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Background Reconstruction of the proximal humerus with a locking plate is often the first surgical approach for proximal humerus fractures. Screw cut-out is a common complication and is relevant in osteoporotic bone of older adults. The Deltoid Tuberosity Index (DTI) is an indirect measure for assessing local bone quality and failure rate before surgery, providing important information for surgical planning. This was the first independent, large-sample retrospective analysis of the correlation between local bone density, indirectly measured through the DTI, and screw cut-out. Methods In total, 306 cases of proximal humerus fractures treated with the PHILOS plate (DePuy Synthes, Oberdorf, Switzerland) were retrospectively analyzed. The DTI was measured on anteroposterior x‑rays. The primary endpoint was screw cut-out defined as the intra-articular position of at least one screw associated with a reduction loss after surgery. Results The mean clinical follow-up was 935 days. The DTI varied from 1.10 to 2.28 (average: 1.45). Screw cut-out occurred on average in 8% of the cases and was positively correlated with a DTI of ≤ 1.44 (p = 0.003). However, the rate of cut-out and correlation with DTI varied widely according to age group: for ages 65–80 years, a DTI of ≤ 1.44 increased the cut-out rate from 0% to 17% (p = 0.02); in younger ages ( 80 years) cut-out rates were high (17–20%) independently of the DTI. Conclusion We confirm the correlation between a DTI of ≤ 1.44 and screw cut-out. High-risk groups for screw cut-out are patients over 65 years with a DTI of ≤ 1.44 or any patient older than 80 years. Applying the DTI in the age group of 65–80 years offers relevant information for surgical planning in the trauma setting via a fast, cheap, and easy-to-use tool. Level of Evidence: Level 3, Retrospective Cohort Study.

Background: The aim of this study was to assess the phenotype of multifocal motor neuropathy (MMN) and amyotrophic lateral sclerosis (ALS) in quantitative MR neurography. Methods: In this prospective study, 22 patients with ALS, 8 patients with MMN, and 10 healthy volunteers were examined with 3T MR neurography, using a high-resolution fat-saturated T2-weighted sequence, diffusion-tensor imaging (DTI), and a multi-echo T2-relaxometry sequence. The quantitative biomarkers fractional anisotropy (FA), radial and axial diffusivity (RD, AD), mean diffusivity (MD), cross-sectional area (CSA), T2-relaxation time, and proton spin density (PSD) were measured in the tibial nerve at the thigh and calf, and in the median, radial, and ulnar nerves at the mid-upper arm. Results: MMN showed a characteristic imaging pattern of decreased FA (p = 0.018), increased RD (p = 0.014), increased CSA (p < 0.001), increased T2-relaxation time (p < 0.001), and increased PSD (p = 0.025) in the upper arm nerves compared to ALS and controls. ALS patients did not differ from controls in any imaging marker, nor were there any group differences in the tibial nerve (p > 0.05). Conclusions: MMN shows a characteristic pattern of quantitative DTI and T2-relaxometry parameters in the upper-arm nerves, primarily indicating demyelination. Peripheral nerve changes in ALS seem to be below the detection level of current state-of-the-art quantitative MR neurography.

BACKGROUND: Proximal humerus fractures (PHF) are common and lead to post-traumatic humerus head necrosis (HHN) in 3–35% after ORIF with an internal locking plate. Few studies focus on this condition and risk factors remain a discussion topic. Hertel’s criteria for initial head ischemia right after fracture (fracture complexity, medial hinge displacement and short metaphyseal head extension) have recently been correlated to HHN, but there is still a clear lack of evidence on the topic. Due to its anatomical similarities to the proximal femur, some authors argue that PHF may as well benefit from early surgery to avoid head necrosis. METHODS: In this 10-year retrospective study, we assessed 305 patients from a single center. All cases were treated with a PHILOS plate through a deltopectoral approach. The mean follow-up time was 467 days. The primary endpoint was HHN. RESULTS: HHN was diagnosed in 12 patients (4%), 10 of which were diagnosed within the first year and one case 4 years after surgery. A positive correlation (p

In order to minimize the risk of damaging the radial nerve while using a long PHILOS plate for proximal humerus fractures, recent studies have proposed twisting the plate in a helical form. This implies a modified surgical approach being yet unclear whether it leads to different middle to long-term shoulder function. This study compares the one-year shoulder functional outcomes of both techniques (helical vs. control). In this retrospective comparative study, we analyzed 30 patients that fit the inclusion criteria, being 14 treated with a helical plate and 16 with a conventional straight long PHILOS plate. The primary endpoint was the normalized constant score after a minimum follow up of one year. Both groups had a good one-year shoulder function, and no significant difference between the normalized constant scores was seen. There was no significant difference in the surgical complications as well. Opting for a helical long PHILOS plate in order to avoid radial nerve damage provided a safe treatment with similarly good one-year shoulder function compared to straight PHILOS plates. Level 3, Retrospective Cohort Study.

Background. Reconstruction of the proximal humerus with a locking plate is often the first approach for proximal humerus fractures. Screw cut-out is the most common complication and is especially relevant in osteoporotic bone of the elderly population. The Deltoid Tuberosity Index (DTI) has recently been proposed as an indirect measure to assess osteopenia and failure rate before surgery, which may provide important information for surgical planning. Though simple and assessable, the DTI lacks scientific evidence to back its broad clinical usage. This study gives the first independent, large-sample retrospective analysis of the correlation between the local bone density, indirectly measured through the DTI, and screw cut-out.Methods. 306 cases of proximal humerus fractures treated with PHILOS plate were retrospectively analyzed. The DTI was measured in AP x-rays. The primary endpoint was screw cut-out defined as the intra-articular position of at least one screw associated to a reduction loss after surgery.Results. The mean clinical follow up was 467 days. The DTI varied from 1.10 to 2.28 (average: 1.42). Screw cut-out occurred on average in 8% of the cases and did correlate positively with a DTI ≤ 1.44 (p = 0.003). However, the rate of cut-out and correlation to DTI varied widely according to age group: within the age of 65-80 years a DTI ≤ 1.44 increased the cut-out rate from 0% to 17% (p = 0.02); on the other hand, in younger ages (< 65 years) the DTI did not correlate to cut-out and in the oldest group (> 80 years) cut-out rates were high (17-20%) independently of the DTI. Age and medial hinge displacement also correlated to cut-out. This was not the case for gender, fracture pattern and quality of surgical reduction.Conclusions. We confirm the correlation between a DTI ≤ 1.44 and screw cut-out. This correlation alone however may be too simplistic and not relevant in all age spectrum. High risk groups for screw cut-out are patients older than 65 years with a DTI ≤ 1.44 or any patient older than 80 years. Applying the DTI in the age group of 65 to 80 years offers relevant information for surgical planning in the trauma setting through a tool that is fast, cheap, and easy to perform. Level of Evidence: Level 3, Retrospective Cohort Study.

