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Aim: CoCrMo alloys are contraindicated for sufferers from allergy. For these patients, uncemented and cemented prostheses made of non-allergenic titanium alloy are indicated. Knee prostheses machined from that alloy, however, may have poor tribological behaviour, especially in contact to UHMWPE inlays. Therefore, high-strength oxide ceramics may be especially suitable for knee replacement in allergy patients with mobile bearing prostheses. For adhesion to bone cement, the ceramic surface only exhibits mechanical retention spots that are less adequate than those with a textured metal surface. Generating undercuts by corundum blasting is highly efficient for mechanical adhesion to a CoCrMo surface, but is not possible on a ceramic surface, due to the brittleness of ceramics. Lack of retention of bone cement promotes micromotions of the prostheses. As a consequence of micromotions, early aseptic loosening is predictable. Silicoating (silicate and silane layering) of the ceramic surface would allow specific adhesion and hence would result in increased and hydrolytically more stable bonding between the bone cement and the prosthesis surface - thereby preventing early aseptic loosening. Silicoating, however, presupposes a chemically active surface that is not blocked by a layer of chemisorbed molecules, e.g. water. Desorption of this chemisorbed layer is mandatory and can be attained by baking out the surface., Method: In order to evaluate the effectiveness of surface activation via thermal treatment by baking out, with subsequent silicoating of the surface, the bond strengths of thermally treated and silicate layered ZPTA samples were compared with thermally treated surfaces that had not been silicoated. In our study of thermal surface treatment for baking out the surface, we focused on the question of whether there is a minimal "critical" temperature Ts for effective desorption of a chemisorbed water layer. The samples were prepared for the traction-adhesive strength test (sequence: ceramic disc, silicate and silane layering, protective lacquer ("PolyMA" layer), bone cement, TiAlV probes for the traction-adhesive strength test) and their traction-adhesive strengths were then measured., Results: The bond strength was measured as a function of temperature for ceramic discs that had been baked out and subsequently silicoated. This was graduated, exhibits with a pronounced increase in the bond strength at a baking temperature of Ts ≈ 350 °C. The observed bond strengths before the step are ≤ 20 MPa and after the step ≥ 30 MPa., Conclusion: Silicoating is effective in achieving high bond strength of bone cement on surfaces of oxide ceramics and can also stabilise the long term behaviour of the bond strength, provided the surface has been thermally treated prior to silicoating. Because of the proposed migration of the silicoating layer, micromotions and debonding should be widely reduced or even eliminated., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Low vitamin D is a major risk factor for osteoporotic fractures. Evidence also suggests correlation between deficiency and musculoskeletal pain., Objective: Non-interventional study in patients undergoing spine surgery to investigate links between vitamin D levels and clinical features., Methods: 25-OH vitamin D levels were assessed in two cohorts: Cohort 1 (vertebral fractures; VF) and Cohort 2 (other spinal issues; excluding VF). Lab values as well as painDETECT questionnaires, VAS and Oswestry Disability Index (ODI) were recorded. Follow-up visits were conducted a few days and 6 weeks postoperatively., Results: One hundred and nine patients were enrolled. Mean VAS measured 72 mm in Cohort 1 and 55 mm in Cohort 2. Mean vitamin D concentrations were 16.8 ± 11 ng/ml in Cohort 1 and 18.3 ± 11 ng/ml in Cohort 2. VAS and ODI significantly correlated with vitamin D levels. Median painDETECT scores were 9 in Cohort 1 and 16 in Cohort 2. Six weeks postoperatively mean VAS was 31.4 ± 28 mm in Cohort 1 and 23.3 ± 21 mm in Cohort 2. Median painDETECT scores were 5 in both cohorts., Conclusion: Interactions are apparent between neuropathic pain and vitamin D serum levels. Consequently, vitamin D should be monitored in all patients requiring spinal surgery.

