The development of whole blood titanium levels after instrumented spinal fusion - is there a correlation between the number of fused segments and titanium levels?

Most modern spinal implants contain titanium and remain in the patient's body permanently. Local and systemic effects such as tissue necrosis, osteolysis and malignant cell transformation caused by implants have been described. Increasing tissue concentration and whole blood levels of ions are necessary before a disease caused by a contaminant develops. The aim of the present study was the measurement of whole blood titanium levels and the evaluation of a possible correlation between these changes and the number of fused segments.A prospective study was designed to determine changes in whole blood titanium levels after spinal fusion and to analyze the correlation to the number of pedicle screws, cross connectors and interbody devices implanted.Blood samples were taken preoperatively in group I (n = 15), on the first, second and 10th day postoperatively, as well as 3 and 12 months after surgery.Group II (n = 16) served as a control group of volunteers who did not have any metal implants in the body. Blood samples were taken once in this group.The number of screw-rod-connections and the length of the spinal fusion were determined using radiographic pictures. This study was checked and approved by the ethical committee of the University of Tuebingen.The mean age in group I was 47 ± 22 years (range 16 - 85 years). There were three male (20%) and twelve female (80%) patients. The median number of fused segments was 5 (range 1 to 11 segments).No statistically significant increase in the titanium level was seen 12 months after surgery (mean difference: -7.2 ?g/l, 95% CI: -26.9 to 12.5 ?g/l, p = 0.446). By observing the individual titanium levels, 4 out of 15 patients demonstrated an increase in titanium levels 12 months after surgery.No statistically significant correlation between fused segments (r = -0.188, p = 0.503) length of instrumentation (r = -0.329, p = 0.231), number of interbody devices (r = -0.202, p = 0.291) and increase of titanium levels over the observation period was seen.Instrumented spinal fusion does not lead to a statistically significant increase in whole blood titanium levels. There seems to be no correlation between the number of pedicle screws, cross connectors and interbody devices implanted and the increase of serum titanium levels

Indications for total hip arthroplasty in young adults - idiopathic osteoarthritis seems to be overestimated.

New aspects like acetabular overcoverage, acetabular retroversion and proximal femoral head-neck dysplasia have been detected as a main cause of osteoarthritis. The study addresses the detection of reasons for osteoarthritis requiring THA in young adults. We wanted to prove the hypothesis that idiopathic reasons play an overestimated role in osteoarthritis in young patients.228 total hip arthroplasties in patients aged <= 60 years were performed at our institution. After the detection of the primary reasons for osteoarthritis of the hip, the radiographic pictures of all other patients were analyzed for radiographic signs of hip dysplasia or femoroacetabular impingement. For interobserver quality testing, this was done by two different observers.132 patients were initially classified as having idiopathic osteoarthritis of the hip. There was no pathological radiographic finding in only 5 patients. 80 patients presented a reduced head-neck offset as a sign of CAM impingement with a mean head ratio of 1.52 ± 0.35 and an alpha angle of 62.8 ± 9.28°. 21 patients presented a figure-8 sign as an indicator for acetabular retroversion. 68 patients presented at least one radiographic finding for "dysplasia" and 60 patients at least one radiographic finding for excessive "overcoverage". The Bland-Altman Plot for testing interobserver reliability demonstrated good interobserver agreement.Idiopathic OA in young adults is rare if you look hard enough for the underlying pathology. If treated, patients might benefit and THA could be postponed for several years

A classification-system improves the intra- and interobserver reliability of radiographic diagnosis of "pistol-grip-deformity".

