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PubMed1975

[Disturbances of venous flow (author's transl)].

1. Local rupture of the veins by fracture. Compression and local spiral thrombi. 2. Failure of the venous pump at the ankle joint due to immobilization. 3. Failure of the pump in the calf muscles, leading to propagation of thrombi in the venae gastrocnemiae and in the veins of the soleus muscle, frequently with varicosity. 4. In 22 percent of left-sided fractures a venous spur is found in the left V. iliaca com.; increased likelihood of thrombosis in left leg in case of stasis due to immobilization.

Femoral Fractures↗

PubMed2006

Treatment of children with osteogenesis imperfecta.

Children with moderate to severe forms of osteogenesis imperfecta (OI) require adequate physiotherapy, rehabilitation and orthopedic surgery. Supportive treatment with bisphosphonates can improve the effects of these nonmedicinal treatment modalities. Benefits of bisphosphonate treatment include decreased pain, lower fracture incidence, and better mobility. Among the various bisphosphonates, intravenous pamidronate has been studied in most detail. However, the optimal treatment regimen and the long-term consequences of pamidronate treatment in children are currently unknown. Given these uncertainties, treatment with bisphosphonates during growth should be reserved for patients who have significant clinical problems, such as vertebral compression fractures or long-bone deformities. Medical therapies other than bisphosphonates play a minor role at present. Gene-based therapy currently remains in the realm of preclinical research.

Adolescent↗

PubMed2005

Vertebroplasty and kyphoplasty: a comprehensive review.

Vertebroplasty and kyphoplasty are relatively new techniques used to treat painful vertebral compression fractures (VCFs). Vertebroplasty is the injection of bone cement, generally polymethyl methacrylate (PMMA), into a vertebral body (VB). Kyphoplasty is the placement of balloons (called "tamps") into the VB, followed by an inflation/deflation sequence to create a cavity prior to the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The mechanism of action is unknown, but it is postulated that stabilization of the fracture leads to analgesia. The procedures are indicated for painful VCFs due to osteoporosis or malignancy, and for painful hemangiomas. These procedures may be efficacious in treating painful vertebral metastasis and traumatic VCFs. Much evidence favors the use of these procedures for pain associated with the aforementioned disorders. The risks associated with the procedures are low but serious complications can occur. These risks include spinal cord compression, nerve root compression, venous embolism, and pulmonary embolism including cardiovascular collapse. The risk/benefit ratio appears to be favorable in carefully selected patients. The technical aspects of the procedures are presented in detail along with guidelines for patient selection. A comprehensive review of the evidence for the procedures and the reported complications is presented.

Humans↗

PubMed2006

Treatment for myeloma bone disease.

Multiple myeloma (MM) is a B cell malignancy characterized by enhanced bone loss commonly associated with diffuse osteopenia, focal lytic lesions, pathologic fractures, hypercalcemia, and bony pain. Bone destruction in MM results from asynchronous bone turnover wherein increased osteoclastic bone resorption is not accompanied by a comparable increase in bone formation. Consequently, patients with MM frequently require radiation therapy, surgery, and analgesic medications. The recent development of minimally invasive surgical procedures such as kyphoplasty allows patients with myeloma with vertebral compression fractures to have immediate improvement in their quality of life with shorter hospital stays. Bisphosphonates are specific inhibitors of osteoclastic activity, and these agents have been evaluated in patients with MM with bone disease during the past 15 years. Monthly i.v. infusions of either pamidronate or zoledronic acid have reduced the skeletal complications among patients with MM and are now a mainstay of myeloma therapy. Orally administered bisphosphonates, in contrast, have shown little ability to slow the development of skeletal complications in these patients. Although preclinical studies suggest that nitrogen-containing bisphosphonates have potent antitumor effects, clinical trials will be necessary, probably at higher doses given more slowly, to establish their possible antitumor effects clinically. Moreover, recent advances in the use of bone-seeking radiopharmaceuticals make these attractive therapeutic candidates to combine with bisphosphonates or radiosensitizing drugs (e.g., bortezomib) to achieve a synergistic effect. As our understanding of the pathophysiology of myeloma bone disease continues to grow, new target therapies will continue to emerge, offering new and more advanced options for the management of myeloma bone disease.