In Germany and other European countries, cancer is the second most common cause of death after cardiovascular disease. Although 5-year survival rates for several types of cancer have significantly improved over the last 30 years, metastasis to the bone almost always leads to incurable disease. Aside from the rare primary bone tumours, the treatment of bone metastases now accounts for a major part of tumour orthopaedic workload and requires close interdisciplinary coordination between specialists in oncology, radiology and the discipline of the primary tumour entity. Due to improvements in oncological treatment regimes, long survival times can be achieved. Therefore, the management of so-called "SRE" (skeletal-related events) has gained importance, even in palliative situations. On the basis of a selective literature review, the following article points out the underlying pathophysiological processes of bone metastases and outlines different diagnostic approaches and their relevance in the current clinical setting., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Periprosthetic joint infection is a serious complication and reconstruction after failed revision total knee arthroplasty with significant bone loss and compromised soft-tissues can be challenging. Objective of this study was to assess clinical and functional results, implant survival and infection recurrence rates in patients treated with two-stage arthrodesis after failed revision TKA with extensor mechanism deficiencies due to PJI, and to identify the factors that affect outcomes after surgery., Methods: Thirty seven patients with PJI treated within a two-stage exchange and reimplantation of an arthrodesis nail between 2008 and 2014 were included. Systemic and local risk factors were graded preoperatively according to McPherson et al. All patients were treated according to a structured treatment algorithm. Clinical and functional evaluation was performed using the Oxford Knee Score and the Visual Analogue Scale., Results: Thirty two of 37 patients (86.5%) were graded as free of infection. Five patients (13.5%) had recurrent infection after arthrodesis with the need of revision surgery. Mean leg-length discrepancy was 2.2cm. The mean VAS for pain was three, the mean Oxford Knee Score was 38±9. Total implant survival at a 74month follow-up was 74.3% (95% CI: 45.4 to 91.1%), as determined by Kaplan-Meier survival curves. Local McPherson Score, as well as number of revisions was found to be of significant influence to the survival rate., Conclusions: Septic failure of revision knee arthroplasty can be effectively treated with two-stage arthrodesis using a modular intramedullary nail, providing a stable and painless limb with satisfactory functional results and acceptable infection eradication rates., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background Multiple myeloma is a haematological blood cancer of the bone marrow and is classified by the World Health Organisation (WHO) as a plasma cell neoplasm. In multiple myeloma, normal plasma cells transform into malignant myeloma cells and produce large quantities of an abnormal immunoglobulin called monoclonal protein or M protein. This ultimately causes multiple myeloma symptoms such as bone damage or kidney problems. The annual worldwide incidence of multiple myeloma is estimated to be 6 - 7/100,000 and accounts for 1% of all cancer. In Germany, there are about 6,000 cases of newly diagnosed multiple myeloma per annum. In the current era of new agents, such as immunomodulatory drugs and proteasome inhibitors and antibodies, enormous progress has been achieved in the therapy of multiple myeloma. In orthopaedics, it is essential to be able to recognise the of alarming symptoms of multiple myeloma in clinical routine and to be aware of basic diagnostic features to confirm this disease. Surgical treatment of myeloma-related bone lesions - such as stabilisation of pathological fractures - is an important domain of tumour orthopaedic surgery. Methods A comprehensive literature search was performed in PubMed using the keywords "multiple myeloma" and "diagnostic" or "therapy". This served to evaluate the available primary and secondary literature on the current status of the diagnostic testing and therapy of multiple myeloma. Systematic reviews, meta-analyses and clinical studies as well as international recommendations in therapy were included until the spring of 2016. Results There are now very sensitive screening methods for the diagnosis of multiple myeloma. Accurate diagnosis is generally based on several factors, including physical evaluation, patient history, symptoms, and diagnostic testing results. The standards for initial diagnostic tests are determined by blood and urine tests as well as a bone marrow biopsy and skeletal imaging, such as X-rays, CT scans and MRI scans. Major and minor criteria are required to confirm the diagnosis of multiple myeloma and help to determine the classification and staging of multiple myeloma, and whether it is smoldering myeloma (asymptomatic), symptomatic myeloma, or a monoclonal gammopathy of undetermined significance (MGUS). Multiple myeloma treatment options have increased significantly over the last 10 years. Standard of basic myeloma treatment consists of high dose chemotherapy in combination with autologous stem cell transplantation. Several factors may determine multiple myeloma treatment, such as age and general health, results of laboratory and cytogenetic (genomic) tests as well as symptoms and disease complications. After evaluation of these factors, an individual and often multimodal treatment plan is created and implemented in interdisciplinary cooperation. Conventional treatment options have to be evaluated for older patients (> 70 - 75 years), who are not eligible for high dose chemotherapy and autologous stem cell transplantation due to their age and/or severe comorbidities. It is essential to include supportive therapy in the integral treatment concept, in order to control pain or retain function or mobility. Supportive drugs such as bisphosphonates but also radiation therapy and orthopaedic surgery may be required in order to manage complications of the disease as well as side effects of treatment. Conclusion Current studies show promising results in the treatment of multiple myeloma, due to new agents such as immunomodulatory drugs, proteasome inhibitors and antibodies, which may improve prognosis and survival rate among myeloma patients in the future. However treatment algorithms have become more complex and expensive., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Vertebral compression fractures (VCF) change the natural spinal alignment and inevitably lead to a decreased quality of life., Objective: The aim of the study was to evaluate changes in pulmonary function after VCF were treated by radiofrequency kyphoplasty (RF-TVA)., Methods: Twenty-five patients were treated with RF-TVA and analyzed in 3 subgroups taking into account the spinal location of the VCF. Pain as measured by visual analogue scale (VAS), Oswestry-Disability-Index (ODI), vertebral height, forced expiratory volume in 1 second (FEV1), and peak expiratory flow (PEF) were assessed before, directly after and 30 days after RF-TVA., Results: The mean vertebral height was improved in all subgroups, with a minor reduction from one to 30 days postoperatively. The mean VAS and ODI significantly decreased in the main and upper diaphragm groups from baseline to the follow-up after 30 days. Patients treated below the main diaphragm region showed a significant improvement of ODI and a clear trend to significant improvements of VAS. PEF and FEV1 were significantly improved in the main diaphragm group. FEV1 also increased significantly in the upper diaphragm group with a clear trend to significance in the lower diaphragm group., Conclusions: Results indicate that RF-TVA may improve pulmonary function especially in cases where fractures are located in the main spinal region of the diaphragm.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: To remove loosened prosthesis components, to perform augmentation, to address osseous defects, to perform neutrally aligned ankle arthrodesis, and to achieve postoperative pain relief., Indications: Symptomatic, aseptic loosening of total ankle replacement (TAR) with/without substantial bone defect of the tibial and/or talar bone stock., Contraindications: General surgical or anesthesiological risks, periprosthetic infection, local or systemic infection, nonmanageable soft tissue problems., Surgical Technique: Removal of both prosthesis components using the previous incision (mostly using anterior ankle approach). Careful debridement of bone stock at the tibial and talar side. Osseous augmentation of defects using autologous or homologous cancellous bone, if needed, using structural allografts., Postoperative Management: A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6-8 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated gradually after progressive osseous healing has been confirmed., Results: Between January 2007 and December 2012, ankle arthrodesis was performed in 9 patients with failed TAR (6 men and 3 women, mean age 56.4 ± 7.0 years, range 47.8-66.0 years). The mean time between the initial TAR and revision surgery was 4.5 ± 2.4 years (range 1.2-7.9 years). In one patient irrigation and debridement was performed due to superficial wound infection. Another patient had a delayed osseous healing 11 months after the revision surgery.

Pain coming from the sacroiliac (SI) joints can explain up to 25% of all chronic low back pain. A careful differential diagnosis is required to avoid misdiagnosis of low back pain. In addition to historical findings, positive findings on physical examination maneuvers that stress the SI joint are a key component diagnosis. The SI joint is confirmed as a pain generator when intraarticular injection of local anaesthetics provides acute back pain relief. Minimally invasive SI joint fusion is clearly superior to invasive open surgical procedures, with decreased blood loss and tissue disruption, shorter procedure times and shorter hospital stays. Especially well documented are the results of minimally invasive SI joint fusion using iFuse Implant System ® . The device's triangular profile, combined with a titanium plasma spray coating, ensures both an immediate and long-lasting joint stabilization., Competing Interests: Interessenkonflikt: Nein., (Georg Thieme Verlag KG Stuttgart · New York.)

