Suramin, a polysulphonated naphthylurea used in the treatment of human African trypanosomiasis (HAT), is known to cause adrenocortical insufficiency in doses exceeding the quantity used for treatment of HAT. We have previously reported that Trypanosoma brucei rhodesinese infection causes a combined central and peripheral adrenal insufficiency. To evaluate whether suramin therapy acts as an additional adrenotoxic factor, we assessed adrenocortical function in 72 patients suffering from HAT at different times during treatment with either suramin or melarsoprol by a rapid adrenocorticotropic hormone test. We found a significantly diminished peak cortisol response to stimulation in the acutely ill patients (P = 0.001), indicating impaired adrenocortical function, as well as a high incidence of partial adrenocortical insufficiency (27%). During and after trypanocidal therapy the incidence of partial adrenal insufficiency gradually declined (to 25% and 18% respectively). Stimulated peak cortisol levels did not differ significantly between patients receiving suramin and those given melarsoprol. No correlation was found between serum suramin concentration and the cortisol response to stimulation (r = 0.09, P = 0.47). Thus we conclude that suramin in trypanocidal doses neither causes nor worsens the adrenocortical dysfunction observed in Rhodesian HAT.

Addison Disease↗

PubMedDate not supplied

[Surgical reconstruction of fibrous dysplasia of bone in long-term follow-up].

PURPOSE: To examine how different operative measures influence the surgical outcome in patients with fibrous dysplasia of bone. METHODS: 118 dysplastic fibrous lesions of bone were surgically treated and reviewed in 70 patients between 1983 to 1993 (eleven years) with a median follow-up of six and a half years. Surgery consisted of intralesional curettage in 93 and marginal en bloc resection in 25 lesions. Bony defects were reconstructed with autogenous iliac crest graft in 55 lesions, with autogenous fibula graft in 9, with homologous bone chips in 28, and 5 times with a homologous fibula graft from the bone bank. In 33 lesions the entire defect was filled with polymethylmethacrylate. Osteosynthesis was performed in 41 patients. RESULTS: Recurrences requiring surgical revision were observed in 26 of 74 primary lesions (= 35% overall recurrence rate) at a mean 123.6 weeks postoperatively. The most frequent primary and recurrence location was the proximal femur (85% revision rate). 69% of all recurrences occurred under the age of 20. After intralesional curettage the reoperation rate was 32% and after marginal resection 8%. After reconstruction with autogenous iliac crest graft recurrence rate was 36%, after autogenous fibula graft 55%, after homologous bone chips 18%, after polymethylmethacrylate 9% and allograft fibula reconstruction showed no recurrences. A combined stable osteosynthesis bridging the fibrous osseous defect significantly reduced the revision rate to 3% (p = 0.01). CONCLUSION: Intralesional curettage and reconstruction with autogenous iliac crest graft in fibrous dysplasia of bone leads to a high recurrence rate. Reconstruction with cortical grafts or bone chips from the bone bank, if necessary in combination with a durable osteosynthesis in mechanically demanding locations, or solely bone cement in mechanically less demanding areas, reduces the revision rate in patients with monoostotic and polyostotic fibrous dysplasia.

Adolescent↗

PubMedDate not supplied

[Ablative and extremity salvage tumor surgery of the lower extremity--a 10 year comparison].

AIM: The treatment of choice for local tumor control was amputation in the 1970's. Nowadays, limb salvage procedures have become the new standard, implicating that limb salvage surgery results in a better quality of life. This study attempts to prove this hypothesis. METHOD: In total, 102 patients who survived longer than ten years after tumor treatment of the lower extremities were investigated, of these, 71 patients underwent ablative procedures compared to 31 patients with limb salvage surgery. Operative revisions, education level, and occupational situation were evaluated in both groups. To analyze the outcome of every patient regarding functional results, quality of life, life contentment, and social parameters, the functional evaluation system of the Muskulo-Skeletal-Tumor Society (MSTS), the Freiburger Life-Contentment-Questionnaire (FLZ) and the Quality of Life Questionnaire (QLQ-C-30) of the European Organization of Research and treatment of Cancer (EORTC) were used. RESULTS: Patients treated with a limb salvage procedure underwent more surgical revisions (p < 0.000). Educational level and occupational situation showed no difference in both groups. Functional results reached similar levels in both groups (74.6% vs. 73.8%). Life contentment and Quality of Life measurements showed good results in both groups. The FLZ-questionnaire showed significantly better results for the ablative group in some items. CONCLUSION: The type of surgical local therapy of lower extremity tumors has no measurable effect on quality of life according to long-term follow-up in lower extremity tumors. In cases with a risk of inadequate margins when performing limb salvage surgery, an ablative procedure should be preferred.