Generell stellen Wirbelsaulenverletzungen bei Kindern im Alter unter 16 Jahren eine seltene Verletzungsentitat dar. Fur Deutschland liegen keine belastbaren Daten bezuglich der Epidemiologie von Verletzungen der Wirbelsaule im Kindesalter vor. Gerade bei padiatrischen Patienten, bei denen sowohl die Anamnese, die klinische Untersuchung, aber auch die Durchfuhrung der bildgebenden Diagnostik haufig erschwert sind, mussen samtliche Hinweise auf eine Verletzung der Wirbelsaule mitberucksichtigt werden. Das Ziel der vorliegenden Studie war die Bereitstellung epidemiologischer Daten von padiatrischen Patienten mit Wirbelsaulenverletzungen in Deutschland, um diese zukunftig in die Entscheidungsfindung bei der Diagnostik und Therapie dieser Patienten einfliesen lassen zu konnen. Im Rahmen einer nationalen Multizenterstudie wurden retrospektiv Patientendaten innerhalb eines Zeitraums von 7 Jahren aus 6 Wirbelsaulenzentren erhoben. Neben den demografischen Daten wurden der Unfallmechanismus, die betroffene Wirbelsaulenregion und auch die Begleitverletzungen erhoben. Zudem erfolgte die Erfassung der bildgebenden Diagnostik sowie der jeweiligen Therapie. Es konnten 367 Kinder (weiblich: mannlich = 1:1,2) mit insgesamt 610 Verletzungen an der Wirbelsaule in die Studie eingeschlossen werden. Das mittlere Alter betrug 12 (±3,5) Jahre. Die haufigsten Unfallmechanismen in allen Altersgruppen waren ein Sturz aus unter 3 m Hohe sowie Verkehrsunfalle. Die bildgebende Diagnostik musste nur in Ausnahmefallen in Narkose durchgefuhrt werden. Wahrend jungere Kinder (0 bis 9 Jahre) eher Verletzungen im Bereich der Halswirbelsaule erlitten, zeigten sich Verletzungen der thorakolumbalen Wirbelsaule eher bei Kindern >10 Jahren. Die Kinder wiesen haufige Begleitverletzungen an Kopf und Extremitaten auf. Im Bereich der Wirbelsaule befanden sich weitere Verletzungen meist benachbart und nur selten in anderen Regionen. Rund 75 % der Kinder wurden konservativ behandelt. Die Ergebnisse unterscheiden sich von den Erkenntnissen aus der Erwachsenenmedizin und beschreiben spezielle Gegebenheiten fur padiatrische Patienten mit Wirbelsaulenverletzungen. Trotz gewisser Limitationen konnen sie so bei der Entscheidungsfindung uber die durchzufuhrende Diagnostik und Therapie dieser Patienten helfen.

Wirbelsaulenverletzungen im Kindesalter sind insgesamt sehr selten. Aktuelle einschlagige Studien mit grosen Fallzahlen, aus welchen sich evidenzbasierte Empfehlungen zu Diagnostik und Therapie von Wirbelsaulenverletzungen bei padiatrischen Patienten ableiten lassen, existieren nicht. Formulierung von Empfehlungen zu Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsaule im Kindesalter. Zunachst erfolgte eine Recherche von Primar-, aber auch Sekundarliteratur zum Themenkomplex Diagnostik und Therapie von Verletzungen der Wirbelsaule bei Kindern. Eine entsprechende interne Literaturdatenbank wurde angelegt und gepflegt. Im Zeitraum von April 2017 bis Dezember 2019 fanden sich die Mitglieder der Arbeitsgemeinschaft Wirbelsaulentrauma im Kindesalter der Sektion Wirbelsaule der Deutschen Gesellschaft fur Orthopadie und Unfallchirurgie zu einem Konsensusprozess zusammen. In 9 Arbeitstreffen wurden systematisch Empfehlungen zu Diagnostik und Therapie von Verletzungen der Wirbelsaule bei Kindern formuliert. Es konnten Empfehlungen zu Diagnostik und Therapie von Verletzungen der Brust- und Lendenwirbelsaule fur 3 Altersstufen (Altersstufe I: 0 bis 6 Jahre; Altersstufe II: 7 bis 9 Jahre; Altersstufe III: 10 bi s16 Jahre) formuliert werden. Die Prinzipien der Diagnostik und Therapie aus der Erwachsenenmedizin konnen nicht problemlos ubertragen werden. Wirbelsaulenverletzungen im Kindesalter sind selten und sollten der Behandlung in geeigneten Zentren zugefuhrt werden. Die MRT-Diagnostik sollte beim kardiopulmonal stabilen Kind mit Verdacht auf ein Monotrauma der Wirbelsaule als initiale Bildgebung indiziert werden. Die grundlegenden Therapieziele bei Verletzungen der Brust- und Lendenwirbelsaule im Kindesalter sind die Wiederherstellung der Stabilitat, der Schutz der neurogenen Strukturen und das Wiederherstellen der anatomisch korrekten Verhaltnisse. Bei der Indikationsstellung zur konservativen vs. operativen Therapie mussen das Korrektur- und Regenerationspotenzial der einzelnen Wirbelsaulenabschnitte in Abhangigkeit vom Patientenalter berucksichtigt werden. Die operative Stabilisierung soll v. a. uber minimalinvasive Techniken, im Sinne einer Instrumentierung ohne Spondylodese und fruhzeitiger Metallentfernung, erfolgen.

Congenital myopathies are a group of early onset muscle diseases of variable severity often with characteristic muscle biopsy findings and involvement of specific muscle types. The clinical diagnosis of patients typically relies on histopathological findings and is confirmed by genetic analysis. The most commonly mutated genes encode proteins involved in skeletal muscle excitation-contraction coupling, calcium regulation, sarcomeric proteins and thin-thick filament interaction. However, mutations in genes encoding proteins involved in other physiological functions (for example mutations in

Genetic diagnosis of facioscapulohumeral muscular dystrophy (FSHD) remains a challenge in clinical practice as it cannot be detected by standard sequencing methods despite being the third most common muscular dystrophy. The conventional diagnostic strategy addresses the known genetic parameters of FSHD: the required presence of a permissive haplotype, a size reduction of the D4Z4 repeat of chromosome 4q35 (defining FSHD1) or a pathogenic variant in an epigenetic suppressor gene (consistent with FSHD2). Incomplete penetrance and epistatic effects of the underlying genetic parameters as well as epigenetic parameters (D4Z4 methylation) pose challenges to diagnostic accuracy and hinder prediction of clinical severity. In order to circumvent the known limitations of conventional diagnostics and to complement genetic parameters with epigenetic ones, we developed and validated a multistage diagnostic workflow that consists of a haplotype analysis and a high-throughput methylation profile analysis (FSHD-MPA). FSHD-MPA determines the average global methylation level of the D4Z4 repeat array as well as the regional methylation of the most distal repeat unit by combining bisulphite conversion with next-generation sequencing and a bioinformatics pipeline and uses these as diagnostic parameters. We applied the diagnostic workflow to a cohort of 148 patients and compared the epigenetic parameters based on FSHD-MPA to genetic parameters of conventional genetic testing. In addition, we studied the correlation of repeat length and methylation level within the most distal repeat unit with age-corrected clinical severity and age at disease onset in FSHD patients. The results of our study show that FSHD-MPA is a powerful tool to accurately determine the epigenetic parameters of FSHD, allowing discrimination between FSHD patients and healthy individuals, while simultaneously distinguishing FSHD1 and FSHD2. The strong correlation between methylation level and clinical severity indicates that the methylation level determined by FSHD-MPA accounts for differences in disease severity among individuals with similar genetic parameters. Thus, our findings further confirm that epigenetic parameters rather than genetic parameters represent FSHD disease status and may serve as a valuable biomarker for disease status.

