Fragestellung: Hypermobilität des ersten Tarsometatarsalgelenkes (TMT-1) ist häufig mit ausgeprägter Hallux valgus Deformität (HV) vergesellschaftet, und könnte HV-Rezidive nach chirurgischer Korrektur des ersten Strahles begünstigen. Rezente anatomische Untersuchungen belegen die funktionelle Beteiligung der Tibialis anterior Sehne (TAT) an der TMT-1 Stabilisation, was zur Entwicklung des ‘Cross-Glide Test’ (Video bei Präsentation) zur Überprüfung der TMT-1 Stabilität geführt hat.

Fragestellung Infektionen im Operations-(OP)-Gebiet an der Wirbelsäule (WS) und chronische Implantatinfektion werden als Ursache für anhaltende Schmerzen, Implantatlockerung und Entwicklung eines ‘Failed back surgery Syndroms’ diskutiert.

Fragestellung Schädel-Hirn-Traumata (SHT) sind eine der Hauptursachen für Krankenhauseinweisungen und Mortalität bei Trauma-Patienten. Intrakranielle Blutungen (IKB) stellen eine Komplikation nach SHT dar, besonders in älteren Pateinten besteht dann auch ein erhöhtes Mortalitätsrisiko. Niedrige Komplikationstoleranz in der öffentlichen Wahrnehmung und unklare Risikoeinschätzung führt bei leichtem SHT häufig zu exzessiver Diagnostik und Hospitalisation, welche unnötig und kostspielig ist. Studienziel war die Identifikation von Risikofaktoren für IKB, Voranschreiten der Blutung und Mortalität von Pateinten mit leichtem SHT (1) zur Verbesserung der Risikoeinschätzung und (2) Identifikation von niedrig-Risiko-Gruppen, in welchen eine exzessive Abklärung kontraindiziert scheint.

Accurate placement of spinal pedicle screws (PS) is mandatory for good primary segmental stabilization allowing consequent osseous fusion, requiring judgmental experience developed during a long training process. Computer navigation offers permanent visual control during screw manipulation and has been shown to significantly lower the risk of pedicle perforation. This study aims to evaluate whether safety, accuracy, and judgmental skills in screw placement, comparable to an experienced surgeon, can be developed during training using computer navigation. Lumbosacral PS were placed in 18 patients in a prospective setting, in one segment side with conventional fluoroscopy by a senior spine-surgeon, and computer navigated on the other side by a trainee without prior experience in the technique. At the beginning and at the end of the study, PS were placed freehand in solid foam models by the trainee. PS placement time, intraoperative placement revisions, PS placement accuracy on postoperative CT scans, and postoperative complications were assessed. Significant improvement of trainee’s PS placement accuracy (Sclafani score 8.2–8.83; p = 0.006) and time (13.3–6.8 min per screw; p = 0.005) to a similar level as the experienced surgeon state (5.2–4.1 min per screw; p = 0.39) was explored; similar improvement was explored in the foam models. The number of intraoperative placement revisions kept on a low level for surgeon (3.3–0.0%) and trainee (5.1–2.6%) during the whole study, no postoperative complications occurred. Navigated PS insertion allows safe teaching from the early beginning of surgical training, due to steady intraoperative control on PS placement. Adequacy of PS placement is similar to screws placed by an experienced surgeon. Progress in judgmental skills in screw placement can be gained rapidly by the trainee, which can also be transferred to non-computer navigated PS placement.

Intraoperative radiography imaging is essential for accurate spinal implant placement. Hazards caused by ionizing radiation raised concern on personnel’s work life long exposure in the operating room (OR). To particularize a cumulative risk estimation of radiation of personnel and patient, depending on used methods (C-arm fluoroscopy, O-arm navigation) and patient characteristics during spinal surgery, detailed investigation of radiation exposure in a clinical setting is required. Lumbosacral dorsal spinal fusion was performed in 37 patients (19 navigated, 18 fluoroscopy) during this prospective study. Radiation exposure was measured on several body regions with thermoluminescent dosimeters on patient and OR personnel (surgeon, assistant, sterile nurse, radiology technologist). Comparison between patient characteristics and radiation exposure was included. The highest patients values were measured in the surgery field and gonads area during navigation (43.2 ± 19.4 mSv; fluoroscopy: 27.7 ± 31.3 mSv; p = 0.02), followed by the thoracic region during fluoroscopy (7.7 ± 14.8 mSv; navigation: 1.1 ± 1.0 mSv; p = 0.06), other measured regions can be considered marginal in comparison. Amongst OR personnel exposure of the surgeon was significant higher during fluoroscopy (right hand: 566 ± 560 µSv and thoracic region: 275 ± 147 µSv; followed by thyroid and forehead) compared to navigation (right finger: 49 ± 19 µSv; similar levels for all regions; p < 0.001 in all regions). When compared to the surgeon, other OR personnel had significantly lower radiation doses on all body regions using fluoroscopy, and similar dose during navigation. The highest eye’s lens region value was measured during fluoroscopy for the patient (185 ± 165 µSv; navigation: 205 ± 60 µSv; p = 0.57) and the surgeon (164 ± 74 µSv; navigation: 92 ± 41 µSv; p < 0.001). There was a significant correlation between patient BMI and radiation exposure to the surgery field during fluoroscopy. To our knowledge, these data present the first real life, detailed comparison of radiation exposure on OR personnel and patients between clinical use of navigation and fluoroscopy. Although patient’s radiation dose is approximately 3-fold during navigation compared to the fluoroscopy, we found that a spinal surgeon could perform up to 10-fold number of surgeries (10.000 versus 883) until maximum permissible annual effective radiation dose would be reached. Especially for a spinal surgeon, who is mainly exposed amongst OR personnel, radiation prevention and protection must remain a main issue.