Activities of Daily Living↗

PubMedDate not supplied

[Correction of deformities with conventional and hexapod frames--comparison of methods].

AIM: Distraction osteogenesis for the correction of deformities with an external fixator is well established. The hexapod principle of robotic technique was invented for the Ilisarov apparatus (e. g. Taylor-Spatial-Frame/TSF). Treatment with conventional frames needs a patient-customised frame mounting. This demanding procedure is markedly reduced using this technology. The aim of this study was to analyse the value of the hexapod principle in external fixation. METHOD: The potential of a frame to correct deformities is limited by its work space. The geometry of a conventional frame is different from the geometry of a hexapod frame, which is the reason for their different work spaces. The work space of the hexapod frame is compared to the work space of a conventional frame. Important parameters for this analyses are minimal and maximal frame heights and the potential of correction. RESULTS: The minimal frame height of hexapod fixators is higher compared to conventional Ilisarov fixators. The standard hexapod frame (TSF 155 mm ring diameter) can correct 23 degrees of angulation, 36 mm of shortening, 71 mm of translation and 43 degrees of rotation without changing the telescope rods. The standard conventional frame (160 mm ring diameter) can correct 90 degrees of angulation, 100 mm of shortening, 25 mm of translation and 12.5 degrees of rotation without remounting of the frame. CONCLUSION: The different work spaces of the different frames result in consequences for their clinical application. The hexapod frame has more power to correct translation and rotational deformities than a conventional frame. Correction of extensive angulation and shortening deformities almost always needs an exchange of telescopic rods. Conventional frames are usually able to correct these deformities with the primary mounting. Because of its increased minimal frame height, the indication for hexapod constructs in child orthopaedics can be limited.

Adolescent↗

PubMedDate not supplied

[Minimally invasive treatment of osteoid osteoma with CT-guided radiofrequency ablation in long-term follow-up].

AIM: We treated 74 patients with symptomatic osteoid osteoma by CT-guided radiofrequency ablation (CT-RF) and investigated the rate of success and complications. PATIENTS AND METHODS: 74 patients were treated by CT-RF between March 1997 and August 2001. The nidus was first located by thin-cut CT sections and then penetrated by a 2 mm coaxial drill or an 11-gauge Jamshidi needle followed by insertion of the RF probe and heat application for a period of 4-6 minutes at 90 degrees C. We investigated the recurrence of pain, complications, hospital stay, duration of postoperative pain and function. RESULTS: Nine recurrences occurred after the initial procedure, and one after a second CT-RF (rate of primary success 87.8 %, rate of secondary success 88.8 %; 98.6 % success rate in all). There was one minor complication in one case. CONCLUSIONS: CT-guided RF ablation cured 73 of 74 patients (98.6 %). It is a safe, simple, cost effective and minimally invasive treatment, which has stood the test of a long-term follow-up and we suggest it to be the treatment of choice in most cases.

Adolescent↗

PubMedDate not supplied

[Limb lengthening with a fully implantable mechanical distraction intramedullary nail].

AIM: The morbidity of fixator-assisted distraction osteogenesis should be reduced by intramedullary lengthening devices. The ISKD (intramedullary skeletal kinetic distractor) is a new, fully implantable mechanical lengthening nail. In a prospective cohort trial the possibilities and limitations of the device used on femur and tibia are examined. METHODS: 22 patients with a mean age of 25 (range: 16-46) years were treated with an ISKD for femoral (n = 16) and tibial (n = 6) lengthening. The average leg length discrepancy was 48 (range: 25-80) mm. The follow-up was 21 (range: 7-37) months. Clinical and radiological results and complications were evaluated. RESULTS: The results of femoral and tibial applications of the ISKD are different. At the tibia, in three patients a pseudarthrosis occurred and slow callus formation was observed twice. An equinus contracture became evident in 2 patients. At the femur, in one case the lengthening was not accomplished with the device. Five patients were manipulated under anaesthesia at least once to achieve the aim of distraction. Three of these patients received retrograde implantation of the ISKD. An infection or interlocking screw failure was not observed either at the femur or the tibia. CONCLUSION: The ISKD reduces fixator-associated problems but incorporates its own difficulties which are mainly based on the guidance of the device. Careful patient advice in monitoring the lengthening process is mandatory. At the femur 8 cm of lengthening can be achieved but the nail tends to "block". Proper reaming and osteotomy techniques are important. A lengthening of more than 1 mm/day is recommended to prevent early consolidation. At the tibia weak callus formation and soft tissue contractures occur, therefore not more than 4 cm lengthening should be planned, the distraction speed has to be reduced noticeable below 1 mm/day and the initial immobilisation should be for more than a week.

