Objective: Osteoporosis (OP), osteoarthritis (OA) and vitamin D deficiency are age-related disorders. We investigated the association between bone mineral density (BMD), vitamin D and OA in patients undergoing total hip or knee replacements. Method: In total, 82 women and 35 men with mean ages of 70 and 68 years, respectively, were recruited for the study. The BMD of the lumbar spine and the proximal femur were measured by dual-energy X-ray absorptiometry. The vitamin D status was assessed by 25(OH)D levels, with a cut-off of ≤30 ng·ml–1. Results: In total, 84.7% of the patients had a vitamin D deficiency; 20% of the men had a T-score below –2.5; 23.2% of the women were affected by OP. Furthermore, 37.1 and 42.7% of the male and female patients, respectively, had osteopenia. We concluded that OP and osteopenia were not due to immobility. Conclusion: The average age, rather than the frequency of OP, in cases with OA of the hip or knee differed from the general population. The incidence of low BMD in the male cohort was notably higher than expected. We detected a high prevalence of vitamin D deficiency, independent of the BMD.

A case of the very rare primary-hypertrophic-osteoarthropathy (Touraine-Solente-Gole-Syndrom) is reported. A middle-aged women was suffering from chronic joint- and limb-pain for more than twenty years. All diagnostical experiences only showed a cortical thickening mainly of the tubular bones and a craniosclerosis but no link for the possible origin. As typical for the disease, periostal reactions could be discovered in X-ray examinations too. Thickening of the facial skin as well as drumstick-configurations of the fingers could be seen. A pulmonary affection leading to a secondary pulmonary osteoarthropathy (Pierre-Marie-Bamberger's Syndrom) could be excluded. The syndrom presented here is only to be found in 3 to 5% of all cases with hypertrophic osteoarthropathy. It is a rare differential-diagnosis of chronic bone and joint pain.

The purpose of this study was to analyse the number and types of secondary fractures, and to investigate the impact of intradiscal cement leaks for adjacent vertebral fractures. Patients with osteoporotic vertebral fractures were treated with vertebroplasty. Results were documented and prospectively followed by means of computed tomography (CT) and magnetic resonance imaging. The frequency and the types of cement leakages were analysed from multiplanar CT images and secondary fractures were characterised as follows: (1) adjacent fracture in the immediate vicinity of an augmented vertebra; (2) sandwich fracture, fracture of an untreated vertebra between two vertebrae that had been previously augmented, and (3) distant fractures not in the vicinity of augmented vertebrae. A total of 385 osteoporotic vertebral fractures were treated in 191 patients (61 men, 130 women, age 70.7 ± 9.7 years). The overall rate of cement leaks was 55.6%, including all leaks detectable by CT. Intradiscal leaks through the upper, the lower, and both endplates occurred in 18.2%, 6.8%, and 2.6%, respectively. In 39 patients (20.4%), a total of 72 secondary fractures occurred: 30 adjacent fractures in 23 patients (12.0%) with a time to fracture of 2 months [median; 1.0/4.0 months, first/third quartile (Q1/Q3)]; 11 secondary sandwich fractures in 11 patients (5.8%) after 1.5 months (median; 0.25/7.5 months, Q1/Q3); and 31 distant fractures in 20 patients (10.5%) after 5 months (median; 2.0/8.0 months, Q1/Q3). Ten of 30 adjacent fractures occurred in the presence of pre-existing intradiscal cement leaks and 20 where there was no leakage. Six of 11 sandwich fractures occurred in the presence of intradiscal leaks (five leaks in both adjacent disc spaces, one leak in the lower disc space) and five where there was no leakage. The rate of secondary adjacent and non-adjacent fractures is quite similar and there is no specific impact of intradiscal leakages on the occurrence of adjacent secondary fractures. Adjacent fractures occur sooner than distant secondary fractures. Sandwich fractures are associated with specific biomechanical conditions, with a 37.9% fracture rate in sandwich constellations.