Animals↗

PubMed1997

[Malignoma versus bacterial spondylodiscitis: value of spinal MRI for the differential diagnosis in an emergency situation. Description in an acute case with progressive paraplegia].

BACKGROUND: For the radiation oncologist in an emergency situation with acute progressive paraplegia distinguishing between benign versus malignant vertebral compression fracture without known malignoma may cause a severe diagnostic problem, when a rapid therapeutic decision is required. PATIENT AND METHOD: A case of an elderly diabetic patient with acute onset of a progressive neurologic deficit is reported. No malignancy was known so far. The CT of the spine showed a destruction of the 7th and 8th thoracic vertebral body with compression of the spinal cord. The patient was referred to the radiotherapist for radiation of a presumed malignant spinal process. RESULT: For differential diagnosis a magnetic resonance imaging (MRI) of the spine was performed and could lead to the correct diagnosis of an infectious spondylodiscitis. CONCLUSION: The MRI of the spine has a potential role for correct differentiation between benign and malignant spinal lesions and may thereby assist the radiotherapist in the decision making in an emergency situation.

Aged↗

PubMed2003

Vertebroplasty and kyphoplasty for osteolytic vertebral collapse.

As many as 70% of patients with cancer and multiple myeloma initially present with osteolytic involvement of the spine. These vertebral fractures are associated with significant morbidity and mortality and represent a tremendous personal and societal burden. Traditional medical and surgical options often are inadequate or too invasive for this population debilitated by cancer. Vertebroplasty involves the injection of polymethylmethaerylate to strengthen a vertebra. This minimally invasive method, which has been adopted by practitioners during the past decade to treat symptomatic osteoporotic compression fractures is reported to provide quick pain relief in 90% of patients, with only infrequent, mostly minor, complications. In patients with osteolytic fractures, vertebroplasty is associated with an increased rate of cement leak and less predictable pain relief. Kyphoplasty is an extension of vertebroplasty that uses an inflatable bone tamp to restore the vertebral body toward its original height while creating a cavity to be filled with bone cement. Preliminary data indicate that kyphoplasty is a safe procedure associated with a lower risk of cement leak, restoration of vertebral body height, and sagittal spinal alignment. In patients with osteolytic fractures secondary to multiple myeloma, kyphoplasty yields quick pain relief, and is associated with a statistically significant improvement in generic health outcome measures.

Bone Cements↗

PubMed1997

High incidence of significant bone loss in patients with severe congenital neutropenia (Kostmann's syndrome).

OBJECTIVE: Clinical observation of bone pain, unusual fractures in two patients, and diffuse osteopenia/osteoporosis led us to assess bone mineral content and density in 30 patients with severe congenital neutropenia who were treated with recombinant-methionyl-human granulocyte colony-stimulating factor (r-metHuG-CSF). STUDY DESIGN: We reviewed roentgenograms in 29 of these 30 patients to evaluate bone loss before and during treatment. In addition, in 17 of the 30 patients, bone mineral status could be assessed by both quantitative computed tomography (Q-CT; n = 16) and dual energy x-ray absorptiometry (DXA; n = 1). In one patient, Q-CT was not possible because of severe vertebral fractures. RESULTS: Of the 30 patients investigated, 15 had evidence of osteopenia/osteoporosis observed on spine radiographs (n = 5), on Q-CT/DXA (n = 1/n = 1), or on radiographs and Q-CT (n = 8). In 13 of the 30 patients, only a lateral radiograph of the lumbar spine was available, 5 of 13 showing either increased kyphosis and wedging of the vertebrae or compression fractures of the vertebral bodies, indicating severe established osteoporosis. In eight patients, the findings of the spinal radiographs were normal. In nine patients, spinal radiographs were taken before r-metHuG-CSF treatment. Osteoporotic vertebral deformation (n = 3) or reduced bone mass (n = 3) was seen in six of these nine patients. The levels of serum biochemical markers of bone metabolism were all within normal ranges except for mild elevation of the serum alkaline phosphatase level. The degree of spinal bone mineral loss did not correlate with dose and duration of r-metHuG-CSF treatment or with the age or sex of the patients. CONCLUSIONS: These data indicate a high incidence of bone mineral loss in children with severe congenital neutropenia. The underlying pathogenesis of bone demineralization is not clear. It is more likely that the bone loss was caused by the pathophysiologic features of the underlying disease, but it is possible that r-metHuG-CSF accelerates bone mineral loss.