Early detection of pistol-grip-deformity may be beneficial in optimising the outcome and the cost effectiveness of surgery. It is important to identify reliable radiographic parameters in assessing femoro-acetabular impingement (FAI) to develop a treatment algorithm. Radiographs of 47 patients ranging from "pistol grip deformity" to a normal head-neck-junction were measured for alpha angle and head ratio, and then classified by two different observers. The Bland-Altman plot was used for inter- and intraobserver agreement of alpha angle and head ratio. Inter- and intraobserver agreement for classification of "pistol grip deformity" was determined using weighted Cohen's kappa coefficient. Observer I achieved a kappa coefficient of 0.97. Observer II achieved a kappa coefficient of 0.92. An interobserver kappa coefficient between 0.87 and 0.92 was achieved by using a classification system. By testing for interobserver agreement, a bias of -0.004 with an upper limit of 0.461 and a lower limit of -0.47 was seen for the ratio and a bias of -3.7 with an upper limit of 17.2 and a lower limit of -24.6 for the alpha angle. Therefore, poor results were seen for intra- and interobserver reliability by using only a single plane for classification of "pistol grip deformity". The strength of agreement could be improved by using a classification system (based on two planes)

The influence of ibandronate treatment on bone density and biochemical bone markers in patients with osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is characterized by different signs including increased bone fragility, short stature, blue sclera, abnormal tooth growth and often secondary immobility. No curative therapy has been found for this rare disease up to now, and different pharmacological substances have been tried as treatment for severe forms of OI. Promising results were seen with intravenous bisphosphonates in the treatment of patients with OI. The aim of present study was to show the effect of intravenous ibandronate therapy on bone density and bone metabolism markers. We analyzed the data of 27 patients with the diagnosis of OI who were treated off-label with intravenous ibandronate. Ibandronate was administered by intravenous infusion every three months at a dosage of 0.3-2 mg. Bone turnover markers and bone density were measured before starting therapy and every three months during treatment. Bone density was measured by using an ultrasound imaging system providing an accurate image of the calcaneus and by evaluating broadband ultrasound attenuation (BUA). Twenty-seven patients were treated with intravenous ibandronate during the observation period. 18 were female. The mean age of all patients was 23.9 years ± 19.6 (range 4-63). Seventeen patients were categorized to have OI Type I, 5 patients to have OI Type III and 5 patients to have OI Type IV. There was a statistically significant decrease in total alkaline phosphatase (P<0.0001). We detected also a statistically significant decrease in the ratio urinary deoxypyridinoline/urinary creatinine (P=0.0048) and the ratio urinary pyridinoline/urinary creatinine (P<0.0001) respectively. There was also a statistically significant increase in serum magnesium (P=0.034) and BUA (P=0.0071). No statistically significant changes were seen for total serum calcium (P=0.16), the ratio of urine calcium/urine creatinine (P=0.29), alkaline phosphatase (isoform bone) (P=0.3), procollagen-I-peptide (P=0.5), osteocalcin (P=0.9), serum phosphatase (P=0.71), parathormone (P=0.11) and the ratio urine phosphatase/urine creatinine (P=0.58) Therapy with ibandronate in patients with OI leads to a normalisation of bone turnover markers and increasing bone density. Therefore serum alkaline phosphatase and bone density are possible parameters to monitor bisphosphonate treatment in patients with OI

Clear-cell sarcoma of the soft tissue - a rare diagnosis with a fatal outcome.

IPACH I., MITTAG F., KOPP H.-G., KUNZE B., WOLF P. & KLUBA T. (2012) European Journal of Cancer Care21, 412-420 Clear-cell sarcoma of the soft tissue - a rare diagnosis with a fatal outcome Clear-cell sarcomas account for less than 1% of all soft tissue tumours. They most often occur in middle-aged adults as a deeply located lesion with predilection to the tendons and aponeuroses. The aim of the present study was to show possible influencing factors on the outcome after surgical treatment in a detailed case series. We reviewed the medical records of 11 patients with the diagnosis of a clear-cell sarcoma of the soft tissue. These cases were analysed with regard to age, gender, localisation, tumour size, recurrence free survival and overall survival. A minimum follow up of 12 months was achieved. The mean age at the point of diagnosis was 47.9 years. Metastases occurred after a mean of 19.2 months. In the cases with a tumour diameter >5 cm, metastases occurred earlier. When treated in a specialist centre, metastases occurred later. Patients died a mean of 18.4 months after developing metastatic disease. Patients with tumour size >5 cm at the point of primary diagnosis died earlier than patients with a tumour size <5 cm. It is important to detect clear-cell sarcomas as soon as possible and the final surgical treatment should be performed in a centre familiar with the treatment of soft tissue tumours not only to prolong overall survival, but also to treat the patient in a multiprofessional team

A New Classification for "Pistol Grip Deformity"-Correlation Between the Severity of the Deformity and the Grade of Osteoarthritis of the Hip.