Adolescent↗

PubMedDate not supplied

[2- to 4-year outcome of dorsal double rod instrumentation spondylodesis in idiopathic scoliosis].

INTRODUCTION: In order to evaluate the results of posterior correction and fusion using the Münster Posterior Doublerod-System (MPDS) 48 patients with idiopathic scoliosis were studied prospectively. METHODS: All patients underwent clinical examination and radiological analysis of the frontal and sagittal plane preoperatively, postoperatively and at follow-up (2-4 years). Pedicle screws were used at the lumbar and thoracolumbar spine exclusively. RESULTS: The preoperative average Cobb angle was 61.4 degrees with an average flexibility of 36.8% to 38.8 degrees. The average postoperative Cobb angle was 24.8 degrees (59.6%) with an average loss of correction of 2.6 degrees Cobb angle (3.6%). Due to the use of thoracolumbar and lumbar pedicle screws instrumented fusion could be stopped at the lower endvertebra in 71%. Patients in whom only pedicle screws had been used improved correction of frontal plane could be shown compared to combined instrumentations with hooks and screws. CONCLUSION: The posterior instrumentation guarantees primary stability with good results of correction and allows brace free treatment postoperatively. The postoperative correction compared to the results at follow-up proves the stability of the instrumentation largely. The results of mainly pedicle screw based instrumentations verify that an improved correction can be achieved. In most cases fusion levels end at the lower end vertebra and therefore are shorter compared to instrumentation's based on hooks only.

Adolescent↗

PubMedDate not supplied

[Computerized tomography monitoring of the position of pedicle screws in scoliosis surgery].

With the increasing use of pedicle screws in instrumented spine surgery the neurological risk must be evaluated critically. Studies, which evaluated the accuracy of pedicle screw placement in scoliosis surgery, have not been published up to date to our knowledge. In 25 consecutive patients with idiopathic scoliosis, who underwent posterior instrumented curve correction and stabilization, the accuracy of pedicle screw placement was evaluated using axial computed tomography. There was a total of 178 screws between T5 and L4. The preoperative Cobb angle of the curve averaged 60.7 degrees, the mean rotation of the instrumented vertebrae was 19.1 degrees according to Perdriolle. 145 pedicle screws (81.5%) were placed correctly within the pedicles, of which 4 screws (4.5%) penetrated the anterior aspect of the vertebral body with a mean of 0.9 mm. 22 screws (12.4%) showed lateral penetration of the pedicle with a mean of 1.9 mm, of which one screw was placed completely lateral of the pedicle. 8 screws (4.5%) penetrated the medial wall of the pedicle by 1.3 mm on average. One screw each penetrated the cranial and caudal border of the pedicle. Statistical analysis did not reveal any significant relationships between pedicle screw misplacement and grade of vertebral rotation or site of instrumentation. Neurological complications were not noted in any of the cases. In our mind the risk of pedicle screw threaded curve correction and fusion in scoliosis surgery in the hands of an experienced spine surgeon is calculated acceptably low.

Bone Screws↗

PubMedDate not supplied

[Thoracoscopic interventions in deformities of the thoracic spine].

AIM OF THE STUDY: We prospectively studied 9 patients with deformities of the thoracic spine who underwent thoracoscopic surgery to critically evaluate the benefits and limitations of thoracoscopy. METHODS: Seven patients with deformities of the thoracic spine (5 scoliosis, 2 kyphosis) underwent a thoracoscopic release and posterior correction and fusion in a single stage. In one case of a crankshaft-phenomenon a thoracoscopic epiphyseodesis und in another case of a posttraumatic kyphosis a thoracoscopic instrumentation and fusion were performed. The average age was 21 years, the follow-up was 18 months with a minimum of 12 months. The perioperative data including complications were collected and a radiographic analysis concerning curve correction was carried out. RESULTS: The scoliotic curves measured preoperatively 84 degrees on average with a Cobb angle of 62 degrees on the traction films and were corrected by 57% to averagely 36 degrees at follow-up. In the two cases of Scheuermann kyphosis a preoperative kyphosis of 94 degrees respectively 82 degrees was corrected to 52 degrees respectively 58 degrees. Between 4 and 5 discs were excised with an average operative time of 160 min and a blood loss of 380 ml. A conversion to open thoracotomy was not necessary in any case. There were no intraoperative neurovascular complications. CONCLUSIONS: Thoracoscopic procedures in deformities of the thoracic spine are technically demanding; however, it is a minimally invasive procedure with a reduced approach-related morbidity compared to open thoracotomy. The indications for a thoracoscopic release are rigid kyphosis and scoliosis with rigid curves between 80 and 90 degrees Cobb angle in which an anterior correction and instrumentation alone is not considered.