Adolescent↗

PubMed1976

Fractures of the dorsal and lumbar spine.

A study of 60 children with thoracic and lumbar spine injuries indicates that the child's response to trauma is unique. It is concluded that the potential for growth and development and the presence of healthy tissues separate these injuries from comparable injuries in adults. The epiphyseal growth partly or completely restores vertebral body height, leads to a mild spinal deformity in stable injuries, and can contribute to rapidly progressive spinal deformity in unstable injuries with or without paralysis. Healthy intervertebral discs account for the multiple compression fractures and lack of long term degenerative changes of the spine. On the basis of this review, a practical approach to patient care is presented.

Adolescent↗

PubMed2000

Osteoporosis management in long-term care. Survey of Ontario physicians.

OBJECTIVE: To survey physicians in Ontario regarding their approach to diagnosis and treatment of osteoporosis among residents of long-term care facilities. DESIGN: Mailed questionnaire covering physician demographics; current clinical practice relating to osteoporosis; and perceived barriers to prevention, diagnosis, and treatment of the disease. SETTING: Long-term care facilities in Ontario. PARTICIPANTS: Medical directors of long-term care facilities. MAIN OUTCOME MEASURES: Demographic variables; physician attitudes; and practices concerning awareness, diagnosis, and treatment of osteoporosis. RESULTS: Respondents returned 275 of 490 questionnaires, for a response rate of 56.1%. Most respondents (92.4%) were family physicians; 28.7% were caring for more than 100 patients in long-term care. Most (85.8%) saw from one to 10 hip fractures yearly in their practices. Although 49.6% of respondents estimated the prevalence of osteoporosis to be 40% to 80% among their long-term care patients, 45.5% said that they did not routinely assess their patients for the disease, and 26.8% do not routinely treat it. Half (50.9%) of physicians would treat patients at high risk based on clinical history; 47.9% if patients had a vertebral compression fracture on plain x-ray examination; 43.8% if patients were highly functional; 42.0% if osteoporosis were confirmed with bone mineral densitometry; and 30.0% if patients had a recent fracture. Perceived barriers to initiating treatment included cost of therapy, patient or family reluctance to accept therapy, and time or cost of diagnosis. CONCLUSION: Although physicians are aware that patients in long-term care facilities are at high risk for osteoporosis and hip fractures, the disease remains underdiagnosed and undertreated.

Aged↗

PubMed2006

The biomechanics of 1, 2, and 3 levels of vertebral augmentation with polymethylmethacrylate in multilevel spinal segments.