PURPOSE: Two types of femoroacetabular impingement (FAI) are described as reasons for the early development of osteoarthritis of the hip. Cam impingement develops from contact between an abnormal head-neck junction and the acetabular rim. Pincer impingement is characterized by local or general overcoverage of the femoral head by the acetabular rim. Both forms might cause early osteoarthritis of the hip. A decreased head/neck offset has been recognized on AP pelvic views and labeled as "pistol grip deformity". The aim of the study was to develop a classification for this deformity with regard to the stage of osteoarthritis of the hip. MATERIALS AND METHODS: 76 pelvic and axial views were analyzed for alpha angle and head ratio. 22 of them had a normal shape in the head-neck region and no osteoarthritis signs, 27 had a "pistol grip deformity" and osteoarthritis I and 27 had a "pistol grip deformity" and osteoarthritis II°-IV°. The CART method was used to develop a classification. RESULTS: There was a statistically significant correlation between alpha angle and head ratio. A statistically significant difference in alpha angle and head ratio was seen between the three groups. Using the CART method, we developed a three-step classification system for the "pistol grip deformity" with very high accuracy. This deformity was aggravated by increasing age. CONCLUSION: Using this model it is possible to differentiate between normal shapes of the head-neck junction and different severities of the pistol grip deformity

The prevalence of acetabular anomalies associated with pistol-grip-deformity in osteoarthritic hips.

Acetabular retroversion, excessive acetabular coverage and abnormal head-neck-junction with a so-called "pistol-grip-deformity" were added to the classical description of hip dysplasia to describe pathological hip morphology. The aim of the current study was the detection of pathological acetabular geometry in patients with an abnormal head-neck-junction.Femoroacetabular impingement and hip dysplasia features are frequent in patients with end-stage osteoarthritis before 60 years of age.We analysed our data bank retrospectively for all patients who received a Total Hip Arthroplasty (THA) due to end-stage osteoarthritis before the age of 60 years. The pelvic-views and the Dunn-view of these patients were screened for an abnormal head-neck-junction by measuring the head-ratio and the alpha-angle. An orthopaedic surgeon and a radiologist did this independently. These radiographies were measured for signs of acetabular dysplasia, excessive acetabular coverage and crossing sign.A consecutive series of 135 total hip arthroplasties were performed in patients aged less or equal to 60 years because of end-stage osteoarthritis. From these, 81 patients were classified as having an abnormal head-neck-junction. The mean head-ratio in these 81 patients was 1.52±0.35, the mean alpha-angle was 62.5°±9.3°. The mean CE-angle of these 81 patients was 35.8°±10.4°, the mean CA-angle was 36.7°±5.7°, the mean depth-width ratio was 49.1±10, the mean extrusion index was 19.1±9.2 and the mean CCD-angle was 131.7°±7.3°. Of these 81hips, 14 had isolated pistol-grip-deformity, while 11 hips had associated dysplasia, 38 had excessive acetabular coverage, and 14 had crossing sign. In addition, a crossing sign was identified in four of the 11 dysplastic hips and 19 of the 38 of the hips having excessive acetabular coverage. There was no statistically significant difference in regard to the age between the four groups (P=0.087). In contrast, the hips that had excessive acetabular coverage had increased CE-angle (44.6°±7.2°) and decreased extrusion index (12.6±6.5) (P<0.001), while dysplastic hips had increased roof obliquity (17.5°±4.5°) and increased extrusion index (29.6±9.1), as well as decreased CE-angle (20.7°±3.0°) (P<0.001).There is a high coincidence of radiographic findings associated with an abnormal head-neck-junction consisting in excessive acetabular coverage and retroversion as well as hip dysplasia. These results advocate for restoring of the normal anatomy at the early stage to prevent end-stage osteoarthritis.Level IV retrospective historical study