Background Differential diagnosis between amyotrophic lateral sclerosis (ALS) and multifocal motor neuropathy (MMN) relies on clinical examination and electrophysiological criteria. Peripheral nerve imaging might assist this differential diagnosis. Purpose To assess diagnostic accuracy of MR neurography in the differential diagnosis of ALS and MMN. Materials and Methods This prospective study was conducted between December 2015 and April 2017. Study participants with ALS or MMN underwent MR neurography of the lumbosacral plexus, midthigh, proximal calf, and midupper arm of the clinically more affected side using high-resolution T2-weighted sequences. Matched healthy study participants who underwent MR neurography served as a control group. Two blinded readers independently rated fascicular lesions and muscle denervation signs on a five-point scale and made an image-only diagnosis, which was compared with the clinical diagnosis to assess diagnostic accuracy (reported for ALS vs non-ALS and MMN vs non-MMN). The Kruskal-Wallis test was used to compare readers' scoring results. Results Twenty-two participants with ALS (12 men and 10 women; mean age ± standard deviation, 62.3 years ± 9.0), eight participants with MMN (seven men and one woman; mean age, 57.6 years ± 18.6), and 15 healthy participants (seven men and eight women; mean age, 59.1 years ± 10.9) were enrolled in this study. Nerves of participants with ALS either appeared normal or showed T2-weighted hyperintensities without fascicular enlargement (reader 1, 22 of 22 participants; reader 2, 21 of 22 participants). In contrast, nerves in MMN were characterized by fascicular swellings (reader 1, six of eight participants; reader 2, seven of eight participants). Muscle denervation signs were more prominent in ALS than in MMN. Inter-rater reliability for blinded diagnosis was κ of 0.82. By consensus, the sensitivity to diagnose ALS (vs MMN and healthy control participants) was 19 of 22 (86% [95% confidence interval {CI}: 67%, 95%]). The corresponding specificity was 23 of 23 (100% [95% CI: 86%, 100%]). The sensitivity to diagnose MMN (vs ALS and healthy control participants) was seven of eight (88% [95% CI: 53%, 99%]). The corresponding specificity was 37 of 37 (100% [95% CI: 91%, 100%]). Conclusion MR neurography is an accurate method for assisting in the differential diagnosis of amyotrophic lateral sclerosis and multifocal motor neuropathy. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Andreisek in this issue.

Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist.The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients.Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process.Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients.Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.

In general, pediatric spinal injuries are rare. No reliable data on the epidemiology of spinal injuries in pediatric patients in Germany are available. Especially in pediatric patients, for whom the medical history, clinical examination and the performance of imaging diagnostics are difficult to obtain, all available information on a spinal injury must be taken into account.The aim of this study was to provide epidemiological data for pediatric patients with spinal trauma in Germany in order to enhance future decision-making for the diagnostics and treatment of these patients.Within the framework of a national multicenter study, data were retrospectively obtained from 6 German spine centers for 7 years between January 2010 and December 2016. In addition to the demographic data, the clinical databases were screened for specific trauma mechanisms, level of injury as well as accompanying injuries. Furthermore, diagnostic imaging and the treatment selected were also analyzed.A total of 367 children (female: male = 1:1.2) with a total of 610 spinal injuries were included in this study. The mean age was 12 years (±3.5 years). The most frequent trauma mechanisms were falls from3 m and traffic accidents. The imaging diagnostics were only rarely carried out with the child under anesthesia. Younger children (0-9 years old) suffered more injuries to the cervical spine, whereas injuries to the thoracic and lumbar spine were more frequently found in older children (10 years old). The children frequently showed accompanying injuries to the head and the extremities. Accompanying spinal injuries mostly occurred in adjacent regions and only rarely in other regions. Around 75% of the children were treated conservatively.The results were different from the knowledge obtained from adult patients with spinal trauma and describe the special circumstances for pediatric patients with spinal trauma. Despite certain limitations these facts may help to enhance future decision-making for the diagnostics and treatment of these patients.

Severe cervical spine injuries in children under the age of 17 years are rare. Recommendations or even guidelines for the diagnostics and treatment of such injuries in children are currently not available.The aim of the study was to formulate recommendations for diagnostics and treatment of injuries of the cervical spine in pediatric patients.First, a search of primary and secondary literature on the topic complex of diagnostics and treatment of cervical spine injuries in children was carried out. An appropriate internal literature database was defined and maintained. Second, within the framework of 9 meetings from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) systematically formulated recommendations for the diagnostics and treatment of injuries of the cervical spine in pediatric patients by a consensus process.Recommendation for the diagnostics and treatment for injuries of the cervical spine could be formulated for three age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). The diagnostic and therapeutic principles known from adult patients suffering from injuries to the cervical spine cannot be easily transferred to pediatric patients.Injuries to the pediatric spine are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. Classification systems and therapeutic recommendations for injuries to the cervical spine known from adult patients could also be used for adolescent patients. This is not possible for children under the age of 10 years. Only few classification systems exist for this age group. Basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical relationships as well as the protection of all neural structures.

Altered autophagy accompanied by abnormal autophagic (rimmed) vacuoles detectable by light and electron microscopy is a common denominator of many familial and sporadic non‐inflammatory muscle diseases. Even in the era of next generation sequencing (NGS), late‐onset vacuolar myopathies remain a diagnostic challenge. We identified 32 adult vacuolar myopathy patients from 30 unrelated families, studied their clinical, histopathological and ultrastructural characteristics and performed genetic testing in index patients and relatives using Sanger sequencing and NGS including whole exome sequencing (WES). We established a molecular genetic diagnosis in 17 patients. Pathogenic mutations were found in genes typically linked to vacuolar myopathy (GNE, LDB3/ZASP, MYOT, DES and GAA), but also in genes not regularly associated with severely altered autophagy (FKRP, DYSF, CAV3, COL6A2, GYG1 and TRIM32) and in the digenic facioscapulohumeral muscular dystrophy 2. Characteristic histopathological features including distinct patterns of myofibrillar disarray and evidence of exocytosis proved to be helpful to distinguish causes of vacuolar myopathies. Biopsy validated the pathogenicity of the novel mutations p.(Phe55*) and p.(Arg216*) in GYG1 and of the p.(Leu156Pro) TRIM32 mutation combined with compound heterozygous deletion of exon 2 of TRIM32 and expanded the phenotype of Ala93Thr‐caveolinopathy and of limb‐girdle muscular dystrophy 2i caused by FKRP mutation. In 15 patients no causal variants were detected by Sanger sequencing and NGS panel analysis. In 12 of these cases, WES was performed, but did not yield any definite mutation or likely candidate gene. In one of these patients with a family history of muscle weakness, the vacuolar myopathy was eventually linked to chloroquine therapy. Our study illustrates the wide phenotypic and genotypic heterogeneity of vacuolar myopathies and validates the role of histopathology in assessing the pathogenicity of novel mutations detected by NGS. In a sizable portion of vacuolar myopathy cases, it remains to be shown whether the cause is hereditary or degenerative.