STUDY DESIGN: Experimental biomechanics of multilevel segments with 0, 1, 2, and 3 vertebral levels of polymethylmethacrylate augmentation. OBJECTIVE: To compare multilevel spinal segments with different numbers (0, 1, 2, and 3) of vertebral levels augmented with polymethylmethacrylate. SUMMARY OF BACKGROUND DATA: The stiffness and strength of single-level polymethylmethacrylate augmentations in individual and multilevel vertebrae treated by kyphoplasty and vertebroplasty have been studied, but the biomechanics of multilevel segments with more than 1 vertebral level augmented with polymethylmethacrylate are lacking, yet this is clinically relevant in multilevel compression fracture treatment. MATERIALS AND METHODS: A total of 48 multilevel segments (T3-T5, T6-T8, T9-T11, T12-L2, and L3-L5) from 12 spines with known bone mineral density (BMD) were allocated into 6 groups based on the number of vertebral levels augmented: 0 levels (n = 13), control group; 1 level (n = 7), group 2; 2 levels, groups 3, 4, and 5 (n = 7 in each); and 3 levels (n = 7), group 6. They were compressed to failure, disarticulated into individual vertebrae, and retested. Stiffness and strength were statistically analyzed using a univariate analysis of variance comparing the main effects, using least significant difference comparisons with 0.05 probability level. RESULTS: Strength was dependent on BMD (P < 0.001 multilevel segments, P < 0.001 individual vertebrae), with no differences among the 6 different augmentation groups, and no significant differences between augmented and nonaugmented individual vertebrae. Stiffness was dependent on BMD (P = 0.009 multilevel segments, P < 0.004 individual vertebrae), with no significant differences among the 6 different augmentation groups, and no significant differences between augmented and nonaugmented individual vertebrae. CONCLUSIONS: Multilevel segment biomechanics are dependent on BMD and not the pattern of augmentation, so the augmentation of fractured vertebrae can be extended to adjacent levels at risk for fracture to maintain stiffness and strength, thus preventing further fractures.

Aged↗

PubMed2005

Severe thoracic kyphosis in the older patient in the absence of vertebral fracture: association of extreme curve with age.

BACKGROUND AND PURPOSE: Limited data exist on the natural history of thoracic kyphosis in elderly patients. The purpose of this study was to determine the statistical distribution of the thoracic kyphotic angle (TKA) measurement in older patients without vertebral body abnormalities when compared with a young population. METHODS: The TKA was measured by Cobb angle on digital lateral chest radiographs in 90 patients >65 years of age, 60 patients 51-65 years of age, 67 patients 36-50 years of age, and 63 patients 18-35 years of age. Patients with vertebral compression, vertebral body angulation, congenital anomaly, or significant scoliosis were excluded. RESULTS: In patients >65 years of age, average TKA was 41.9 degrees , but the distribution was unexpectedly bimodal, with a low mode at 28.3 degrees and an upper mode at 51.5 degrees (P < .001). Elderly women and men independently demonstrated a bimodal TKA distribution. Two-thirds of elderly women and half of elderly men had a TKA >40 degrees (upper mode). In young patients, average TKA was 26.8 degrees . In middle-aged patients, TKA was intermediate and nonbimodal. CONCLUSION: The TKA distribution in elderly patients (>65 years) without vertebral body abnormality is unexpectedly bimodal (non-normal distribution) with a subpopulation of patients significantly more affected by extreme kyphosis. Extreme thoracic kyphosis therefore occurs independently in a large subset of people, in the absence of vertebral wedge compression. The development of extreme thoracic kyphosis might contribute to excess biomechanical stress in the spine and may identify a population at risk for future vertebral compression fracture in particular at the thoracolumbar junction.

Adult↗

PubMed2007

Transoral vertebral augmentation with polymethylmethacrylate in the treatment of a patient with a dens fracture nonunion and subarticular vertebral body fracture of C2.

The injection of polymethylmethacrylate (PMMA) is a minimally invasive, image-guided procedure used to treat vertebral fractures due to osteoporosis, metastatic lesions, multiple myeloma, and benign but destabilizing bone tumors. The injection of PMMA into the C2 vertebral body using the transoral technique has been reported in three separate patients for treatment of benign tumors (a vertebral hemangioma and an aneurysmal bone cyst) and for multiple myeloma in the third patient. Although the injection of PMMA into the vertebral body is most commonly performed to treat benign vertebral compression fractures, a transoral C2 approach has not been reported in the English literature as a treatment for a benign fracture of C2. We report the treatment of a fracture and nonunion of the base of the dens and a subarticular fracture of the vertebral body of C2 using a bilateral transoral approach.

