There is an ongoing debate on which fixation technique should be preferred for the prophylactic fixation of the asymptomatic contralateral hip in slipped capital femoral epiphysis (SCFE). In the case of Kirschner-wire (K-wire) fixation, there is a possibility of secondary loss of fixation because of longitudinal growth of the physis, whereas in screw fixation, physeal growth of the femoral neck might be impaired. The aim of this matched-pair study was to compare the longitudinal growth of the femoral neck in screw fixation versus K-wire fixation of the asymptomatic contralateral hip in SCFE. All 18 patients (female:male=3:15), who had undergone screw fixation of the asymptomatic contralateral hip between 9/2001 and 9/2011, were matched according to age, bone age, sex, and time to follow-up to another 18 patients with K-wire fixation. The length of the femoral neck of the contralateral hip was measured in parallel to either screw or K-wire from the apex of the femoral head to the opposite cortical bone. The ratio of the femoral neck length measured directly after surgery and on follow-up was defined as femoral neck growth. There was no significant difference between groups with respect to age, modified Oxford Bone age score, and time to follow-up. We found a significant difference in femoral neck growth between patients with screw fixation (5.5 ± 4.3%) compared with K-wire fixation (8.9 ± 5.7%, P = 0.048 matched Wilcoxon test). The difference in femoral neck growth of patients with K-wire or screw fixation of the contralateral asymptomatic hip in SCFE was small, but statistically significant. Thus, despite high rates of secondary loss of fixation, K-wire fixation should still be considered, especially in very young patients.
Spinal infections are relatively rare entities but the incidence is significantly increasing due to the rapidly growing numbers of interventions on the spine. Primary infections of intervertebral discs (spondylodiscitis) and vertebral bodies (spondylitis) are distinguished from secondary postinterventional infections. Treatment relies primarily on either conservative or surgical management. In the absence of indications for surgery, a conservative approach is indicated when the patient is neurologically intact and the bony destruction is minimal. Conservative therapeutic options are based on the microbiological diagnosis and use of antibiotics, immobilization, analgesics and orthotics. Indications for a surgical intervention are the presence of neurological deficits, intraspinal abscesses, extensive osseous destruction and failure of conservative management. Surgical therapy focusses on the decompression of neural structures, debridement and eradication of the focus of infection, pathogen identification, correction of the deformity and restoration of a physiological spinal profile. Following a postoperative infection a timely diagnosis including assessment of the extent of infection is crucial. In the case of a purely superficial infection, antibiotic prophylaxis and close monitoring is indicated. If findings are pronounced surgical revision, debridement together with antibiotic therapy and if necessary vacuum-assisted closure as well as revision ranging from exchange of implants to complete removal of osteosynthetic material are required. Spinal infections are severe conditions frequently with residual long-term sequelae, whether the patients are managed conservatively or surgically.
Background: In 2005, the German Association of Occupational Accident Insurance Funds (DGUV) defined radiological evaluation criteria for the assessment of degenerative occupational diseases of the lumbar spine. These include the measurement of intervertebral osteochondrosis and classification of vertebral osteosclerosis, antero-lateral and posterior spondylosis, and spondyloarthritis via plain radiography. The measures currently remain in daily use for determining worker compensation among those with occupational diseases. Here, we aimed to evaluate the inter-and intraobserver reliability of these evaluation criteria. Methods: We enrolled 100 patients with occupational degenerative diseases of the lumbar spine. Native antero-posterior and lateral radiographs of these patients were evaluated according to DGUV recommendations by 4 observers with different levels of clinical training. Evaluations were again conducted after 2 months to assess the intra-observer reliability. Results: The measurement of intervertebral osteochondrosis showed good inter-observer reliability (ICC: 0.755) and excellent intra-observer reliability (ICC: 0.827). The classification of vertebral osteosclerosis exhibited moderate kappa values for inter-observer reliability (К: 0.426) and intra-observer reliability (К: 0.441); the remaining 3 criteria showed poor interand intra-observer reliabilities. Conclusion: The measurement of intervertebral osteochondrosis and classification of vertebral osteosclerosis showed adequate inter-and intra-observer reliability in the assessment of occupational diseases of the lumbar spine, whereas the classification of antero-lateral and posterior spondylosis and spondyloarthritis stage exhibited insufficient reliability. Hence, we recommend the revision of the DGUV recommendations for the evaluation of occupational diseases of the lumbar spine.
Zusammenfassung Hintergrund Störungen der Kopfgelenke – allen voran die Läsion der Ligg. alaria sowie die Blockierung des Atlas – werden insbesondere in der Laienpresse mit zahlreichen Symptomen assoziiert. Dementsprechend häufig werden Ärzte mit Patienten konfrontiert, die darin eine monokausale Ursache komplexer Beschwerden sehen und auf eine schnelle Lösung hoffen. Fragestellung Diese Übersicht stellt die aktuell verfügbare evidenzbasierte Literatur zu Atlasblockade und Lig.-alare-Läsion dar, um ihre Bedeutung differenziert einschätzen zu können. Material und Methoden Zusammenfassung und kritische Bewertung einer umfangreichen Literaturrecherche zu Diagnostik, Symptomatik und Therapie der Atlasblockade und Lig.-alare-Läsion. Ergebnisse Die Studienlage zeigt, dass Lig.-alare-Läsionen nur durch extreme Hochrasanztraumata entstehen und im MRT nur mit mäßiger Reliabilität nachgewiesen werden können. Da zudem in mehreren Studien kein Zusammenhang zwischen Symptomen und Auffälligkeiten im MRT gezeigt werden konnte, ist eine operative Stabilisierung der Kopfgelenke nicht indiziert. Die Vielzahl der Symptome bei Atlasblockade kann durch Konvergenz der Afferenzen C1–C3 auf verschiedene Hirnnervenkerne in neuroanatomischen Untersuchungen erklärt werden, der Zusammenhang ist jedoch bisher nicht bewiesen. Erste Studien zeigen eine hochsignifikante Besserung von zervikalen Schmerzen und Bewegungsumfang durch manualtherapeutische Lösung der Blockierung auch 6 Monate nach Behandlung. Schlussfolgerung Die Bedeutung der Lig.-alare-Läsion wurde in der Vergangenheit häufig überschätzt, diesbezüglich sollte dem Patienten ein differenziertes, multifaktorielles Krankheitsbild vermittelt werden. Die Atlasblockade ist in erster Linie als mögliche Ursache von Schmerzen und Bewegungseinschränkungen der Halswirbelsäule zu sehen, in diesem Kontext ist manuelle Therapie eine wirksame Option.
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