Study Design: Abstract consensus paper with systematic literature review. Objective: The aim of this study was to establish recommendations for treatment of thoracolumbar spine fractures based on systematic review of current literature and consensus of several spine surgery experts. Methods: The project was initiated in September 2008 and published in Germany in 2011. It was redone in 2017 based on systematic literature review, including new AOSpine classification. Members of the expert group were recruited from all over Germany working in hospitals of all levels of care. In total, the consensus process included 9 meetings and 20 hours of video conferences. Results: As regards existing studies with highest level of evidence, a clear recommendation regarding treatment (operative vs conservative) or regarding type of surgery (posterior vs anterior vs combined anterior-posterior) cannot be given. Treatment has to be indicated individually based on clinical presentation, general condition of the patient, and radiological parameters. The following specific parameters have to be regarded and are proposed as morphological modifiers in addition to AOSpine classification: sagittal and coronal alignment of spine, degree of vertebral body destruction, stenosis of spinal canal, and intervertebral disc lesion. Meanwhile, the recommendations are used as standard algorithm in many German spine clinics and trauma centers. Conclusion: Clinical presentation and general condition of the patient are basic requirements for decision making. Additionally, treatment recommendations offer the physician a standardized, reproducible, and in Germany commonly accepted algorithm based on AOSpine classification and 4 morphological modifiers.

Humerus shaft fractures are common and often treated surgically with a proximal humerus internal locking system like the long PHILOS® plate. Due to its close anatomical proximity to the humerus, the radial nerve is particularly susceptible to traumatic and iatrogenic damage. The iatrogenic radial nerve damage associated with internal locking systems is described in about 7% of the cases. In order to avoid this lesion, helical plates have been suggested since 1999. This technique continues to not being used as standard as there is still a clear lack of evidence. This study aimed to understand if twisting a long PHILOS plate can reduce the rate of iatrogenic radial nerve damage in humerus shaft fractures. In this 10-year retrospective comparative study, patients with primary traumatic proximal humerus shaft fracture treated with a straight or twisted helical PHILOS® plate were analyzed and compared. Among the 62 patients meeting the inclusion criteria between 2008 and 2018, 33 received a conventional straight plate, while 29 were treated with a helical plate. The primary endpoint was iatrogenic radial nerve damage immediately after surgery with a follow-up of at least 3 months. No case of radial nerve damage was reported in the helical group. In the control group, iatrogenic radial nerve damage occurred in two cases (6%), which was not statistically significant when comparing both groups (p = 0.18). Manually twisting long PHILOS® plates is a safe procedure to avoid radial nerve lesion in humerus shaft fractures. Even though the group size did not allow a statistically relevant difference, we underline that only the helical group showed no iatrogenic radial lesion. This technique deserves further attention. Level 3, retrospective cohort study.

Study Design:Review of literature and case series.Objectives:Update and review of current treatment concepts for spine fractures in patients with ankylosing spinal disorders.Methods:Case presentation and description of a diagnostic and therapeutic algorithm for unstable spinal injuries with an underlying ankylosing spinal disorder (ASD) of the cervical and thoracolumbar spine.Results:Nondisplaced fractures can be missed easily using conventional X-rays. Thus, computed tomography (CT) scans are recommended for all trauma patients with ASD. In doubt or presence of any neurologic involvement additional magnetic resonance imaging (MRI) scans should be obtained. Spine precautions should be maintained all times and until definitive treatment (Conclusions:Current concepts, treatment options, and recommendations of the German Orthopedic Trauma Society–Spine Section for spinal fractures in the ankylosed spine have been outlined.

Background Though the Expanded Disability Status Scale (EDSS) is commonly used to assess disability level in relapsing-remitting multiple sclerosis (RRMS), the criteria defining disability progression are used for patients with a wide range of baseline levels of disability in relatively short-term trials. As a result, not all EDSS changes carry the same weight in terms of future disability, and treatment benefits such as decreased risk of reaching particular disability milestones may not be reliably captured. The objectives of this analysis are to assess the probability of confirmed disability worsening to specific EDSS milestones (i.e., EDSS scores ≥3.0, ≥4.0, or ≥6.0) at 288 weeks in the Tysabri Observational Program (TOP) and to examine the impact of relapses occurring during natalizumab therapy in TOP patients who had received natalizumab for ≥24 months. Methods TOP is an ongoing, open-label, observational, prospective study of patients with RRMS in clinical practice. Enrolled patients were naive to natalizumab at treatment initiation or had received ≤3 doses at the time of enrollment. Intravenous natalizumab (300 mg) infusions were given every 4 weeks, and the EDSS was assessed at baseline and every 24 weeks during treatment. Results Of the 4161 patients enrolled in TOP with follow-up of at least 24 months, 3253 patients with available baseline EDSS scores had continued natalizumab treatment and 908 had discontinued (5.4% due to a reported lack of efficacy and 16.4% for other reasons) at the 24-month time point. Those who discontinued due to lack of efficacy had higher baseline EDSS scores (median 4.5 vs. 3.5), higher on-treatment relapse rates (0.82 vs. 0.23), and higher cumulative probabilities of EDSS worsening (16% vs. 9%) at 24 months than those completing therapy. Among 24-month completers, after approximately 5.5 years of natalizumab treatment, the cumulative probabilities of confirmed EDSS worsening by 1.0 and 2.0 points were 18.5% and 7.9%, respectively (24-week confirmation), and 13.5% and 5.3%, respectively (48-week confirmation). The risks of 24- and 48-week confirmed EDSS worsening were significantly higher in patients with on-treatment relapses than in those without relapses. An analysis of time to specific EDSS milestones showed that the probabilities of 48-week confirmed transition from EDSS scores of 0.0–2.0 to ≥3.0, 2.0–3.0 to ≥4.0, and 4.0–5.0 to ≥6.0 at week 288 in TOP were 11.1%, 11.8%, and 9.5%, respectively, with lower probabilities observed among patients without on-treatment relapses (8.1%, 8.4%, and 5.7%, respectively). Conclusions In TOP patients with a median (range) baseline EDSS score of 3.5 (0.0–9.5) who completed 24 months of natalizumab treatment, the rate of 48-week confirmed disability worsening events was below 15%; after approximately 5.5 years of natalizumab treatment, 86.5% and 94.7% of patients did not have EDSS score increases of ≥1.0 or ≥2.0 points, respectively. The presence of relapses was associated with higher rates of overall disability worsening. These results were confirmed by assessing transition to EDSS milestones. Lower rates of overall 48-week confirmed EDSS worsening and of transitioning from EDSS score 4.0–5.0 to ≥6.0 in the absence of relapses suggest that relapses remain a significant driver of disability worsening and that on-treatment relapses in natalizumab-treated patients are of prognostic importance.

Die Riesenzellarteriitis (RZA) kann durch Manifestation an hirnversorgenden Arterien zerebrale Ischamien verursachen und ist eine wichtige Differenzialdiagnose der zerebralen Makroangiopathie. Bevorzugt betroffen sind die extrakraniellen Abschnitte der Vertebralarterien. Wir berichten uber 3 Patienten, bei denen sich eine RZA mit hochgradigen intrakraniellen Vertebralisstenosen und Kleinhirninfarkten manifestierte. Nur bei einer Patientin war eine Polymyalgia rheumatica assoziiert, ansonsten lagen keine Symptome vor, die die klinische Diagnose einer Arteriitis cranialis erlaubt hatten, insbesondere initial keine Kopfschmerzen. Die Diagnose konnte bei allen Patienten durch sonografischen Nachweis des Halo-Zeichens an den Vertebral- und Temporalarterien gestellt werden. Die Stenosebefunde bildeten sich unter Behandlung mit Prednisolon bei 2 Patienten kontinuierlich zuruck, bei einem bestanden sie fort. Eine Manifestation der RZA im intrakraniellen Abschnitt der A. vertebralis gilt als seltener Befund. Da die Arterie langstreckig durch die Vaskulitis betroffen ist, konnte die Diagnose in den von uns beobachteten Fallen durch extrakranielle Farbduplexsonografie gestellt werden. Die Untersuchung ist technisch einfach, erfordert aber Erfahrung des Untersuchers. In unklaren Fallen konnen erganzend PET bzw. PET-CT oder spezielle Sequenzen einer kontrastgestutzten MRT, moglichst mit 3 Tesla-System, zur Diagnosesicherung eingesetzt werden. Wichtig ist die Sonografie – zusammen mit klinischen und laborchemischen Verlaufsparametern – fur das Monitoring von Gefasbefunden zur Optimierung der immunsuppressiven und thrombozytenaggregationshemmenden Therapie.