Aged, 80 and over↗

PubMed2005

The optimisation of the initial viscosity of an encapsulated glass-ionomer restorative following different mechanical mixing regimes.

OBJECTIVES: An optimisation of the mixing ratio of an encapsulated glass-ionomer restorative in terms of compressive strength, working characteristics and pore distribution following mechanical mixing with different mixing machines was undertaken. METHODS: Mean compressive fracture strengths, standard deviations and associated Weibull Moduli (m) were determined from series of 30 encapsulated specimens with varying powder/liquid mixing ratios. Working characteristics were assessed using an oscillating rheometer and scanning electron microscopy and image analysis was used to investigate the influence of the mixing ratios and mixing regime on the pore distribution. RESULTS: Cement mixing regime or reducing the powder/liquid mixing ratio did not have any significant influence on the compressive strength. Utilising the one-way ANOVA and Tukey test comparisons at P<0.05 the cement manipulation regime significantly increased the compressive strength on increasing the powder content of the capsule by 10% (G110) when a combination of rotational and centrifugal action rather than vibration were employed. Utilising a Rotomix at a powder content of G110 was beneficial in reducing porosity levels within the restorative investigated compared with a conventional mixing machine. Increasing the powder content reduced the working characteristics regardless of the mixing regime. SIGNIFICANCE: The increased reliability of encapsulated restoratives reported in the literature following mixing with a combination of rotational and centrifugal compared with vibrational action was only evident when the powder content of the restorative under investigation was increased by 10%. The finding suggests that the initial viscosity of the cement mass of the Ketac Fil Plus Aplicap as supplied by the manufacturer may not have been optimised.

Compressive Strength↗

PubMed2003

Influence of powder/liquid mixing ratio on the performance of a restorative glass-ionomer dental cement.

The influence of powder/liquid mixing regime on the performance of a hand-mixed restorative glass-ionomer cement (GIC) was evaluated in terms of compressive strength, working characteristics and the porosity distribution. Mean compressive fracture strengths, standard deviations and associated Weibull moduli (m) were determined from series of 20 cylindrical specimens (6mm height, 4mm diameter) prepared by hand-mixing the relative proportions of the powder and liquid constituents. Working characteristics were assessed using an oscillating rheometer whilst scanning electron microscopy and image analysis were used to investigate the influence of the mixing regime on pore distribution. For a constant volume of liquid (1ml) the mean compressive strength decreased from 102.1+/-23.1MPa for 7.4g of powder, to 93.8+/-22.9, 82.6+/-18.5 and 55.7+/-17.2MPa for 6.66, 5.94 and 3.7g of powder, respectively. A concomitant increase in both the working and setting times was also observed.GICs manipulated to a powder/liquid mixing consistency below the manufacturers' recommend ratio, for a constant volume of liquid, resulted in reduced porosity levels in the cement mass and extended working and setting times. Unfortunately, a reduction in the concentration of reinforcing glass particles in the set material below that specified by the manufacturers decreases the cements' load bearing capacity so that they fail at lower compressive stress levels in the posterior region of the mouth.

Biocompatible Materials↗

PubMed2003

The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit: finite-element analysis.