AIMS:The main complication in total hip arthroplasty is aseptic loosening. Wear-induced inflammatory processes lead to periprosthetic granulation tissue, which induces bone degradation due to aseptic osteolysis. At the site of bone degradation,the cell populations have not been further analysed so far. Therefore, the present study was designed to analyse bone degradation tissue in comparison to periprosthetic granulation tissue. METHODS:Tissue specimens of 14 patients with failed modular cup components of cementless total hip arthroplasties were obtained during revision surgery. Immunohistochemistry was performed by using anti-CD 31 (endothelial cells),anti-CD 45 (granulocytes and lymphocytes) and anti-CD 68 antibodies (mononuclear phagocyte system, MPS). Fibroblasts and osteoblasts were immunohistochemically distinguished as CD 31/45/68-negative cells. Semiquantitative analyses,including a morphometric study, were then performed both in the bone degradation zone and in the periprosthetic granulation tissue. RESULTS:At the site of bone degradation, the majority of cells belonged to MPS (73.6 +/- 3.31%),while fibroblasts were significantly less frequent (9.6 +/-1.67%). A distinct population of endothelial cells (7.75+/- 1.4%) as well as lymphoplasmacellular cells (5.75+/-2.35%) were observed. In addition,only a small amount of neutrophilic granulocytes (0.7 +/- 0.4 %) were detected. In the periprosthetic granulation tissue, findings were very similar to those of the bone degradation zone,with the exception of higher amounts of fibroblasts (15.69 +/- 2.74%). CONCLUSIONS:This study confirms that, in aseptic hip arthroplasty loosening, the majority of cells detected at the site of bone degradation are of the MPS, which are predominantly involved in osteolytic processes. There is no pathologically significant difference between the cell population of periprosthetic granulation tissue and granulation tissue at the sites of bone degradation.

OBJECTIVE Aseptic hip prosthesis loosening is the most important long-term complication in total hip arthroplasty. Polyethylene (PE) wear is the dominant etiologic factor in aseptic loosening, which together with other factors induces mechanisms resulting in bone loss, and finally in implant loosening. The single-shot radiograph analysis (EBRA, abbreviation for the German term ""Einzel-Bild-Röntgenanalyse"") is a computerized method for early radiological prediction of aseptic loosening. In this study, EBRA parameters were correlated with histomorphological parameters of the periprosthetic membrane. METHODS Periprosthetic membranes obtained from 19 patients during revision surgery of loosened ABG I-type total hip pros-theses were analyzed histologically and morphometrically. The pre-existing EBRA parameters, the thickness of the PE debris lay-er and the dimension of inclination and anteversion, were compared with the density of macrophages and giant cells. Addi-tionally, the semiquantitatively determined density of lymphocytes, plasma cells, giant cells and the size of the necrotic areas were correlated with the EBRA results. RESULTS All periprosthetic membranes were classified as debris-induced type membranes. We found a positive correlation between the number of giant cells and the thickness of the PE debris layer. There was no significant correlation between the number of macrophages or all semiquantitative parameters and EBRA parameters. The number of giant cells decreased with implant duration. CONCLUSION The morphometrically measured number of foreign body giant cells more closely reflects the results of the EBRA. The semiquantitative estimation of giant cell density could not substitute for the morphometrical analysis. The density of macrophages, lymphocytes, plasma cells and the size of necrotic areas did not correlate with the EBRA parameters, indicating that there is no correlation with aseptic loosening.

In order to treat patients with postoperative acute pain effectively, we have developed a standardised algorithm for analgesia. This process includes three levels and the appropriate supply of medication. The therapy level is defined based on the scale of the operation. Accordingly, the prescription and handling of the pain medication is simplified for the attending physician and nurses. The pain level has to be measured by the nursing staff sing a visual analogue scale (VAS). Thus, the efficiency of the analgesics will be continuously evaluated and controlled. The standardised supply medication can be applied in those cases with pain levels > or = 4 (VAS). It is possible to up- or down-grade the level within the system depending on the actual pain experienced by the patient. With this structured pain therapy algorithm we now have a guideline for the consistent postoperative analgesic treatment of patients.