We describe two patients who developed subacute axonal peripheral neuropathy under duodopa treatment. Comprehensive diagnostic workup including muscle and sural nerve biopsy revealed that the most probable cause of subacute axonal peripheral neuropathy was cobalamin and vitamin B6 deficiency in both the patients.

The authors report on a prospectively followed series of 35 patients with injuries of the thoracolumbar spine from T7 to L3. The radiological course after combined posterior-anterior surgery with anterior column reconstruction with a distractible vertebral body replacing implant demonstrated a stable reconstruction technique with almost no re-kyphosing. In 18/18 patients with CT follow-up intervertebral fusion was observed as bony bridging lateral to the VBR implant. The functional/clinical outcome of the patients was analysed with a set of eight validated outcome scales. After an average follow-up period of 2(1/2) years encouraging results were noticed. The neurological improvement rate (or =1 Frankel/ASIA grade) was 8/12 patients (67%) with a complete recovery in 6 cases. 17/29 patients returned to former occupation; 20/29 patients returned to former leisure activities; 24/28 patients rated their general outcome as "unlimited and pain free" or "occasionally and/or mild complaints" with a VAS score of80 (scale 0-100). The psychometric questionnaires revealed good results with strong correlation comparing the different scoring systems statistically: mean McGill Pain Questionnaire 12.5 (0-40); mean Oswestry Disability Index 20% (0-51). 13/29 patients scored4 in the Roland and Morris Disability Questionnaire. The German back pain questionnaire (Funktionsfragebogen Hannover Rücken) showed a mean "functional capacity" of 75%, corresponding with moderate restriction. We concluded the presented method as highly effective to completely reduce and maintain an anatomic spinal alignment. The outcome tended to be better in comparison with non-operatively treated patients as well as with norm populations with low back pain.

Die Arbeitsgemeinschaft „Wirbelsaule“ (AG WS) der Deutschen Gesellschaft fur Unfallchirurgie (DGU) stellt im dritten und letzten Teil der zweiten prospektiven multizentrischen Sammelstudie (MCS II) zur Behandlung von Verletzungen der gesamten Brust- und Lendenwirbelsaule Ergebnisse der Nachuntersuchungen (NU) eines 865 Patienten umfassenden Patientenkollektives aus 8 Zentren vor. Teil I der Arbeit befasste sich mit den epidemiologischen Daten des Studienkollektivs und Teil II mit Details zu den Operationen und rontgenologischen Befunden. Der gesamte Studienzeitraum umfasst die Jahre 2002 bis 2006 mit einem 30-monatigen Nachuntersuchungszeitraum vom 01.01.2004 bis 31.05.2006. NU-Ergebnisse wurden in Anlehnung an Teil I und II unter Berucksichtigung von drei charakteristischen Behandlungsgruppen (OP, KONS, PLASTIE), unterschiedlichen Operationstechniken (dorsal, ventral, kombiniert) und der Verletzungslokalisationen (BWS, TLU, LWS) ausgewertet. Die Nachuntersuchungsergebnisse von 638 (74%) Patienten wurden mit Hilfe einer internetbasierten Datenbank zusammengetragen. Nach der Entlassung aus der stationaren Behandlung folgten Aufenthalte von durchschnittlich 4 Wochen in einer Rehabilitationsklinik, die signifikant langer dauerten bei Patienten mit persistierenden neurologischen Ausfallen (O 10,9 Wochen) oder Wirbelsaulenverletzungen, die im Rahmen eines Polytraumas auftraten (O 8,6 Wochen). Ambulant wurde im Mittel fur weitere 4 Monate physiotherapeutisch nachbehandelt, mit signifikant langerer ambulanter Nachbehandlung der Patienten mit neurologischen Ausfallen zum Zeitpunkt der NU (O 8,7 Monate) und Typ-C-Frakturen (O 8,6 Monate). Die Verletzungslokalisation hatte keinen signifikanten Einfluss auf die Dauer der stationaren Rehabilitation und ambulanten Physiotherapie. 382 (72,2%) primar dorsal oder kombiniert operierte Patienten unterzogen sich nach durchschnittlich 12 Monaten einer Operation zur Metallentfernung. Im Verlauf der NU wurden nach Operationen bei 56 (8,8%) Patienten Komplikationen beobachtet, die in 18 (2,8%) Fallen operativ revidiert wurden. Die haufigsten Ursachen der Komplikationen waren Infektionen, Korrekturverluste/Fehlstellungen oder implantatassoziierte Probleme. Klinische Ergebnisse zeigten, dass Raucher im Vergleich zu Nichtrauchern ein 2,9-mal hoheres relatives Risiko fur Wundheilungsstorung hatten. Im Gesamtkollektiv besserte sich der neurologische Zustand bis zur NU bei 81 (60,4%) von 134 Patienten, die zum Zeitpunkt der stationaren Aufnahme neurologische Ausfalle hatten. Verschlechterungen wurden in 8 (1,3%) Fallen dokumentiert. Die Besserungsrate fur komplette QS-Lasionen nach Verletzungen der BWS betrug 9% und 59% am TLU. Die Art der operativen Versorgung (dorsal vs. kombiniert) hatte keinen signifikanten Einfluss auf das neurologische NU-Ergebnis. Das Patientenalter, das Geschlecht und das Vorliegen eines neurologischen Defizites hatte einen statistisch signifikanten Einfluss (p 2 Jahre nach dem Unfall beschwerdefrei. Die relative Haufigkeit der Patienten mit uneingeschrankter Ruckenfunktion war groser nach isoliert dorsaler Operation (24,2%) oder ventraler Behandlung (13,8%) als nach kombinierter Operation 17,3% (p=0,005; χ²-Test). Fur unterschiedliche Verletzungslokalisationen wurden keine signifikanten Unterschiede (p>0,05) errechnet (BWS (17,4%), TLU (22,5%) und LWS (13,6%). Der Anteil der Patienten mit Verletzungen des TLU, die zur NU bezuglich des ventralen Zugangs „vollstandig beschwerdefrei“ waren, unterschied sich nicht signifikant nach offenem (55,6%) oder endoskopischem (63,8%) Vorgehen. 56,3% der Patienten waren bei der NU nach Knochenentnahme am Beckenkamm beschwerdefrei. Im VAS-Wirbelsaulenscore zur NU erreichten Patienten der Behandlungsgruppen OP 58,4 Punkte, KONS 59,8 Punkte und PLASTIE 59,7 Punkte. Statistisch signifikante Unterschiede operativer Subgruppen wurden lediglich an der BWS nachgewiesen, wo Patienten nach isoliert dorsaler Operation mehr Punkte (64,9 Punkte) erreichten als nach kombinierter operativer Behandlung (47,8 Punkt; p=0,004). Mindestens 80% oder mehr des ursprunglichen VAS-Wirbelsaulenscorewertes vor dem Unfall erreichten 56,2% der Patienten der Gruppe OP (dorsal 60,4%, ventral 61,1%, kombinert 51,4%), 52,9% KONS und 67,6% der Gruppe PLASTIE. Nach der Operation waren die Patienten durchschnittlich 4 Monate arbeitsunfahig. Die volle Reintegration von Patienten mit sitzender Tatigkeit vor dem Unfall gelang in 71,1% der Falle. Gingen Patienten einer korperlichen Arbeit nach, war die volle berufliche Reintegration nur in 38,9% der Falle moglich. Zur NU gaben 87 (31,2%) Patienten nach dorsalem und 50 (20,1%) nach kombiniertem Eingriff an, keine Einschrankungen ihrer Freizeitaktivitaten zu haben (p=0,001). Die radiologischen NU-Ergebnisse der Behandlungsgruppen PLASTIE und KONS zeigten ein vergleichbares Ergebnis im sagittalen Wirbelsaulenprofil (GDW von −9° bzw. −8,5°). Durch die operativen Masnahmen konnte die unfallbedingte kyphotische Fehlstellung zunachst korrigiert bzw. reduziert werden. Im weiteren Verlauf der NU muss dann jedoch mit unterschiedlichen Korrekturverlusten in Abhangigkeit von der Operationstechnik und Frakturlokalisation gerechnet werden: Nach kombinierter dorsoventraler Behandlung resultierten statistisch signifikant weniger kyphotische Fehlstellungen zur NU (−3,8°) im Vergleich zur isolierten dorsalen Behandlung (−6,1°; p=0,005; ANOVA). Dies bedeutet, dass der Korrekturgewinn nach kombinierter Behandlung groser als nach isoliert dorsaler oder ventraler Versorgung war. Die Verwendung von Wirbelkorperersatzimplantaten (Cage) zur ventralen Rekonstruktion und Abstutzung zeigte signifikant bessere Ergebnisse mit weniger Korrekturverlust des bisegmentalen GDW zur NU (0,3°) als nach Verwendung von Knochenspanen (NU −3,7°; p