Background Stimulating bone regeneration is a central aim in orthopaedic and trauma surgery. Although the replacement of bone with artificial materials like cement or apatite helps to keep up bone stability, new bone often cannot be regenerated. Increasing research efforts have led to the clinical application of growth factors stimulating bone growth (e.g. bone morphogenic protein, BMP) and inhibitors preventing bone consumption (e.g. RANKL blocking antibodies). These factors mostly concentrate on stimulating osteoblast or preventing osteoclast activity. Current Situation It is widely accepted that osteoblasts and osteoclasts are central players in bone regeneration. This concept assumes that osteoblasts are responsible for bone growth while osteoclasts cause bone consumption by secreting matrix-degrading enzymes such as cathepsin K and matrix metalloproteinases (MMP). However, according to new research results, bone growth or consumption are not regulated by single cell types. It is rather the interaction of various cell types that regulates bone metabolism. While factors secreted by osteoblasts are essential for osteoclast differentiation and activation, factors secreted by activated osteoclasts are essential for osteoblast activity. In addition, recent research results imply that the influence of the immune system on bone metabolism has long been neglected. Factors secreted by macrophages or T cells strongly influence bone growth or degradation, depending on the bone microenvironment. Infections, sterile inflammation or tumour metastases not only affect bone cells directly, but also influence immune cells such as T cells indirectly. Furthermore, immune cells and bone are mechanistically regulated by similar factors such as cytokines, chemokines and transcription factors, suggesting that the definition of bone and immune cells has to be thought over. Outlook Bone and the immune system are regulated by similar mechanisms. These newly identified similarities between bone and the immune system imply that medication developed for tumour and autoimmune patients could also be applied in bone diseases., Competing Interests: Conflict of Interest/Interessenkonflikt: None./Nein., (Georg Thieme Verlag KG Stuttgart · New York.)

Bacterial biofilms cause a considerable amount of prosthetic joint infections every year, resulting in morbidity and expensive revision surgery. To address this problem, surface modifications of implant materials such as carbon nanotube (CNT) coatings have been investigated in the past years. CNTs are biologically compatible and can be utilized as drug delivery systems. In this study, multi-walled carbon nanotube (MWCNT) coated TiAl6V4 titanium alloy discs were fabricated and impregnated with Rifampicin, and tested for their ability to prevent biofilm formation over a period of ten days. Agar plate-based assays were employed to assess the antimicrobial activity of these surfaces against Staphylococcus epidermidis. It was shown that vertically aligned MWCNTs were more stable against attrition on rough surfaces than on polished TiAl6V4 surfaces. Discs with coated surfaces caused a significant inhibition of biofilm formation for up to five days. Therefore, MWCNT-modified surfaces may be effective against pathogenic biofilm formation on endoprostheses., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aim: To assess serum levels of RANK-ligand (RANKL) and osteoprotegerin (OPG) as biomarkers for periprosthetic joint infection (PJI) and compare their accuracy with standard tests., Methods: One hundred and twenty patients presenting with a painful total knee or hip arthroplasty with indication for surgical revision were included in this prospective clinical trial. Based on standard diagnostics (joint aspirate, microbiological, and histological samples) and Musculoskeletal Infection Society consensus classification, patients were categorized into PJI, aseptic loosening, and control groups. Implant loosening was assessed radiographically and intraoperatively. Preoperative serum samples were collected and analyzed for RANKL, OPG, calcium, phosphate, alkaline phosphatase (AP), and the bone-specific subform of AP (bAP). Statistical analysis was carried out, testing for significant differences between the three groups and between stable and loose implants., Results: All three groups were identical in regards to age, gender, and joint distribution. No statistically significant differences in the serum concentration of RANKL ( P = 0.16) and OPG ( P = 0.45) were found between aseptic loosening and PJI, with a trend towards lower RANKL concentrations and higher OPG concentrations in the PJI group. The RANKL/OPG ratio was significant for the comparison between PJI and non-PJI ( P = 0.005). A ratio > 60 ruled out PJI in all cases (specificity: 100%, 95%CI: 89, 11% to 100.0%) but only 30% of non-PJI patients crossed this threshold. The positive predictive value remained poor at any cut-off. In the differentiation between stable and loose implants, none of the parameters measured (calcium, phosphate, AP, and bAP) showed a significant difference, and only AP and bAP measurements showed a tendency towards higher values in the loosened group (with P = 0.09 for AP and P = 0.19 for bAP)., Conclusion: Lower RANKL and higher OPG concentrations could be detected in PJI, without statistical significance., Competing Interests: Conflict-of-interest statement: Not declared.

Background: The objectification of pain is essential for evaluation, treatment plan and follow-up; therefore, it is necessary to find reliable clinical parameters., Objective: The goal of the study was the preoperative screening of a neuropathic component in patients with vertebral compression fracture (WKF), herniated disc (NPP) or spinal cord compression (SKS)., Material and Methods: Depending on the preoperative condition on admittance, patients were classified into three groups: group 1 WKF, group 2 NPP and group 3 SKS. To characterize the pain we used the painDETECT questionnaire, the Oswestry questionnaire and further questionnaires. All patients were surgically treated according to the diagnosis, e.g. radiofrequency kyphoplasty, nucleotomy or spondylodesis., Results: We evaluated the data from 139 patients (45% WKF, 34% NPP and 21% SKS). There were no differences in preoperative pain intensity (median ordinal scale 0-10) with a mean preoperative score of 7 for all groups. The total score of the painDETECT questionnaire showed significantly higher results in group 2 (median 18) and in group 3 (median 14) than in group 1 (median 9). There was even a significant difference between groups 2 and 3 (p = 0.03). The highest pain intensity was detected in group 1 with a median visual analog scale (VAS) of 71 mm. The total scores in the painDETECT questionnaire and the scores in the Oswestry questionnaire correlated in groups 2 and 3., Conclusion: The painDETECT questionnaire was shown to be a very suitable instrument for evaluating the neuropathic pain component in patients with dorsalgia. This could be very useful in planning further therapy.

