Do children with primary nocturnal enuresis have a retarded bone age? A cross‐sectional study

OBJECTIVE: Nocturnal enuresis is a common pediatric problem, the etiology of which is unclear. In recent years, various studies have been published stating that children with nocturnal enuresis exhibit growth and skeletal maturation retardation. METHODS: In this cross-sectional study, we included 27 patients (16 boys, 11 girls) between the ages of 6 and 14 years who had presented with primary nocturnal enuresis (PNE) complaints. We included in the evaluation 19 healthy subjects (12 boys, 7 girls), who were the siblings of the children with PNE, as the control group. RESULTS: The patients in both groups were similar in chronological age, bone age, height and weight, with no significant difference between groups (P>0.05). CONCLUSION: The two groups in our study consisted of the same genetic background. Thus, our results were found to be different from the previous studies. We have concluded that there is no direct relationship between enuresis nocturnal and skeletal maturation.     

Lumbosacral fracture dislocation in a lumberjack

Summary Lumberjack fractures normally occur in the thoracic and upper lumbar spine as a result of hyperextension and shear. This case, however, involves a lumberjack who suffered a lumbosacral fracture dislocation without neurological deficits, which occurred as the result of shear and hyperflexion. Due to the high degree of instability of this lesion, the treatment consisted of dorsoventral fusion with instrumentation.     

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.     

Halm-Zielke-Instrumentation als primärstabile Weiterentwicklung der Zielke-VDS bei idiopathischen Skoliosen

Halm-Zielke Instrumentation (HZI) was developed to eliminate the disadvantage of ventral derotation spondylodesis (VDS)-Zielke in terms of lack of primary stability and in order to simplify sagittal plane control. Within a prospective clinical trial started in 1993, we have studied whether HZI fulfills these demands. HZI is an anterior double-rod system with a two screw per vertebral body fixation. The longitudinal components consist of a threaded VDS rod and a solid rod, which are attached to a hinge-conducted lid plate. Twenty-nine consecutive patients with idiopathic scoliosis and curves ranging from 36 degrees to 92 degrees were treated with HZI. The follow-up period ranged from 1 to 4 years. Correction of the frontal plane within the instrumented levels averaged 71.6% and 70.5% postoperatively and at follow-up, respectively. Derotation averaged 53.7% and mean correction of the tilt of the lowest instrumented vertebra was 69.5% at final follow-up. Thoracolumbar kyphosis was present in eight patients and was always completely corrected from +18.8 degrees to 3.3 degrees on average. One implant-related complication involved a screw breakage 18 months postoperatively without adverse effects. There was no case of pseudoarthrosis. All patients were mobilized without any additional external immobilization in terms of a brace or cast, and were allowed to go swimming for physiotherapeutical purposes immediately after wound healing. This study proves that HZI is a primary stable implant to perform VDS. Implant-related disadvantages typical of VDS are eliminated. Thereby, the period of rehabilitation is shortened by many months due to avoidance of cast and brace treatment.     

Mechanism of antithrombin III inhibition of factor VIIa/tissue factor activity on cell surfaces. Comparison with tissue factor pathway inhibitor/factor Xa-induced inhibition of factor VIIa/tissue factor activity

Recent studies have shown that antithrombin III (AT III)/heparin is capable of inhibiting the catalytic activity of factor VIIa bound either to relipidated tissue factor (TF) in suspension or to TF expressed on cell surfaces. We report studies of the mechanism of which by AT III inhibits factor VIIa bound to cell surface TF and compare this inhibitory mechanism with that of tissue factor pathway inhibitor (TFPI)-induced inhibition of factor VIIa/TF. AT III alone and AT III/heparin to a greater extent reduced factor VIIa bound to cell surface TF. Our data show that the decrease in the amount of factor VIIa associated with cell surface TF in the presence of AT III was the result of (1) accelerated dissociation of factor VIIa from cell surface TF after the binding of AT III to factor VIIa/TF complexes and (2) the inability of the resultant free factor VIIa-AT III complexes to bind effectively to a new cell surface TF site. Binding of TFPI/factor Xa to cell surface factor VIIa/TF complexes markedly decreased the dissociation of factor VIIa from the resultant quaternary complex of factor VIIa/TF/TFPI/factor Xa. Addition of high concentrations of factor VIIa could reverse the AT III-induced inhibition of cell surface factor VIIa/TF activity but not TFPI/factor Xa-induced inhibition of factor VIIa/TF activity.     

Long-term results of quality of life in patients with idiopathic scoliosis after Harrington instrumentation and their relevance for expert evidence

AIM: The expert evidence of operated patients with idiopathic scoliosis is determined by functional and pulmonary restriction. The degree of deformity and the extent of fusion is crucial for grading disability. In a retrospective study on the quality of life (SF-36) and low back pain (Roland-Morris Score) of 82 patients (22 - 40 years) with idiopathic scoliosis treated with Harrington instrumentation the grading was registered. METHOD: An average of 16.7 years after the surgery, these data were correlated with the type and size of curve and to the extension of fusion. RESULTS: Compared to the age-matched healthy population, there was no significant difference in the physical SF-36 scale (P = 0.98). Surgically treated patients showed significantly lower scores than at baseline in the psychological SF-36 scale (P = 0.005). Sixty-five (79.3 %) of the eighty-two patients reported no or occasional back pain in the Roland Index. Five patients (6.1 %) complained of chronic back pain. 33 patients (40 %) were legally defined in their rate of disability as severely handicapped patients. The grading disability was associated with the physical SF-36 scale (P < 0.001) and the low back pain (P = 0.02). A significant correlation between the grading disability and the extent of fusion (P = 0.53) or the size of curve (p = 0.4) could not be proven. CONCLUSION: Despite good long-term outcomes, 40 % of operated treated patients with idiopathic scoliosis were legally defined as severely handicapped persons. The additional measurements of quality of life and low-back pain can improve legal assessment in orthopaedics.     

Pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine

While the biomechanical properties of pedicle screws have proven to be superior in the lumbar spine, little is known concerning pullout strength of pedicle screws in comparison to hooks in the thoracic spine. In vitro biomechanical pullout testing was performed to evaluate the axial pullout strength of pedicle screws versus pedicle and laminar hooks in the thoracic spine with regard to surgical correction techniques in scoliosis. Nine human cadaveric thoracic spines were harvested and disarticulated. To simulate a typical posterior segmental scoliosis instrumentation, standard pedicle hooks were used between T4 and T8 and supralaminar hooks between T9 and T12 and tested against pedicle screws. The pedicle screws were loaded strictly longitudinal to their axis; the hooks were loaded perpendicular to the intended rod direction. In total, 90 pullout tests were performed. Average pullout strength of the pedicle screws was significantly higher than in the hook group (T4-T8: 531 N versus 321 N, T9-T12: 807 N versus 600 N, p < 0.05). Both screw diameter and the bone mineral density (BMD) had significant influence on the pullout strength in the screw group. For scoliosis correction, pedicle screws might be beneficial, especially for rigid thoracic curves, since they are significantly more resistant to axial pullout than both pedicle and laminar hooks.