Abstract

An inadequate bucco-lingual and apico-occlusal dimension of the maxillary sinus, is a frequent anatomical restriction for the prosthetic rehabilitation of the posterior region of the upper jaw with implants. Various techniques have been proposed in order to accomplish the necessary bony dimension for the insertion of implants and for many years the surgical technique used for this operation involved a lateral approach, that caused quite a trauma to the patient and required certain technical skills from the surgeon because of its difficulties. In 1994 Summers introduced a new technique with a crestal approach, reducing the problems linked to this surgical procedure but still with some problems related especially to the big malleting. I started to study a new technique in 1990 testing from 1990 to 1993 various kind of drills and it was in 1994 that I finally put in practice my ideas and I created these new drills: in the same year I performed my first sinus lift with my technique. Using the consequential sequence of drills you slowly get closer and closer to the sinus membrane and the shape of the drill prevents the perforation of the membrane. In this way you can reach very easily the sinus membrane and then elevate the membrane with a special instrument (body lifting) pushes up the graft inward. From 1994 until 2002 625 cases of sinus lift were performed with a success rate of 97%. The most important advantages of this new surgical approach to the sinus membrane are that it is easy for a dentist to work with the hand-piece, no mallet, no hammering, the drill perforates but doesn't fracture and the membrane perforation is avoided by the stop and the special cutting angle on the drill. A relatively simple technique which let any dentist, without special surgical requirements, to perform the sinus lifting in its own office, with controlled risks and reduced trauma for the patients. (Presented at the 1303rd Meeting, December 13, 2002.)

Based on a three years clinical experience with a straight antegrade humeral interlocking nail a new nail has been developed for extended use in the treatment of displaced humeral head fractures of type NEER III to Neer IV and V with three or four parts. The upper portion of the nail serves as a central load carrier with threaded holes through which fixation screws are passed. These screws are anatomically positioned according to the main portions of the greater and lesser tubercle. The fixation of the main head fragments is noncompressive or diastatic in order to maintain the anatomic shape of the humeral head. Due to the thread the screws cannot glide or angulate inside the holes of the nail thus establishing a threedimensional rigid construct which allows both early active exercises and undisturbed endosteal healing. If the displaced tubercle is comminuted and unsuitable for direct screw fixation it is kept in place by a tension band suture which is anchored around the head of the corresponding screw. Until now we applied this nail on 193 patients. Due to several factors only 93 patients (72 women, 21 men with an average age of 68.1 years) could be included into a prospective univariate clinical cohort study in which we assessed the functional outcome according to the Constant Score (CS) at three, six and twelve months after the operation. The average CS was 58.7 pts at three months (n=93), 70.5 pts at six months (n=75) and 79.5 pts at 12 months (n=55). Since in elderly patients the normal shoulder function deteriorates progessively each CS was correlated to the contralateral side, resulting in a certain percentage of functional repair. The average functional result was 68.6% at three months, 78.8% at six months and 87% at twelve months. Beside 8.6% severe failures of our treatment ending in either secondary shoulder arthroplasty or in patient accepted poor shoulder function, another 26% minor difficulties occurred mainly consisting of intraarticular protrusion of the screws or of the nail. In these cases early partial or total removal of the implants had to be performed. This complication deteriorated the average functional result to 63.1% – which is still more than what we can expect with primary hemiarthroplasty – wheras the major group of uncomplicated cases achieved an almost complete functional recovery of 93.5% in average. (Presented at the 1307th Meeting, February 26, 2003.)