Study Design: A retrospective study., Objectives: The aim of this study was the evaluation of the safety and effectiveness of radiofrequency-targeted vertebral augmentation (RF-TVA) in comparison with balloon kyphoplasty (BK) for the treatment of acute painful vertebral compression fractures (VCFs) on the basis of matched pairs., Summary of Background: Vertebroplasty and BK are the common surgical interventions for the treatment of VCF. Both are effective and safe but pose some risks such as adjacent fractures and cement leakage. In 2009, RF-TVA was introduced as an innovative augmentation procedure for the treatment of VCF., Materials and Methods: A total of 192 patients (116 female; 51-90 y) with VCF (n=303) at 1 to 3 levels were treated with RF-TVA or BK. Functionality (Oswestry Disability Index), pain (visual analogue scale), vertebral height (anterior, middle), and kyphotic angle were evaluated over a 2-year period (postoperatively, 3-4 d, 3, 6, 12, and 24 mo). In addition, operating time and occurrence of cement leakage were recorded., Results: Pain and functionality were significantly improved after both treatments. In both groups, there was an increase in the vertebral height and a decrease in the kyphotic angle, which remained relatively consistent during 24 months. The incidence of cement leakage was 9.4% (n=9) in the RF-TVA group and 24.0% (n=25) in the BK group. The mean operating time with radiofrequency kyphoplasty was 25.9±9.9 minutes, and with balloon kyphoplasty 48.0±18.4 minutes., Conclusions: RF-TVA is a safe and effective procedure for the treatment of vertebral compression fractures when compared with BK. Improvement in pain and functional scores after RF-TVA are durable through 24 months postprocedure and remained better than those after BK at long-term follow-up. Operating time for RF-TVA is shorter and the risk of cement leakage is lower. Both procedures provided similar results in vertebral height restoration and reduction in the kyphotic angle.

Introduction: Different dissection studies as well as comparative studies about the anterolateral ligament of the knee (ALL) already exist and the structure's topology and properties have been shown. However, most of the studies investigating the ligament were performed in embalmed knees, which is thought to change the structural integrity of ligaments and thus the topologic and dynamic measurements. Since the biomechanical function of the ALL is not fully understood until today and a correlation with the pivot shift phenomenon is yet speculative, further studies will have to clarify its definitive importance. Its function as a limiter of internal rotation and lateral meniscal extrusion leads to the assumption of a secondary knee stabilizer., Methods: Twenty paired fresh-frozen cadaveric knees of ten donors have been dissected in a layerwise fashion. After identification of the ALL, topologic measurements were undertaken using a digital caliper., Results: The ALL could be identified as a tender, pearly structure in front of the anterolateral joint capsule in only 60% of the dissected knee joints. Only 20% of donors had a bilateral ALL while 80% had an ALL only in one side. Mean length, thickness and width as well as topographic measurements were comparable to other available studies investigating fresh-frozen cadavers., Conclusion: Anatomy and topography of the ALL seem to be highly variable, but consistent within certain borders. Prevalence has to be argued though as it strongly differs between studies. The impact of an ALL absence, even if only unilateral, needs to be investigated in clinical and imaging studies to finally clarify its importance.

Purpose and Objective: Bone resection regarding adequate surgical margins is the treatment of choice for malignant bone tumors. In the case of metastasis-related complications, so-called skeletal-related events, it is highly important to achieve pain relief and a stable joint situation to re-mobilize the patients immediately following surgery. To bridge the often large osseous defect zones after tumor resection, both cemented and uncemented modular endoprosthetic systems are widely used. Patients undergoing tumor-related endoprosthetic orthopedic surgery are facing high risk for developing a periprosthetic joint infection (PJI). The immunocompromised condition due to anti-neoplastic treatment and long operation time with large exposure of tissue contributes to a high risk of infection., Methods: The authors present a case series of 100 patients (31% primary bone tumor and 69% metastasis-related surgery) undergoing tumor-related lower limb salvage surgery with special regard to periprosthetic joint infection and the management of this "difficult to treat" situation. Furthermore, a review of the current literature regarding infection following bone tumor resection and endoprosthetic reconstruction is performed and discussed., Results: The median follow-up was 24 months (range 12-108 months). Ten patients (10%) suffered from a periprosthetic joint infection. We recorded six acute infections (type I) <4 weeks after surgery, one infection >4 weeks after surgery (type II), and three late infections (type III). According to the definition of Laffer et al., three of our patients (30%) are probably free of infection, one patient died of PJI-associated sepsis, and five patients were free of infection, but without restoration of the affected joint., Conclusion: In conclusion, our own results show that perimegaprosthetic joint infection among silver-coated implants, in patients undergoing tumor-related surgery of the lower limb, is lower compared to non-silver-coated implants. Due to heterogeneity of patients and potential treatment options, the treatment regime should be tailored for the patients' individual situation.

Background: Periacetabular bony defects remain a great challenge in revision total hip arthroplasty. After assessment and classification of the defect and selection of a suitable implant the primary stable fixation and sufficient biological reconstitution of a sustainable bone stock are essential for long term success in acetabular revision surgery. Biological defect reconstruction aims for the down-sizing of periacetabular defects for later revision surgeries., Technique: In the field of biological augmentation several methods are currently available. Autologous transplants feature a profound osseointegrative capacity. However, limitations such as volume restrictions and secondary complications at the donor site have to be considered. Structural allografts show little weight bearing potential in the long term and high failure rates. In clinical practice, the usage of spongious chips implanted via impaction bone grafting technique in combination with antiprotrusio cages for the management of contained defects have shown promising long time results. Nevertheless, when dealing with craniolateral acetabular and dorsal column defects, the additional implantation of macroporous metal implants or augments should be considered since biological augmentation has shown little clinical success in these particular cases., Prospect: This article provides an overview of the current clinically available biological augmentation methods of peri-acetabular defects. Due to the limitations of autologous and allogeneic bone transplants in terms of size and availability, the emerging field of innovative implantable tissue engineering constructs gains interest and will also be discussed in this article.