Adolescent↗

PubMedDate not supplied

[Halm-Zielke instrumentation (Munster Anterior Double Rod System) as an improvement over Zielke-VDS. Surgical method and preliminary results].

INTRODUCTION AND AIM OF THE STUDY: Halm-Zielke Instrumentation (HZI), in german speaking countries also named the Münster Anterior Doublerod System, was developed to eliminate the disadvantage of VDS-Zielke in terms of lack of primary stability. Additionally sagittal plane control should be improved. Within a prospective clinical trial it was examined, if HZI fulfilled these demands. METHODS: HZI is an anterior doublerod system with a two screw per vertebral body fixation. The longitudinal components consist of a threaded VDS-rod and a solid rod. 12 consecutive patients with idiopathic scoliosis and curves ranging from 36 degrees to 77 degrees were treated with HZI. RESULTS: Correction of the frontal plane averaged 75% and 73.8% postoperatively and at follow-up, respectively. Derotation averaged 49.3%. Thoracolumbar kyphosis was present in four patients and always completely corrected. Implant related complications were not noted. All patients were treated without any additional external immobilisation. CONCLUSION: The aim of improvement of VDS in terms of primary stability and control or improvement of the sagittal plane was completely achieved.

Adolescent↗

PubMedDate not supplied

[The use of massive allograft in reconstruction following resection of bone tumors of the extremities].

Reported are indications, techniques and clinical outcome of 45 patients with resection of a primary malignant or aggressive benign tumor of the extremities, reconstructed with an allograft. The goal of this procedure is to achieve a wide resection of the tumor and to reconstruct the defect saving the limb. Bridging the osseous defect, we used an osteochondral allograft (14), intercalary allograft (16), allograft arthrodesis (14) and composite reconstruction (1). There were 3 deep infections, 3 superficial infections, 2 pseudarthrosis and 1 rejection found as complications. After local revision of the infections by allograft explantation and temporary implantation of antibiotic-loaded chains, another allograft could be implanted with success. Using different, individual adapted operative methods and allografts, a broad spectrum of bone defects after resection of bone tumors and, if necessary revisions, can be treated.

Adolescent↗

PubMedDate not supplied

[The value of ultrasound in evaluating instabilities of the glenohumeral joint].

In a prospective study we evaluated diagnostic ultrasound investigation for shoulder instabilities. We measured the passive aptranslation In 150 healthy persons in relation to the dorsal glenoid as well as the inferior subluxation in relation to the acromion. After establishing normative datas we measured 23 patient with unidirectional instabilities and 34 with multidirectional instabilities. The humeral head position of a normal joint is 8 to 10 mm dorsally to the glenoid. In the control group the anterior translation of the dominant shoulder is significantly higher as in the nondominant shoulder (student-t-test; p less than 0.0045). Patients with anterior instabilities showed a significant increase of anterior translation in the injured shoulder (student-t-test; p less than 0.0001). In comparison with the control group there is a significant increase of downward subluxation in patients with multidirectional instabilities (chi 2 alpha less than 0.05). In habitual or voluntary dislocations the relation of the humeral head to the glenoid can be judged statically and dynamically. Secondary signs of dislocation (Hill-Sachs lesions, joint effusion) are evident.

Adolescent↗

PubMedDate not supplied

[Changes in the lumbar intervertebral disk following use of the Holmium-Yag laser--a biomechanical study].

For a biomechanical study 10 specimen of the lumbar spine (L1-S1) were scanned with MRI. After that 18 normal motion segments were prepared for the experiments. The paraspinal musculature as well as the posterior elements were removed. Under an axial load of 500 N, in each disc 500 J and 1000 J of energy were applicated with a Holmium-Yag laser (2060 nm, fiber thickness 600 microns) into the nucleus pulposus. In nine of the 18 discs also 1500 J and 2000 J were applicated. At the beginning of every standardized experiment of a motion segment, as well as after every 500 J, the height of the disc, intradiscal pressure, the contour of the disc and the size of the transversal plane of the disc were determined with an axial load on the motion segment of 1000 N. The change in radial bulging of the disc was measured using the computer-assisted recordings of each disc contour. All the data were statistically analyzed using the Friedman-/Wilcoxon-test. After every application of 500 J energy, in the 18 discs as well as in the 9 discs, the height and the intradiscal pressure reduced. The differences per 500 J were for all measurements not significant (p < 0.05). Up till the application of 1500 J the radial bulge and the size of the transversal plane of the disc increased, although the differences per 500 J were not significant. From 1500 J to 2000 J the radial bulge and size of transversal plane of the disc decreased.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