STUDY DESIGN: The effect of cement augmentation on an osteoporotic lumbar functional spinal unit was investigated using finite-element analysis. OBJECTIVE: To evaluate the influence of cement augmentation on load transfer, stresses, and strains. SUMMARY OF BACKGROUND DATA: Osteoporosis is the most frequent skeletal disease of the elderly, leading to weakness of the bony structures. Cement injection into vertebral bodies has been used to treat osteoporotic compression fractures of the spine. The clinical results are encouraging. Experimental biomechanical studies showed significant increases in stiffness and strength of treated bodies. However, little is known about the consequences for the adjacent, nontreated levels. METHODS: Three-dimensional finite-element models of L2-L3 were developed and the material properties adapted to simulate osteoporosis. The influence of augmentation level as well as uni- and bipedicular filling with polymethylmethacrylate were investigated. Compression, flexion, and lateral bending were simulated. RESULTS: Augmentation increased the pressure in the nucleus pulposus and the deflection of the adjacent endplate. The stresses and strains in the vertebrae next to an augmentation were increased, and their distribution was changed. Larger areas were subjected to higher stresses and strains. The treatment clearly altered the load transfer. Changes to the overall stress and strain distribution were less pronounced for unipedicular augmentation. CONCLUSIONS: Cement augmentation restores the strength of treated vertebrae, but leads to increased endplate bulge and an altered load transfer in adjacent vertebrae. This supports the hypothesis that rigid cement augmentation may facilitate the subsequent collapse of adjacent vertebrae. Further study is required to determine the optimal reinforcement material and filling volume to minimize this effect.

Biomechanical Phenomena↗

PubMed1989

Occult fracture-subluxation of the midtarsal joint.

In four women with occult fracture-subluxation of the midtarsal joint incurred in trivial accidents, the correct diagnosis was made promptly, assisted in one case by bone scintigraphy. Treatment was conservative, consisting of cast immobilization for six to eight weeks and a weight-bearing restriction. At the minimum follow-up time of 24 months, the functional results were rated good in three patients and fair in one. In the patient with a fair result, a compression fracture of the posterior facet of the calcaneus was diagnosed retrospectively. An occult fracture-subluxation of the mid-tarsal joint can be treated effectively by conservative means.

Adult↗

PubMed1991

[Technical measuring procedures for 3-dimensional movement analysis of experimentally-induced fractures of the thoracolumbar spine and initial results].

Biomechanics and motion following fractures of the thoracolumbar spine have not yet been clarified. The motion acts in 6 degrees of freedom: three rotations and three translations parallel to the system of coordinates. The problem is to measure each rotation and each translation individually. This requires a method allowing precise three-dimensional evaluation of the motion that takes place in the genesis of a spine fracture. This technique should not influence the experiment, should give exact data over a wide range of measurement and, finally, should require as little equipment as possible. To fulfil these conditions we have developed a "double cube" model. Cadaver spine units from T11 to L3 were used. T11 was blocked with T12 and L2 with L3. These blocks were used to fix the spine in a testing machine so that a wedge-compression fracture could be produced in L1. Dorsal to each of the blocks one cube was mounted, the caudal one fixed while the cranial one could be moved by the machine. In the caudal cube a right-handed cartesian system of coordinates was defined, in which the vertebrate above would move and break. This technique can be used to describe either physiological or fracture experiments or, for example, to compare stability tests for different fixation devices. It is demonstrated that precise three-dimensional description of the biomechanics of vertebral fractures is possible with little and simple equipment. The cubes in this model are easily to integrate in the experiment.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomechanical Phenomena↗

PubMed2006

[Balloon kyphoplasty in the therapy of vertebral fractures].

Approximately 500,000 vertebral fractures occur as a result of osteoporosis every year in Europe. One third of the patients thus affected complain of severe back pain and seek treatment. In the past, the treatment of such fractures was limited to conservative methods, such as the use of braces and analgesics and long-term immobilisation followed by physiotherapy. Since 1998 balloon kyphoplasty, a minimally invasive procedure, has also been available for their treatment. During balloon kyphoplasty a balloon system is introduced into a fractured vertebral body to achieve bitranspedicular augmentation, after which low-viscosity bone cement is injected into the vertebral body, where it sets very quickly. In general the patient can be fully mobilized 24-48 h after the procedure and in most cases the symptoms are then considerably attenuated; many patients are actually free of pain. Published studies and our own experience indicate that balloon kyphoplasty is a safe method of treating painful vertebral compression fractures sustained in various ways and that complications are rare with this procedure.

Bone Cements↗