STUDY DESIGN We report the long-term outcome after mono-segmental and bisegmental fusions at the lumbar L4-S1 region of the spine. OBJECTIVE Long-term clinical and radiologic outcome measures were used to determine a lumbar fusion's contribution to degenerative changes in adjacent motion segments (ASD). SUMMARY OF BACKGROUND DATA The role of low lumbar spinal fusions and their long-term contribution to accelerated degenerative changes in the adjacent motion segments continues to be a subject of controversy. PATIENTS AND METHODS We followed-up 102 patients with an average age of 54 (22 to 78) years and a follow-up time of 14 (3 to 22) years. RESULTS Overall results in patients were good, the Oswestry-Disability Index (ODI) showed an average of 26% (0% to 70%) at follow-up, the Visual Analog Scale rose from 2.7 (postoperative) and 2.9 (12 wk follow-up) to 3.6 (latest follow-up) points, respectively. Patient satisfaction with their health-related situation at follow-up was 69% (15% to 100%). Patients who underwent fusions of the segment L5/S1 showed a significant (P

Traumatic facet dislocations and facet-fracture dislocations in the lower cervical spine (C2/C3 to C7/T1) are frequently associated with devastating neurological symptoms. A good outcome can only be achieved if the operator has wide and sound knowledge of reduction techniques and the best possible strategy is devised for the subsequent treatment of these severe lesions.Between 1973 and 1997 a total of 117 of our patients met at least one of the following inclusion criteria: unilateral locked facet dislocation (48%), bilateral locked facet dislocations (23%), unilateral "perched" facet subluxation (14%), bilateral perched facet subluxation (12%), uni- or bilateral dislocation/perched subluxation with facet fractures (3%).Most of the lesions were located at the levels of C5/C6 and C6/7 (n=46 for each). Associated neurological deficits were present initially in 65% of patients: 35% had complete or incomplete spinal cord injuries (tetraplegia), 2% were paraplegic, and 28% had cervical radiculopathies.Closed reduction (e.g. with the aid of a halo ring) should be carried out as soon as possible after lower cervical spine dislocation or facet-fracture dislocation, as both the success rate of reduction and the potential for recovery from neurological deficits are clearly higher when reduction is achieved within the first 4 h after the initial injury.

Das Behandlungskonzept fur die ventrale Rekonstruktion der thorakolumbalen Wirbelsaule ist Gegenstand der Diskussion. Die ersten 50 Patienten (29 mannlich, 21 weiblich, 43 Jahre), die mit dem Titanwirbelkorperersatz Synex operativ behandelt wurden, werden prospektiv erfasst und im stationaren Verlauf sowie bei klinischer und radiologischer Nachuntersuchung nach 12 und 20 Monaten beobachtet. 25/45 Patienten gingen nach 1 Jahr, 29/39 nach 20 Monaten wieder den alten Freizeitaktivitaten nach. Nach 12 Monaten war jeder Zweite, nach 1,5 Jahren zwei Drittel der Patienten wieder im alten Beruf tatig. 25/45 Patienten hatten nach 1 Jahr, spater 6/39 allenfalls geringe Ruckenbeschwerden. Im Follow-up erzielten die Patienten im validierten Wirbelsaulenscore 65/100 gegenuber 87/100 vor dem Unfall. Erreicht wurde eine signifikante Korrektur von 16,9°, der Korrekturverlust im Verlauf betrug 2,3°. Der Korrekturverlust nach Rekonstruktion der ventralen Saule mit Synex war minimal. Ein Grosteil der Patienten erzielte ein gutes klinisches Outcome mit recht hoher beruflicher Wiedereingliederungsrate. Langzeitergebnisse stehen noch aus.

In the operative treatment of spinal injuries, the reconstruction of the anterior column of the thoracolumbar spine is still controversial. We conducted a prospective clinical study to investigate the clinical and radiological outcome of 50 patients treated with a vertebral body replacement of adjustable height (Synex). Fifty consecutive patients were evaluated during in-patient treatment and at 12 and 20 months post-operatively in clinical notes and radiographs. 38/50 patients were operated for traumatic fractures. Out of 50 patients 45 attended the follow-up clinic 1 year post-operatively and 39 of these patients were examined after 20 months. Twenty-five patients returned to pre-injury activities within 1 year. This number increased to 29/39 patients at 20 months. Seventy-three percent of the patients returned to their job. After 1 year 25/45 patients complained of little or no back pain and 6 months later six patients were limited in their back function. At 1 year only three patients complained of surgical site pain which was improved at their final follow-up at 20 months. Individual satisfaction was determined using a score on a visual analog scale containing 19 questions on back pain, and functional limitation of the spine that has to be filled in by the patients at three different points of time. The score decreased from 87/100 pre-operatively to 65/100 at 1 year follow-up (P0.001). The average permanent correction of the injured vertebra was 16.8 degrees (88%) including 2.3 degrees (12%) loss of correction at 12 months after operation. Bony integration was obtained in 83%. Early and intermediate outcome with the Synex vertebral replacement device for reconstruction of the anterior column appears promising. The loss of correction or reduction was only minimal. On the basis of our results we recommend the Synex implant as an alternative for the fixation and stabilisation of thoracolumbar fractures. However, long-term results and a clinically random control study are still required.