Background. Increased metal ion levels following total hip arthroplasty (THA) with metal-on-metal bearings are a highly debated topic. Local soft tissue reactions with chronic pain and systemic side effects such as neuropathy are described. The aim of the current study was to determine the serum metal ion concentrations of Cobalt (Co) and Chrome (Cr) after THA with a ceramic-on-metal (CoM) bearing. Patients and Methods. Between 2008 and 2010, 20 patients underwent THA using a CoM bearing. Clinical function was evaluated by standardized scores systems (Harris Hip Score and WOMAC Score) and radiological examination included X-rays. Patient’s blood samples were obtained for metal ion analysis and correlation analysis was done between these results and implant position. Results. Overall, 13 patients with 14 CoM devices were available for the current series. The mean age at time of surgery was 61 years (range, 41 to 85). The postoperative follow-up ranged from 49 to 68 months (mean, 58). Metal ion determination showed mean concentrations of 3,1 µg/L (range, 0,3–15,2 µg/L) for Co and 1,6 µg/L (range, 0,1–5,5 µg/L) for Cr, respectively. A correlation between cup anteversion and Co and Cr concentrations was shown. Conclusion. The current series showed increments for Co and Cr following CoM THA. However, these levels are lower compared to metal ion concentrations in patients with metal-on-metal bearings and the international accepted threshold for revision of MoM devices. We recommend routine follow-up including at least one obligatory evaluation of serum metal ion concentrations and an MRI once to exclude local soft tissue reactions.

Purpose. Anterior screw fixation has become a popular surgical treatment method for instable odontoid fractures. Screw loosening and migration are a rare, severe complication following anterior odontoid fixation, which can lead to esophagus perforation and requires revision operation. Methods. We report a case of screw loosening and migration after anterior odontoid fixation, which perforated the esophagus and was excreted without complications in a 78-year-old male patient. Results. A ventral dislocated anterior screw perforated through the esophagus after eight years after implantation and was excreted through the gastrointestinal (GI) tract. At a 6-month follow-up after the event the patient was asymptomatic. Conclusion. Extrusion via the GI tract is not safe enough to be considered as a treatment option for loosened screws. Some improvements could be implemented to prevent such an incident. Furthermore, this case is a fine example that recent preoperative imaging is mandatory before revision surgery for screw loosening.

To aid in therapy selection for patients with spinal bone metastases (SBM), predictive models have been developed. These models consider SBM from breast cancer a positive predictive factor, but do not take phenotypes based on estrogen (ER), progesterone (PR) and human epidermal growth factor 2 (HER2) receptors into account. The aim of this study was to ascertain whether receptors are associated with survival, when the disease has progressed up to SBM. All patients who were treated for SBM from breast cancer between 2005 and 2012 were included in this international multi-center retrospective study (n = 111). Reports were reviewed for ER, PR and HER2 status and subsequently subdivided into one of four categories; luminal A, luminal B, HER2 and triple negative. Survival time was calculated as the difference between start of treatment for SBM and date of death. Analysis was performed using the Kaplan-Meier method and log-rank tests. Median follow-up was 3.7 years. Survival times in the luminal B and HER2 categories were not significantly different to the luminal A category and were joined into a single receptor positive category. Eighty-five patients (77 %) had a receptor positive phenotype and 25 (23 %) had a triple negative phenotype. Median survival time was 22.5 months (95 %CI 18.0-26.9) for the receptor positive category and 6.7 months (95 %CI 2.4-10.9) for the triple negative category (p < 0.001). Patients with SBM from breast cancer with a triple negative phenotype have a shorter survival time than patients with a receptor positive phenotype. Models estimating survival should be adjusted accordingly.

Background: Malignant spinal cord compression (MSCC) is most frequently seen in patients with breast, prostate and lung cancer. 5% to 25% of MSCC cases occur as the initial presentation of malignancy. Case report: We report the case of a 43-year-old male patient with sudden onset incomplete paraplegia. Imaging revealed spinal cord compression at the level TH 3/4 and TH 8. Emergency decompressive surgery with tumour biopsy was performed. Two days after surgery, the patient developed large bowel obstruction, and a sigmoid tumour was identified as underlying cause. The sigmoid tumour was diagnosed as colorectal adenocarcinoma, and histological examination of the spinal tumour confirmed metastatic disease. Conclusion: MSCC may be the initial presentation in patients with neoplastic disease, and also tumours that only very rarely metastasize to the skeletal system have to be included in differential diagnosis. Obtaining biopsy material during surgery is crucial to establish a definitive diagnosis.