Introduction/Background: With extended life expectancy, the number of primary joint arthroplasties has also increased. Revision surgery is also more often necessary, due to aseptic or septic loosening of the prosthesis or periprosthetic fracture. Large bone defects often occur in these patients and several non-modular, conventional implants are available to handle this difficult situation. Custom made implants offer an individually designed and defect-adapted shape with perfect covering of the lesion, but may delay the operation. The Modular Universal Tumor And Revision System (MUTARS®) offers the possibility to vary the length and angle of the femoral neck and the antetorsion angle. Thus, it permits intraoperative adaption to the individual patient's defect. The aim of our study is to present clinical, functional results and the rate of complications in a cohort of patients undergoing revision surgery for failed endoprosthetic replacement or failed trauma surgery, using the Modular Universal Tumor And Revision System with short-to midterm follow-up. Patients and Methods: Between August 2005 and September 2014, 25 patients (17 female, 8 male) with an average age of 72 years (min. 56, max. 92 years) were included in a retrospective study using the MUTARS® system. The patients underwent surgical revision of osseous defects that were not susceptible to conventional care. The mean follow-up was 16 months (min. 12, max. 72 months). The indications which led to revision surgery were as follows: loosened metal-on-metal prosthesis with an acetabular defect caused by a metal-induced granuloma (n = 1), pseudoarthrosis after implantation of femur nail (n = 2), cut-out of a femur nail (n = 1), aseptic loosening of an implanted endoprosthesis (n = 4), septic loosening of an implanted endoprosthesis (n = 1), periprosthetic fracture (n = 6) and periprosthetic infection after two stage revision surgery (infection consolidated Girdlestone situation) (n = 10). All patients were followed up at regular intervals, both clinically and radiologically. Apart from comorbidities, clinical and functional parameters were measured, including the Harris Hip Score. An outcome analysis was also performed with respect to peri- and postoperative complications. Serial plain X-rays were followed-up. Results: In all patients, stable reconstruction without the use of an allograft was possible. In total, 23 patients underwent surgery by using a proximal femur prosthesis; three patients also received a custom made acetabular component. One patient was treated by using a distal femur and one patient was treated by implantation of a total femur prosthesis. The average length of hospital stay was 25 days (min.11, max. 47 days). The Harris Hip Score improved from 28 points preoperatively to 81 points after surgery.In total we recorded 24 % of complications after surgery. Two patients suffered recurrent periprosthetic infection and the prosthesis had to be revised in a further two stage exchange; one patient had a tractus gap and was revised by surgery. Two patients suffered periprosthetic fracture due to trauma and the patient with the total femur prosthesis suffered recurrent periprosthetic infection of the silver - coated mega-prosthesis and committed suicide triggered by an episode of major depression. Conclusion: Because of its modular nature, the Modular Tumor And Revision System (MUTARS®) can be used for highly variable intraoperative defect adaption. Good clinical and functional results were achieved in patients with excessive bone defects. However, the high rate of infection, even with silver coated mega-implants, is still a problem and should be studied further., (Georg Thieme Verlag KG Stuttgart · New York.)

Background and Objectives: The aim of our study was to evaluate if there is an increased risk of periprosthetic infection (PJI) in patients following replacement of the proximal humerus by using a modular tumour prosthesis in combination with a trevira tube., Methods: Thirty patients were treated by using a modular tumour endoprosthesis (MUTARS®) following intra-articular resection of the proximal humerus. Fifteen patients received treatment by using a trevira tube. In 15 further cases the use of a trevira tube was not necessary. The mean follow-up time was 26 months (range: 24 months to 84 months). Both, Enneking score and range of motion (ROM), was evaluated. Further radiographs were obtained in two planes., Results: The survival rate one year after surgery was 83 % and 63 % after two years. We recorded a 96 % survival of the limb two years after surgery. We also observed only one case of periprosthetic joint infection (PJI) in the entire follow-up period in one patient who received treatment with a trevira tube. The mean Enneking score was 20 points (range 8 to 26 points). ROM was equal in both study groups. In total 20 % of the treated patients (n = 6) suffered complications., Conclusions: Replacement of the proximal humerus by using a trevira tube in combination with a modular tumour endoprosthesis is a safe and viable treatment option for both, bone tumours and metastases. There is no statistically significant increased risk of infection by using trevira tube even among immunosuppressed patients., Level of Evidence: Level 3, retrospective comparative study.

Background: Sacroiliac joint (SIJ) syndrome can cause various symptoms and may also be one reason for persistent low back pain, especially in patients with prior spinal fusions. If conservative treatments fail to improve symptoms, arthrodesis surgery can be considered. Minimally invasive approaches have emerged recently providing a good alternative to conventional methods. A novel triangular implant system (iFuse) can achieve an arthrodesis of the SIJ without the use of additional screws or bone material., Objective: Aim of the present study was an evaluation of short-term safety and efficacy of the implant system., Methods: Twenty-four patients were included in the study and treated with the iFuse system. In addition to demographic data, pain intensity (visual analogue scale) and functional impairment (Oswestry-disability index) were assessed prior to surgery and 1 month, 3 months, 6 months, 12 months and 24 months thereafter. During surgery and the follow up period all adverse events were documented and the correct implant position was controlled via plain radiographs., Results: VAS scores and ODI improved significantly directly after surgery from 84.3 ± 9.2 mm to 40.7 ± 9.2 mm and from 76.8 ± 9.2% to 40.7 ± 9.2 % (p < 0.001). The ODI improved further to 31 ± 5.4% after 24 months whereas the VAS improved until the 3 months examination and ten stayed constant between 27.7 mm and 26.5 mm to 27 ± 6.6 mm at 24 months. No adverse events, intraoperative complications, implant malpositioning or loosening could be recorded at any time., Conclusions: The iFuse system is an effective and safe treatment for minimally invasive surgical arthrodesis of the SIJ. Pain and functional impairment can be significantly improved. However, in addition to this case series, further controlled studies are necessary, particularly in terms of a previous spinal fusion history.

