ultrasound can correctly visualise partial ruptures of the proximal Achilles tendon.Method:This was a prospective study in which all chronic Achilles tendon injury patients seen at three centres in Germany from 1998 to 2003 were screened. All patients with clinical and/or sonographic signs of abnormalities in the region of the proximal third of the Achilles tendon and tendomuscular junction were included in the analysis. Each of these cases was evaluated by ultrasound following an assessment protocol. Patients with ambiguous ultrasound findings and/or clinical signs were additionally assessed by magnetic resonance imaging (MRI).Results:Sonomorphologic changes suggestive of an abnormality in the proximal third of the Achilles tendon were detected in 13 out of 320 patients (4.2%) with recurring Achilles tendon complaints. Thirteen patients had clinical signs but no sonographic changes in the tendon. The sonographic diagnosis was correct in 19 cases. In six of the 26 cases studied, MRI was needed to establish the correct diagnosis of partial intratendinous rupture of the proximal Achilles tendon. Sensitivity was 0.5, specificity was 0.81, and the overall agreement of the ultrasound examination was 61.5%. All patients were asymptomatic at follow up at a mean of 14 months (range 12–17 months) after surgery.Conclusions:Ultrasound is a useful tool for evaluation of proximal Achilles tendon complaints. However, ultrasound is not sufficiently reliable for diagnosis of all pathologies, especially partial ruptures of the Achilles tendon. Thus, the definitive diagnosis must be established by MRI.

The management of spine injuries in polytraumatized patients remains a great challenge for the diagnostic procedures and institution of appropriate treatment by integrating spinal trauma treatment into the whole treatment concept as well as following the treatment steps for the injured spine itself. The established concept of "damage control" and criteria regarding the optimal time and manner for operative treatment of the injured spine in the polytrauma setting is presented and discussed.