The goal of our study was to evaluate two newly developed implant designs and their behavior in terms of subsidence in lumbar vertebral bodies under cyclic loading. The new implants were evaluated in two different configurations (two small prototypes vs. one large prototype with similar load-bearing area) in comparison to a conventional screw-based implant (MACS TL). A pool of 13 spines with a total of 65 vertebrae was used to establish five testing groups of similar bone mineral density (BMD) distribution with eight lumbar vertebrae each. In additional to BMD assessment via dual-energy X-ray absorptiometry, cancellous BMD and structural parameters were determined using a new generation in vivo 3D-pQCT. The specimens were loaded sinusoidally in force control at 1 Hz for 1000 cycles at three load levels (100, 200, and 400 N). A survival analysis using the number of cycles until failure (Cox regression with covariates) was applied to reveal differences between implant groups. All new prototype configurations except the large cylinder survived significantly longer than the control group. The number of cycles until failure was significantly correlated with the structural parameter Tb.Sp. and similarly with the cancellous BMD for three of five implants. In both large prototypes the cycle number until failure significantly correlated with the preoperative distance to the upper endplates. Although the direct relationship between bone structure or density and mechanical breakage behavior cannot be conclusively proven, all the prototypes adapted for poor bone structure performed better than the comparable conventional implant. © 2006 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res

We report on a 43-year-old male who sustained an isolated distraction injury of the thoracic spine Th7/Th8 (AO/ASIF B 2.3) with wedge compression Th8 and sagittal split Th10 without neurological injury. A bisegmental posterior stabilisation and a monosegmental interlaminar fusion was the treatment of choice. A synthetic bone substitute, beta-tricalcium phosphate (beta-TCP, Chronos) without additional autogenous bone was used to achieve the monosegmental posterior fusion. The clinical course was favourable and 10 months postoperatively the implant was removed. On implant removal the CT scan showed a fused segment and intraoperatively it was found that the fusion was solidly healed. A biopsy was taken from the fusion mass and histology showed vital bone that was rich with osteocytes. Noncalcified osteoid surrounding the bone marrow cavity could be identified. Several studies and the reported case might indicate that osteoconductive material alone can be sufficient for achieving a solid fusion.

Die Autoren schildern die Grundlagen aktueller Behandlungskonzepte fur die Verletzungen der Brust- und Lendenwirbelsaule. Unter Bezugnahme auf biomechanische Konzepte und die Klassifikation der Verletzungen werden Erfahrungen und Ergebnisse geschildert, die bis heute erzielt und veroffentlicht wurden. Die Vor- und Nachteile von operativen und nichtoperativen Behandlungskonzepten werden dargestellt. Auserdem schildern die Autoren die verschiedenen Operationsmethoden, die heute zur Anwendung kommen. Erste eigene Ergebnisse mit dem Wirbelkorperersatzimplantat Synex werden vorgestellt.

Die Operationsmethoden in der Wirbelsaulenchirurgie zeigen mit ihren unterschiedlichen Zugangen, Implantaten und Techniken ein groses, sich standig erweiterndes Spektrum. So erlangten zuletzt minimal-invasive Verfahren mit endoskopischer Technik, die Augmentation mit Knochenzement (Vertebro-/Kyphoplastie) und navigierte Eingriffe an der Wirbelsaule („computer-assisted orthopedic surgery“, CAOS) zunehmende Bedeutung. Fehlerquellen der operativen Versorgung von Wirbelsaulenverletzungen betreffen die Lagerung und geschlossenen Reposition, zugangsbedingte Komplikationen, Fehler bei der Dekompression des Spinalkanals, Komplikationen bei der Instrumentierung bzw. Stabilisierung sowie der operativen Fusion. Der vorliegende Beitrag prasentiert die Daten zweier multizentrischer Erhebungsstudien der Arbeitsgemeinschaft „Wirbelsaule“ der Deutschen Gesellschaft fur Unfallchirurgie bezuglich der aufgetretenen Komplikationen und vergleicht diese mit den Ergebnissen einer kurzlich publizierten Metaanalyse.

Reposition und Stabilisierung von instabilen Wirbelsaulenverletzungen mit dauerhafter Wiederherstellung der physiologischen Krummungsverhaltnisse, Stabilitat und Tragfahigkeit der Wirbelsaule. Instabile Verletzungen und Lasionen der Wirbelsaule von T4 bis L5 mit verminderter Tragfahigkeit der ventralen Saule durch —Wirbelkorperfraktur und Bandscheibenverletzung, —posttraumatische Fehlstellungen, —pathologische Frakturen, —Tumoren. Eingeschrankte Indikationen: —Jungere Patienten mit monosegmentaler Verletzung. —Patienten mit ausgepragter Osteoporose. Schwerwiegende kardiopulmonale Begleitverletzung oder Vorerkrankung als Kontraindikation fur den ventralen Eingriff. Kombinierte dorsoventrale Operation mit 1. dorsaler Reposition und Stabilisierung mit einem Fixateur interne sowie interlaminarer Fusion des verletzten Wirbelsaulenabschnitts mit autogener Spongiosa; 2. thorakoskopischem Wirbelkorper(teil)ersatz zur tragfesten Abstutzung der vorderen Saule mit einem distrahierbaren Wirbelkorperersatzimplantat aus Titan (Synex®) und zusatzliche interkorporelle Fusion mit autogener Spongiosa und/oder β-Tricalciumphosphat. Funktionelle Behandlung und Mobilisation ohne ausere Ruhigstellung. 41 der ersten 50 Patienten, die mit Synex® behandelt wurden, konnten durchschnittlich 19,5 Monate (14–31 Monate) postoperativ nachuntersucht werden. Es handelte sich um 36 frische Frakturen, acht posttraumatische Fehlstellungen, drei Tumoren, zwei veraltete Frakturen und eine Spondylodiszitis. Das Durchschnittsalter der 29 Manner und 21 Frauen betrug 43 Jahre (20–77 Jahre). Synex® wurde bei 30 Patienten bisegmental und bei 20 monosegmental eingesetzt. Bis auf einen Fall wurde weder ein Einsinken noch eine Dislokation des Implantats beobachtet. Zur Nachuntersuchung waren 18/33 der vor der Erstoperation berufstatigen Patienten wieder im alten Beruf tatig, und 32/41 Patienten hatten die vorherigen Freizeitaktivitaten wieder aufgenommen. 32/41 Patienten waren zur Nachuntersuchung beschwerdefrei oder gaben gelegentliche Ruckenschmerzen an. 8/41 Patienten gaben deutliche Ruckenbeschwerden an, ein Patient klagte nach Aufrichtung einer posttraumatischen Fehlstellung uber starke Beschwerden. Vor dem Unfall erreichten die Patienten mit frischer Verletzung im VAS-Wirbelsaulen-Score (0–100 Punkte, visuelle Analogskala, 19 Items) ein durchschnittliches Ergebnis von 83,1 ± 20,2 (21–100). Zur Nachuntersuchung betrug der Score im Mittel 63,8 ± 19,5 (25–99). Der durchschnittliche Scoreverlust lag bei 19,3 ± 22,3. Die rontgenologische Reposition/Aufrichtung bei Patienten mit frischer Verletzung oder posttraumatischer Fehlstellung betrug durchschnittlich 18,6° ± 10° und der Korrekturverlust (Rekyphosierung) 2,1° ± 2,9°.