Objective: Increasing bone mineral density (BMD) has been found in several studies in patients with osteoarthritis (OA). Therefore, the simultaneous occurrence of osteoporosis (OP) and OA is denied by many clinicians. Because of our clinical impression, however, we suggest that we have to consider a common occurrence. In the present study we have examined the relationship between osteoathritis of the knee or the hip and osteoporosis. Method: The BMD of the lumbar spine and the proximal femur of 117 OA patients (82 postmenopausal female patients aged 50-83 and 35 male patients aged 36-86 years) who subsequently required hip or knee replacements, but were otherwise healthy, was measured by dual-energy X-ray absorptiometry (DXA; Hologic QDR-2000). The results are given as required by the WHO and the new German guidelines of the DVO. The BMD was measured and categorised in a sex-related manner and the occurrence of disuse osteoporosis on the affected limb was examined. Furthermore, a comparison was made in the level of BMD between the OA of the involved hip or knee. Results: There was a high occurrence of low BMD among the patients. 23.2% of the women were affected by OP. This reflects the normal distribution of OP in the female population. 20% of the male patients had occult OP. This is astonishingly high. Osteopenia was measured for 37.1% of the male patients and 42.7% of the female patients. Age proved to be a significant factor in the degree of BMD. Neither a disuse osteoporosis, nor a significance in the OA-affected joint to the degree of BMD, could be proven. Conclusion: We cannot support the hypotheses that OA prevents OP. Moreover, the occurrence of OP in our study reflected the incidence of OP in the average female and was astonishingly high in the male population; this does not support the hypothesis that the two conditions are mutually exclusive. Also a lower risk of fractures among OA patients cannot be concluded. There is current open discussion whether a known BMD should influence the decision for a cemented or an uncemented prosthesis.

BACKGROUND:MRI can be too sensitive for detecting degenerative changes and commonly displays pathology that is not necessarily responsible for the patient's symptoms. METHODS:Retrospectively, we investigated MRI findings and results of discography in 23 patients with lower back pain. MRI investigations were performed with a 1.0 and 1.5 Tesla device using T1-weighted and T2-weighted sagittal plane imaging and T2-weighted transverse plane imaging. RESULTS:Of the 35 degenerated discs, 16 were detected on MRI as having a high intensity zone (HIZ). Eleven of the 35 segments had previous lumbar disc surgery with a HIZ rate of 81.8%, whereas the HIZ rate for unoperated segments was only 29.2%. CONCLUSIONS:HIZ is known to be a common lesion found using MRI in lower back pain patients. In operated segments, we found an incidence of 81.8% and in unoperated segments of 28.2%. Discography can discriminate between painful and non-painful discs. With the help of additional parameters such as contrast mean volume and pain characteristics during puncture, the number of false positive discograms can be reduced.

Problematisch ist die Abgrenzung physiologischer Alterungsveränderungen der Bandscheibe von symptomgebenden Diskusveränderungen.

Background. Mill can be too sensitive for detecting degenerative changes and commonly displays pathology that is not necessarily responsible for the patient's symptoms.Methods. Retrospectively, we investigated MRI findings and results of discography in 23 patients with lower back pain. MRI investigations were performed with a 1.0 and 1.5 Tesla device using T1-weighted and T2-weighted sagittal plane imaging and T2-weighted transverse plane imaging.Results. Of the 35 degenerated discs, 16 were detected on MRI as having a high intensity zone (HIZ). Eleven of the 35 segments had previous lumbar disc surgery with a HIZ rate of 81.8%, whereas the HIZ rate for unoperated segments was only 29.2%.Conclusions. HIZ is known to be a common lesion found using MRI in lower back pain patients. In operated segments, we found an incidence of 81.8% and in unoperated segments of 28.2%. Discography can discriminate between painful and nonpainful discs. With the help of additional parameters such as contrast mean volume and pain characteristics during puncture, the number of false positive discograms can be reduced.