Introduction: PMMA-augmentation of pedicle screws strengthens the bone-screw-interface reducing cut-out risk. Injection of fluid cement bears a higher risk of extravasation, with difficulty of application because of inconsistent viscosity and limited injection time., Objective: To test a new method of cement augmentation of pedicle screws using radiofrequency-activated PMMA, which is suspected to be easier to apply and have less extravasations., Methods: Twenty-seven fresh-frozen human cadaver lumbar spines were divided into 18 osteoporotic (BMD ≤ 0.8 g/cm2) and 9 non-osteoporotic (BMD > 0.8 g/cm2) vertebral bodies. Bipedicular cannulated pedicle screws were implanted into the vertebral bodies; right screws were augmented with ultra-high viscosity PMMA, whereas un-cemented left pedicle screws served as negative controls. Cement distribution was controlled with fluoroscopy and CT scans. Axial pullout forces of the screws were measured with a material testing machine, and results were analyzed statistically., Results: Fluoroscopy and CT scans showed that in all cases an adequately big cement depot with homogenous form and no signs of extravasation was injected. Pullout forces showed significant differences (p < 0.001) between the augmented and non-augmented pedicle screws for bone densities below 0.8 g/cm2 (661.9 N ± 439) and over 0.8 g/cm2 (744.9 N ± 415)., Conclusions: Pullout-forces were significantly increased in osteoporotic as well as in non-osteoporotic vertebral bodies without a significant difference between these groups using this standardized, simple procedure with increased control and less complications like extravasation.

Background: 30% of myeloma patients suffer from vertebral compression fractures (VCF). Consequently, augmentation often becomes inevitable to prevent further problems. This study evaluated the interaction of radiation therapy (RT) and radiofrequency kyphoplasty (RFK) in the treatment of myeloma associated VCF., Methods: Eighty-six myeloma patients with VCF were treated with RFK followed by radiation therapy (RFK group) or vice versa (RT group). Visual analgoue scale (VAS), Oswestry-Disability-Index (ODI), vertebral height and kyphosis angle were assessed preoperatively, 3-4 days, 3 and 6 months postoperatively. Adverse events like cement leakage or additional fractures were documented., Results: Both groups achieved comparable outcomes, but the course of VAS and kyphosis angle differed. Early postoperative kyphosis angles improved significantly in the RFK group, but significantly worsened afterwards. The RT group showed a trend towards significantly improvement postoperatively and minor worsening afterwards. VAS remained constant in the RT group and worsened in the RFK group after 6 months. More cement leakages and additional fractures were noted in the RT group., Conclusions: RFK is an effective method for treating VCF in myeloma patients independent of treatment order with regard to radiation therapy. However, RT should be conducted after RFK to minimize risks of cement extrusion and additional fractures.

Purpose: Compared to older patients undergoing total hip arthroplasty (THA) younger patients are considered to be more active, thereby exposing the implant to significantly higher loads over a much longer period of time. Additionally, cases of secondary osteoarthritis caused by hip dysplasia, femoral head necrosis or rheumatic diseases are much more frequent than among the average patient population. Therefore, durable implant fixation and low wear rates are extremely important to achieve good long-term implant survival in this group of patients., Objective: The aim of this retrospective study was to evaluate the mid- to long-term survival of a cementless femoral stem (Zweymüller® SL stem) and a threaded cup (Bicon SL®) in patients younger than 50 years of age., Methods: Therefore, a consecutive series of 100 patients (111 hips) aged 50 years or younger (range: 30 to 50 years) was analysed at a mean follow up of 13.5 years. Follow-up assessment included physical examination and radiographic workup. Hip disability osteoarthritis and outcome score (HOOS) and Harris hip score (HHS) were used to evaluate the pre- and post-operative functional outcome, respectively. Patient satisfaction with the surgical result was assessed by standardized questionnaires., Results: The overall survival rate with any revision as endpoint was 96.8 % (95 % CI: 90.5 % to 98.9 %) at ten years. Gender, operation time and the occurence of osteolyses had no influence on joint function or patient satisfaction. We recorded an overall failure rate of 7.4 % (six cases). In four cases (5 %) the prosthesis had to be revised due to aseptic loosening of the cup after 12 years, eight years, 12 years and 11 years, in one case (1.2 %) recurrent luxation led to a revision operation (acetabular cup and head) after three years of primary implantation. In one case an implant failure was recorded (acetabular cup breakage after eight years of implantation). We recorded the occurence of asymptomatic radiolucent lines of the cup in 21 % and of the stem in 35 % in our series. The HOOS was influenced by the presence or abscence of radiolucent lines of the stem. Patients with radiolucent lines of the stem had a median HOOS score of (74 points) compared to those without radiolucent lines (89 points). Other factors, such as "diagnosis led to operation" and "previous operations" had no influence on the HHS and HOOS., Conclusion: Our study demonstrates excellent long-term survival of cementless femoral stem in combination with a threaded cup in young patients undergoing total hip arthroplasty.

Background: In case of complex vertebral fractures, posterior fixation is often required for correction of deformity and instability. Fixation is commonly supported by balloon kyphoplasty (BKP) anterior. A development of BKP is radiofrequency-targeted vertebral augmentation (RF-TVA), which leads to comparable results for augmentation and pain relief., Objective: This prospective study evaluates the outcome of posterior fixation combined with RF-TVA or BKP, respectively., Methods: VAS, ODI, kyphosis angle and vertebral height of 44 patients were evaluated preoperatively, 3 and 12 months postoperatively., Results: Both treatments improved vertebral height and kyphosis angle. At 12 months, vertebral height restoration was still significantly better in the BKP group (p < 0.001) and the improvement of kyphosis angle was comparable between both groups (p = 0.71). VAS and ODI improvements were significantly better in the RF-TVA group (p < 0.001). 8% of BKP patients had cement extravasations, compared to 10.5% in the RF-TVA group (p = 1.0)., Conclusions: Combining posterior fixation with RF-TVA leads to better results of VAS and ODI, whereas the vertebral height restoration was favorable for patients treated with BKP. Cement leakage was comparable between both groups. It was asymptomatic and within reported ranges. Limitations of this study are the patient number and different stabilization instrumentation.