Transdermal fentanyl was released in Germany in 1995. However, the release was restricted to cancer pain patients, and initial dose finding was only allowed during inpatient treatment, due to concerns about the safety of the system. A nationwide survey was planned and organized from our pain clinic, to collect adequate data on efficacy and safety of the application system. From October 1996 to February 1998 transdermal treatment was documented for 1005 patients (506 men and 499 women with a mean age of 60 years, range 20–92 years) with chronic pain in an open survey including 290 physicians from hospitals and general practitioners throughout Germany. Most patients suffered from cancer pain and only 11 patients had chronic pain from non-malignant disease. Transdermal therapy was documented from day 0 for 824 patients, while 181 patients had been treated with transdermal fentanyl before admission in the survey. Most of the other 824 patients had been treated with other step 3-opioids 55% of the patients) or step-2 opioids (23%) before conversion to transdermal fentanyl, whereas 8% had been treated only with nonopioids and 14% had received analgesics only as required or not at all before inititation of transdermal therapy. The most important reason for switching to transdermal opioid therapy was insufficient pain relief with the previous medication followed by a variety of gastrointestinal symptoms impeding oral analgesic therapy. Initial fentanyl doses ranged from 0.6 to 9.6 mg/day with a median of 1.2 mg/day. Median doses slowly increased throughout the observation period to 2.4 mg/day after 4 months of treatment. Most patients continued transdermal therapy until the time of death (47% of patients). Adverse events were documented as the reason for discontinuation of transdermal therapy in only 49 patients (5%). Dyspnoea was documented for 7 patients as the reason for discontinuation. One of these patients as well as another patient with an episode of apnoea had to be treated with artificial respiration for several hours, but both patients recovered without sequelae. Transdermal therapy with fentanyl was safe and efficient in this nationwide survey. Following the evaluation of the survey, the restrictions on the release were withdrawn in 1998. The Drug Advisory Comittee of the German Medical Board has included transdermal fentanyl as one of the opioids recommended on the third step of the analgesic ladder of the World Health Organisation. In the report of drug prescriptions for Germany 1.6 million defined daily doses (DDD) of slow release morphine had been prescribed in 1990, and this had increased to 15.4 million DDD in 2000. Transdermal fentanyl has overtaken morphine in Germany with 34,0 million DDD in 2000. However, these data do not differentiate between prescriptions for non-malignant and malignant pain, and most of the increases will be related to non-malignant pain. Undertreatment of cancer pain, though getting less, is still a problem for many patients, and transdermal fentanyl is an important therapeutic option for these patients. (Presented at the 1309th Meeting, February 28, 2003.)

Low back pain affects 80% of the population of industrialized countries during the adult lifetime. In the United States, it is the most common cause for disability in working aged individuals. While most episodes of low back pain resolve spontaneously or with non-operative treatments, some patients persist with chronic disabling mechanical low back pain often associated with degenerative changes of the intervertebral discs. Unfortunately, by age 60, over 90% of the asymptomatic population will also have at least one degenerative disc as determined by MRI scanning. The clinicians' challenge is to separate age-related changes with painful anatomic changes. Once non-operative treatments have failed, the surgical approach to patients with symptomatic lumbar disc degeneration has evolved over the last century. Prior to 1980, relatively few fusions were performed for axial low back pain. The posterolateral fusion became popular and then was supplemented with rigid internal fixation. The posterolateral fusions were then supplemented with anterior or posterior interbody fusions for the so-called "360" approach. The advent of metal fusion cages transiently increased the interbody fusion approach and resulted in the "270" with minimally invasive facet joint screws. Most recently, the approval of recombinant bone morphogenetic protein-2 in a titanium fusion cage has rejuvenated the case for stand alone anterior lumbar interbody fusions. Beginning in Europe in the early 1990's and in the United States a decade later, disc replacement strategies have garnered much interest. Several designs that have been successful in Europe have been modified and are currently under investigation in the U.S. Early results are promising when compared to the rather traumatic fusion techniques currently in use. However, a more challenging comparison for disc arthroplasty procedures may be the injectable BMP fusion of the future. Long term questions remain as to the life span of these implants, the effect of wear debris, and whether preserving motion will truly prevent adjacent segment degeneration which may be determined more genetically than mechanically. Perhaps the future generation of treatments will involve more biologic approaches to repair and regeneration of disc tissue. Cell culture and in vivo studies suggest the feasibility of specific proteins to increase the production of key disc matrix components. Also, gene therapy may be an efficient method of delivering the signaling molecules for the intervertebral disc and such studies are underway. One thing is for certain, the approach to treatment for the painful degenerative disc is a continuing evolution. (Presented at the 1312nd Meeting, March 17, 2003.)

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