OBJECTIVE:Increasing bone mineral density (BMD) has been found in several studies in patients with osteoarthritis. Therefore, many clinicians deny the simultaneous occurrence of osteoporosis (OP) and osteoarthritis (OA). Because of our clinical impression however, we suggested that we have to consider a common occurrence. Furthermore, the value of markers of bone turn over with a view to early diagnosis of OP and or as an assessment for bone metabolism in OA is still a matter debate and their clinical use has not been clearly defined in the management of the individual patient.METHOD:The BMD of the lumbar spine and the proximal femur of 119 OA patients (83 postmenopausal female patients aged 50-83 and 35 male patients aged 36-86 years) who subsequently required hip or knee replacements, but were otherwise healthy, were measured by dual energy X-ray absorption (DXA), Hologic QDR-2000. We also measured biochemical markers of bone turn over, i. e., CICP, ICTP, DPD, PTH, estrogen, testosterone, bAP, hydroxy vitamin D and the normal blood count.RESULTS:There was a high occurrence of a low BMD among the patients. A total of 28.9% of women were affected by OP and 52.9% by osteopoenie. This reflects the normal distribution of OP in the female population. Of the male patients 20% had OP and 38.8% osteopoenie. This is astonishing high. Age proved to be a significant factor in the degree of BMD. An association between disuse osteoporosis and degree of BMD in the OA affected joint could not be proven. The use of the biochemical markers for an earlier diagnosis or to assess bone metabolism in OP and OA was not possible.CONCLUSION:We can not support the hypotheses that OA prevents OP. Moreover, the occurrence of OP in our study reflected the incidence of OP in the average female and the astonishingly high incidence in the male population; however does not mean that the two conditions are mutually exclusive. We did not find that the biochemical markers of bone turn over could deliver additional information with respect to bone metabolism and an earlier diagnosis of OP.

PURPOSE:Evaluation of vertebroplasty using a combination of CT-fluoroscopy and conventional lateral fluoroscopy in patients with osteoporotic vertebral fractures.MATERIALS AND METHODS:Fifty-eight patients (23male, 35 women, age 69.7 +/- 10.2 years) with painful osteoporotic vertebral fractures were treated with vertebroplasty in conscious sedation and local anesthesia. Spiral-CT with sagittal reconstructions of the respective vertebral bodies was used for classification of the fracture. The cannula was placed under CT-guidance in the ventral third of the respective vertebral bodies and cement instilled under CT fluoroscopy and lateral fluoroscopy. When cement migrated towards the vertebral canal, the injection was immediately stopped for 30 - 60 seconds. After polymerization in this location, the injection was continued until sufficient filling of the vertebra. Results were documented by spiral CT with sagittal reconstructions.RESULTS:A total of 123 vertebral bodies were treated, comprising 39 thoracic and 84 lumbar vertebral bodies, with a mean of 2.1 +/- 1.3 (range 1 to 6) vertebral bodies in each patient and a maximum of 3 vertebral bodies per session. All interventions were successfully completed in conscious sedation and local anesthesia. A mean volume of 5.9 +/- 0.6 ml (range 2 to 14 ml) cement was applied for each vertebra, with 79.7 % of procedures performed using a unilateral access. To achieve a sufficient cement deposit, a bilateral access was used in 20.3 %. The dorsal wall of the vertebra was included in 23.6 % of the fractures. In one case, cement migration into the spinal canal was detected, reducing the diameter of the canal by 30 %. In two other cases, cement leakage was seen at the puncture site of the vertebra (one intercostotransversally in the 10 (th) thoracic vertebra and one dorsolaterally in the 1 (st) lumbar vertebra) with retrograde cement migration through the neuroforamen into the epidural space. In one of these cases, the cannulation of the vertebra had been changed before cement application resulting in a hole in the dorsolateral vertebral wall. However, all patients were discharged without evidence of neurologic complications. Multiplanar reconstructions of CT scans were used for the detection of extraosseous cement leaks: The incidence of extraosseous cement leaks was 4.1 % in epidural veins, 6.5 % in paravertebral vessels (6 veins, 2 arteries), and 17.9 and 11.4 %, respectively, for upper or lower end plates. At discharge, 25 patients (43.1 %) were free of pain and 28 (48.3 %) significantly improved with a considerable reduction of analgetic drugs. Significant complaints persisted in 5 patients (8.6 %) with concomitant degenerative disease in four and vasculitis in one case.CONCLUSION:Percutaneous vertebroplasty is effective for stabilization and pain management of osteoporotic vertebral fractures. The procedure can be safely performed in conscious sedation and local anesthesia. Compared to conventional fluoroscopy alone, CT fluoroscopy provides an excellent additional monitoring of the procedure and probably contributes to the safety of the procedure.