Background: This study reports one year post-operative monitoring of the efficacy and safety of iFuse Implant System® in patients with sacroiliac joint syndrome. Material and Methods: After 6 months of inadequate conservative treatment, patients with properly proven ISG syndrome were selected for surgery. The iFuse implants had a triangular profile and coating of porous titanium plasma spray and were used in the minimally invasive procedures. The procedure was performed under general anaesthesia and fluoroscopic control. In each case, three implants were placed. Results: 24 patients (22 f; 92 %; 54.9 ± 14 years) participated in the study. The operations were performed in 11 patients (46 %) on the left and in 13 patients (54 %) on the right. The mean operative time was 42.4 minutes (95 % CI: 35.6-49.3). The reduction in pain intensity on the VAS scale was 58 ± 11 mm (68 ± 7 %). The Oswestry score showed a median decrease of 44 percentage points (57 %). After 12 months, 15 patients (63 %) reported that they were taking no more painkillers. Conclusion: The minimally invasive treatment of patients with sacroiliac joint syndrome using the iFuse Implant System leads to significant analgesic effects over the period of one year; it also contributes significantly to improving the functioning of the patient., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The perception of back pain subjective is hard for physicians to measure. For this reason, questionnaires are an important instrument to evaluate the pain 1. The main point of this study was to verify differentiation of pain symptoms in patients with different pain mechanisms. The most important parameter was the PainDetect questionnaire, which can differentiate between nociceptive and neuropathic pain. Additional parameters were measured before and after surgery to characterise pain symptoms in detail. Material and Methods: We selected patients with diagnosed vertebral compression fracture, herniated disc or with spinal cord compression. To characterise the preoperative condition on admittance, we collected the data from the physical examination, as well as clinical data, including X-ray, CT and MRI. To characterise the pain, we used the painDetect questionnaire, the Oswestry Index questionnaire (ODI) and the visual analogue scale (VAS). Depending on the diagnosis, patients were treated by surgery (radiofrequency kyphoplasty, nucleotomy, spondylodesis). At 2 to 3 days and 6 months after surgery, we repeated the questionnaire and compared the results with those before the operation. Data on patient satisfaction and adverse events were also collected. Results: This study included 62 patients with vertebral compression fracture (group 1: VBF, 89 % female, mean age 71 years) and 77 patients with herniated disc or spinal cord compression (group 2: non-VBF, 55 % female, mean age 53 years). There was no difference between both groups in preoperative pain intensity (acute, maximum, average): median ordinal scale 0 to 10; group 1: 6, 8, 7; group 2: 6, 9, 7. The total score in the painDetect questionnaire differed significantly between the two groups (median group 1 = 9, group 2 = 17; effect size r = 0.5; p = 0.000). The existence of neuropathic pain was presumed (> 90 %) in 3 % of the patients in group 1 and in 13 % of patients it was not excluded. In contrast, in group 2 it was presumed (> 90 %) in 43 % of patients and in 30 % of patients it could not be excluded. Patients with vertebral compression fracture had greater pain intensity (VAS 71) than patients from group 2 (VAS 53). There was no difference in the total score of the Oswestry questionnaire between the two groups (56 % vs. 58 %). Pain intensity was significantly reduced in both groups after the operations. Six months postoperatively, pain intensity (median ordinal scale 0 to 10; acute, maximum, average) was 2, 5, 3 in group 1 and 2, 4, 2 in group 2. Moreover, the final scores of the painDetect questionnaires were significantly lower in both groups after the operations (4 in both groups). The median score of the ODI was reduced in both groups, with an effect size of 0.6. 98 % of the patients in group 1 and 94 % in group 2 were satisfied with the outcome of the operation. Conclusion: The preoperative pain characteristics of patients with vertebral compression fracture is different from those of patients with herniated disc or with spinal cord compression. 43 % of patients in group 2 exhibited a neuropathic pain component and in 30 % this could not be excluded. In contrast, in group 1 only 3 % of the patients exhibited a neuropathic pain component. Postoperatively, pain symptoms were significant reduced in both groups, so that the risk of chronic pain was considerably less., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Rapid and reliable differentiation between septic and aseptic presentations can be challenging in patients with painful total knee arthroplasties. Clinical symptoms, serum tests, as well as the analysis of synovial fluid, are important parameters. Nevertheless, deep intra-articular tissue samples exhibit greater sensitivity and specificity regarding the diagnosis of a suspected periprosthetic joint infection. In 2014, Hügle et al. introduced novel retrograde forceps to acquire tissue samples and synovial fluid simultaneously in an outpatient setting. In this article, we present the first use of their device in patients with total knee arthroplasty. Methods: After approval by a local ethics board, retrograde forceps were used via the standard lateral suprapatellar approach. The technique was comparable to conventional aspiration of a total knee arthroplasty. Beside joint aspiration, tissue samples were gathered for further microbiological and histopathological examination. Results and Discussion: It is easy to collect synovial fluid and tissue samples using the retrograde forceps in patients with suspected periprosthetic infections of the knee joint. This is a safe and feasible method and can be performed in an outpatient setting. We have not yet observed any complications and consider that the risks are comparable to those with conventional joint aspiration. In our opinion, this technique may be useful in detecting infections in patients with painful total knee arthroplasty., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Radiofrequency ablation (RFA) temperatures reaching 45°C in adjacent tissues are cytotoxic to the spinal cord, nerves and surrounding tissues., Objective: This study compares different RFA electrodes with regard to the temperature distribution during ablation of spinal metastases., Methods: In vitro experimental study in isolated lumbar vertebrae of a human cadaveric spine. The temperature distribution of RFA electrodes was measured during ablation in human cadaveric lumbar vertebrae containing a simulated vertebral body lesion. The analysis compared a novel bipolar RFA electrode with two conventional monopolar RFA electrodes. A vertebral metastasis model was prepared in eight lumbar vertebrae for each electrode. Differences between the electrodes were evaluated with a one-way ANOVA., Results: The lowest temperature at the thermocouples adjacent to the simulated lesion was achieved when using the bipolar RFA electrode (46.4 ± 3.3°C), but temperature difference to the monopolar RFA electrodes was not significant. In the neural foramen and epidural space of lumbar vertebrae the maximal temperature measured when using the bipolar RFA electrode was 37.0 ± 0°C and 37.3 ± 0.7°C, which was significantly lower than during ablation via either of the monopolar RFA electrodes (p ≤ 0.001)., Conclusions: Temperatures in areas of adjacent tissue during RFA using a specific for spinal ablation designed electrode with integrated thermocouples were significantly lower compared to other electrodes, potentially reducing temperature related risks during ablation.