Transpedicular instrumentation in the thoracic spine is technically difficult because of small pedicle diameters. There are not many studies assessing in vivo accuracy, complications, and the revision rate of transpedicular screws in the thoracic spine. In this retrospective study 278 thoracic pedicle screws of 43 patients were assessed using a scoring system and postoperative computed tomography (CT) scans. 43 consecutive patients with traumatic thoracic spine fractures underwent posterior transpedicular reduction and fixation. The universal spine system was used for placement of 278 pedicle screws under fluoroscopic control. Fractures were classified according to the Magerl classification by plain radiographs and CT scans. Evaluation of pedicle screw placement was assessed by a scoring system from grade I to grade III. Revision rate of pedicle screws as well as pre- and postoperative neurologic status were analyzed. In the thoracic spine, vertebral body T7 was mainly fractured followed by T6 and T5. In 37 (86.0%) of 43 patients type C fractures and in three patients each type A and B fractures were determined, respectively. Of all 278 pedicle screws, 78.1% were inserted in pedicles T4–T9. The rate of optimally placed grade I screws was 84.5%. Grade II screws were scored in 6.8% and grade III screws in 8.6%. The revision rate of all pedicle screws was 5.0%, whereas 64.3% of these were grade III. None of the patients suffered neurologic or vascular structure compromise postoperatively. Although most pedicle screws were placed in pedicles of the middle thoracic spine where the pedicle width is smallest, most screws were optimally placed with grade I. The revision rate of pedicle screws was acceptable and associated with the grade of pedicle screw placement.

Esophageal perforation in ankylosing spondylitis (AS) is a rare complication in anterior cervical spine surgery and has not been reported before. A 50-year-old patient with AS developed incomplete tetraplegia after minimal trauma. C5 pedicle fracture was diagnosed and treated predominantly by physical therapy until neurological symptoms progressed. Cervical spine MRI showed C6/7 fracture and spinal cord compression. The patient underwent dorsal laminectomy, C5-7 anterior cervical fusion using allograft iliac crest and CASPAR-plate fixation. Delayed esophageal perforation appeared 10 months postoperatively when he came first to our hospital. He complained of dysphagia and developed acute dyspnea. Posterior stabilization with two plates was performed followed by removal of the ventral plate and screws. The esophageal laceration was sutured. The patient was treated with antibiotics and percutaneous endoscopic gastrostomy. Position of fracture and implants were accurate at 18 months postoperatively. The patient had persistent minor neurological deficits (Frankel D) at last follow-up. We conclude that esophageal perforation after anterior spinal fusion is a rare complication. Minor traumas in patients with AS are unstable and can result in significant spinal injury. Dorsoventral stabilization should be performed to avoid further complications.

A sucrose (Suc) transporter cDNA has been cloned from Alonsoa meridionalis, a member of the Scrophulariaceae. This plant species has an open minor vein configuration and translocates mainly raffinose and stachyose in addition to Suc in the phloem (C. Knop, O. Voitsekhovskaja, G. Lohaus [2001] Planta 213: 80–91). These are typical properties of symplastic phloem loaders. For functional characterization, AmSUT1 cDNA was expressed in bakers' yeast (Saccharomyces cerevisiae). Substrate and inhibitor specificities, energy dependence, and K m value of the protein agree well with the properties measured for other Suc transporters of apoplastic phloem loaders. A polyclonal antiserum against the 17 N-terminal amino acids of the A. meridionalis Suc transporter AmSUT1 was used to determine the cellular localization of the AmSUT1 protein. Using fluorescence labeling on sections from A. meridionalis leaves and stems, AmSUT1 was localized exclusively in phloem cells. Further histological characterization identified these cells as companion cells and sieve elements. p-Chloromercuribenzenesulfonic acid affected the sugar exudation of cut leaves in such a way that the exudation rates of Suc and hexoses decreased, whereas those of raffinose and stachyose increased. The data presented indicate that phloem loading of Suc and retrieval of Suc in A. meridionalis are at least partly mediated by the activity of AmSUT1 in addition to symplastic phloem loading.

Background. There are several therapeutic strategies for restoring the anterior column of the vertebral body after trauma, tumor and infection. We present a multicenter study with a new distractable titanium implant for vertebral body replacement. Methods. Prospective documentation was collected of the first 126 patients treated with Synex during the 1st year of the clinical course. There was an evaluation of surgical indication, classification, localisation of the lesion, operative details, complications, and clinical course. Results. A total of 70 men and 56 women (average age 46.9 years) underwent surgery for vertebral fracture, correction of posttraumatic kyphosis, infection, vertebral tumor and metastasis, and other diseases such as ankylosing spondylitis. Synex was used in open and minimally invasive surgery. In almost every case, an additional anteriorly or posteriorly stabilizing implant was used. Anterior fusion was performed with cement in tumors and autologous bone in fractures. Mono- and multisegmental lesions in the thoracic and lumbar spine were treated. Conclusions. The Synex implant is very easy to manage and is suitable for many indications such as vertebral fracture, correction of posttraumatic kyphosis, infection, vertebral tumor/metastasis, and other diseases. The vertebral body replacement can be used for defects of different sizes with the option of in situ distraction. No cases of implant failure, dislocation, or other implant-related complication have been observed. As a consequence of this prospective series, an additional implant size has been added, and the distraction device (spreading forceps) has been modified for more powerful spreading.

An investigation was conducted into the effects of double-level T12–L2 posterior fixation on the mobility of neighboring unfused segments. The segmental mobility of adjacent segments above and below the fixation in ten cadaveric human thoracolumbar spine specimens was measured before and after fixation by biomechanical testing in flexion, extension, right lateral bending, and right rotation, and the data were compared. In flexion and extension, mobility of the segment above the double-level T12–L2 posterior fixation was significantly increased (P

In order to study differences between sugar transport in oligosaccharide-translocating and sucrose-translocating species, two members of the Scrophulariaceae, Asarina barclaiana Pennell and Alonsoa meridionalis O. Kuntze, were analysed regarding minor-vein anatomy, sugar concentrations in leaves and phloem sap, and expression of sucrose transporters. The minor veins of Asarina barclaiana possess mainly transfer cells and modified intermediary cells and those of Alonsoa meridionalis have intermediary cells and ordinary companion cells. Phloem sap from these plants was collected by the laser-aphid-stylet technique. The main carbon transport forms in Asarina were sucrose and in Alonsoa raffinose and stachyose. The sum of the carbohydrate concentrations in the phloem sap of both species was as high as that in apoplastic phloem loaders. In Asarina the ratio of the sucrose concentration in the phloem to that in the cytosol of source cells was about 35 and the corresponding ratio in Alonsoa was about two. Sucrose transporter cDNAs were isolated from leaves of both species. By means of semi-quantitative reverse transcription-polymerase chain reaction, sucrose transporter mRNA was detected in different organs and also in the phloem sap. This is the first time that sucrose transporters have been found in oligosaccharide-translocating species and that the mRNA of these sucrose transporters has been localized directly in the phloem sap. Taken together, our observations indicate that Asarina is an apoplastic phloem loader, while the results for Alonsoa are ambiguous: some properties are typical of the symplastic phloem-loading mechanism, but probably a sucrose transporter is involved in loading and/or retrieval of sucrose into the phloem.