Objective This study aimed to investigate specific inflammatory pathomechanisms, i.e. the expression of the stem cell factor receptor KIT (CD117) in tissue specimens from patients with aseptic hip prosthesis loosening (AHPL) with special emphasis on colocalization with the mast cell specific marker tryptase. Methods Immunohistochemical analysis of CD117 was performed in tissue specimens from 10 patients with aseptically loosened acetabular components of failed non-cement total hip replacements and compared to control samples obtained at primary hip surgery (n=4). The CD117 expressing cells were characterized further with mast cell tryptase (MCT) by serial section analysis and a double staining method. CD117 and MCT expression was examined by semi-quantitative analysis. Additionally, double labeling of the CD117 or MCT expression by immunohistochemistry and of polyethylene (PE) particles by Oil Red reaction was performed. Results In AHPL, CD117 was almost exclusively detected in MCT positive cells. Co-expression tended to be highly correlated (r=0.86, p<0.01). CD117 was found mainly in two regions: first, in perivascular lymphocyte-rich areas and; secondly, near macrophages and multinucleated giant cells (MGC). PE particles were not detected in CD117 and MCT positive cells. In control samples, CD117/MCT positive cells were less frequent. Conclusion This is the first report on CD117 expression in AHPL. CD117 is almost exclusively expressed in a distinct mast cell subgroup. As an important growth factor receptor, CD117 could play a major role in recruitment and activation of mast cells in AHPL. Furthermore, mast cells do not contain significant amounts of PE particles. However, it remains to be investigated whether this cell population could influence phagocytosis of PE particles. (Journal of Applied Biomaterials & Biomechanics 2005; 3: 11–7)

Purpose: Evaluation of vertebroplasty using a combination of CT-fluoroscopy and conventional lateral fluoroscopy in patients with osteoporotic vertebral fractures. Materials and Methods: Fifty-eight patients (23 male, 35 women, age 69.7 +/- 10.2 years) with painful osteoporotic vertebral fractures were treated with vertebroplasty in conscious sedation and local anesthesia. Spiral-CT with sagittal reconstructions of the respective vertebral bodies was used for classification of the fracture. The cannula was placed under CT-guidance in the ventral third of the respective vertebral bodies and cement instilled under CT fluoroscopy and lateral fluoroscopy. When cement migrated towards the vertebral canal, the injection was immediately stopped for 30-60 seconds. After polymerization in this location, the injection was continued until sufficient filling of the vertebra. Results were documented by spiral CT with sagittal reconstructions. Results: A total of 123 vertebral bodies were treated, comprising 39 thoracic and 84 lumbar vertebral bodies, with a mean of 2.1 +/- 1.3 (range 1 to 6) vertebral bodies in each patient and a maximum of 3 vertebral bodies per session. All interventions were successfully completed in conscious sedation and local anesthesia. A mean volume of 5.9 +/- 0.6 ml (range 2 to 14 ml) cement was applied for each vertebra, with 79.7% of procedures performed using a unilateral access. To achieve a sufficient cement deposit, a bilateral access was used in 20.3%. The dorsal wall of the vertebra was included in 23.6% of the fractures. In one case, cement migration into the spinal canal was detected, reducing the diameter of the canal by 30%. In two other cases, cement leakage was seen at the puncture site of the vertebra (one intercostotransversally in the 10(th) thoracic vertebra and one dorsolaterally in the 1(st) lumbar vertebra) with retrograde cement migration through the neuroforamen into the epidural space. in one of these cases, the cannulation of the vertebra had been changed before cement application resulting in a hole in the dorsolateral vertebral wall. However, all patients were discharged without evidence of neurologic complications. Multiplanar reconstructions of CT scans were used for the detection of extraosseous cement leaks: The incidence of extraosseous cement leaks was 4.1% in epidural veins, 6.5% in paravertebral vessels (6 veins, 2 arteries), and 17.9 and 11.4%, respectively, for upper or lower end plates. At discharge, 25 patients (43.1%) were free of pain and 28 (48.3%) significantly improved with a considerable reduction of analgetic drugs. Significant complaints persisted in 5 patients (8.6%) with concomitant degenerative disease in four and vasculitis in one case. Conclusion: Percutaneous vertebroplasty is effective for stabilization and pain management of osteoporotic vertebral fractures. The procedure can be safely performed in conscious sedation and local anesthesia. Compared to conventional fluoroscopy alone, CT fluoroscopy provides an excellent additional monitoring of the procedure and probably contributes to the safety of the procedure.

Zusammenfassung Noch immer werden in Deutschland 28.000 Amputationen/Jahr bei Patienten mit diabetischem Fußsyndrom (DFS) durchgeführt.Bei gleichzeitig häufig vorhandener ischämischer und osteomyelitischer Komponente führt ein operatives Vorgehen in der Regel zu Wundheilungsstörungen,Nachamputationen und oft auch Extremitätenverlust.Die Ergebnisse eines interdisziplinären Therapieregimes werden evaluiert und im Literaturvergleich bewertet. Nach Diagnostik hinsichtlich des Vorliegens einer Polyneuropathie,Osteomyelitis und vor allen Dingen einer pAVK hat nach Infektkontrolle die primäre distale Bypasschirurgie höchste Priorität, ihr Erfolg ist richtungsweisend für den weiteren Verlauf der Erkrankung.Die sparsame Resektion osteomyelitisch veränderter Knochen erfolgt im Anschluss.Die spezialisierte diabetologische Fußambulanz übernimmt die Nachsorge und koordiniert die Sekundärprophylaxe. Vorgestellt werden die radiologischen und klinischen Ergebnisse einer konsekutiven Serie von 77 Patienten, die im Laufe eines Jahres dieses interdisziplinäre Behandlungskonzept inklusive selektiver Knochenchirurgie oder Minor-Amputation durchliefen. Bei lediglich 3 dieser Patienten persisierte eine Läsion und bei fortschreitender Osteomyelitis war eine weitere Operation erforderlich. Eine spätere Major-Amputation musste im Verlauf über 12 Monate nicht durchgeführt werden. Die Major-Amputationsrate bei allen interdisziplinär auf der diabetologischen Schwerpunktstation betreuten Patienten mit DFS,die eine schwere,osteomyelitischischämische Verlaufsform zeigten,liegt bei nur 10,3% und sinkt sogar auf 8,9%,wenn die Läsionen rein polyneuropathisch bedingt sind. Dank der intensiven interdisziplinären Kooperation im Bemühen um die Erhaltung der Extremität beim DFS ist in unserem Zentrum die Zahl der noch erforderlichen Major-Amputationen niedrig,nach Minor-Amputation oder kleinen Eingriffen ist aufgrund der suffizienten Nachsorge mit einer guten Abheilungsrate zu rechnen.

Fragestellung: Untersuchung der dynamischen EMG in der Rehabilitation zur Bestimmung der funktionellen Integration nach Implantation einer Hüft- und Knietotalendoprothese.

Fragestellung: Ziel der Studie war die Analyse von Behandlungsfällen retrospektiv und prospektiv und ein Vergleich der abgebildeten Diagnosen und Schweregrade.

Zusammenfassung: Hanieh, Lewonowski und Arai berichten über eine erhöhte Koinzidenz von idiopathischen Skoliosen und Syringomyelien in bis zu 20% aller Fälle. Hanieh schlussfolgerte daraus, dass alle Patienten mit einer idiopathischen Skoliose kernspintomographisch untersucht werden sollten. Dies war für uns Anlass, unser eigenes Krankengut darauf zu überprüfen.