Background: Patients with lumbar degenerative disk disease (DDD) often require an interbody fusion. Several spacer systems have been developed to achieve an adequate fusion. The newly developed flexible interbody spacer system (Luna®, Benvenue Medical Inc.) expands to the disk space and is adjustable to the patient's anatomy., Objective: Prospective monocentric evaluation of interbody fusions performed with the new system in patients with DDD to assess the device's efficacy and safety., Methods: The study includes patients with DDD of one or two contiguous lumbar levels. All patients were treated with the new flexible cage system. To evaluate the clinical outcome, examinations were conducted preoperatively, 6 weeks, 6 months and 12 months postoperatively. At each study visit possible implant loosening was assessed by plain radiography and any adverse events were documented. Furthermore, back pain was evaluated using the visual analogue scale (VAS), functional impairment using the Oswestry-Disability-Index (ODI) and quality of life using the SF36., Results: A total of 30 patients (age: 52.8 ± 11 years, gender: 53% male) were included. None of the patients showed signs of implant loosening and the total number of adverse events was low (3%). The VAS improved significantly from 81.2 ± 9.5 mm at baseline to 28 ± 26.2 mm after 12-months (p ≤ 0.0001). The ODI also improved significantly from 57.9 ± 9.6% at baseline to 20 ± 15.6% after 12-months (p ≤ 0.0001). The physical component score (PCS) of the SF36 improved significantly ongoing from 29.2 ± 9.3 at baseline to 56.1 ± 14.9 after 12-months (p = 0.0079) and the mental component score (MCS) improved significantly from 49.2 ± 20.7 at baseline to 62.8 ± 18.9 after 12 months (p = 0.013)., Conclusions: Minimal-invasive lumbar interbody fusion with the new flexible system is a safe and effective treatment method for patients with DDD. Complication rates are low and treatment leads to an improvement of pain, functional impairment and quality of life.

Background: Myeloma patients often suffer from painful vertebral fractures (VCF) which impair their quality of life. Common methods for augmentation of the vertebrae are vertebroplasty, kyphoplasty and radiofrequency-targeted vertebral augmentation (RF-TVA)., Objective: This study evaluates the long-term effectiveness and safety of RF-TVA in the treatment of myeloma associated VCF., Methods: Eighty-seven myeloma patients (mean age: 64.7 ± 9.5 years) with VCF were treated with RF-TVA. Patient data were assessed preoperatively and in five postoperative examinations up to 12 months. Pain was measured with the visual analogue scale (VAS) and the impairment was evaluated with the Oswestry-Disability-Index (ODI) at each examination. In addition, the mid vertebral height, kyphosis angle, and additional fractures were evaluated by x-rays. Furthermore, cement leakage was documented., Results: The VAS values were significantly improved in comparison to the preoperative values (p≤ 0.001), but slightly fluctuating during the follow-up period. The ODI was also significantly improved (p≤ 0.001), but it showed a worsening from the 12 months evaluation to the 24 months evaluation. The kyphosis angle and the vertebral height were significantly improved after surgery (p = 0.03, p ≤ 0.001), but worsened steadily to the last follow up examination. Cement leakage was asymptomatic and occurred in 18% of the patients. In 10% of the patients additional fractures were detected in the 24 months evaluation., Conclusions: The results of our study show that RF-TVA is a safe treatment for myeloma associated vertebral compression fractures, which achieves an acceptable improvement of patient's pain and quality of life.

Background: Painful vertebral compression fractures (VCF) caused by osteoporosis are a common health problem in the elderly population. If conservative treatments are unsuccessful, surgical treatments like vertebroplasty or kyphoplasty are recommended. But the use of Polymethylmethacrylat (PMMA) bone cement for augmentation surgery is associated with risks., Objectives: Evaluation of the effectiveness and safety of a newly developed silicon polymer (VK100) that can be used instead of PMMA bone cement for kyphoplasty treatments., Study Design: A retrospective study of 30 patients comparing the outcomes of kyphoplasty treatments conducted with PMMA and VK100., Setting: Clinic for Orthopedics and Trauma Surgery Bonn, Germany., Methods: Thirty patients with one to 3 VCF were treated either with balloon kyphoplasty using VK100 or balloon kyphoplasty using PMMA bone cement. Data from both groups was compared by a matched pair analysis. The medial vertebral height was measured at each examination radiologically. The patients stated their pain intensity using the Visual Analogue Scale (VAS) and the patient's functional impairment was evaluated with the Oswestry-Disability-Index (ODI).All data were assessed before surgery, and 3 days, 3 months, 6 months, and 12 months after surgery. Intraoperative and postoperative adverse events were documented., Results: The patients' functional impairment and pain improved significantly after surgery. The course of ODI and VAS was comparable in both treatment groups, but the improvement in the VK group was significantly ongoing until the 12 month follow-up. Vertebral height improvement was significant in both groups, but the PMMA group achieved a better absolute restoration. The vertebral height stayed constant during the follow-up in the VK group and worsened significantly in the PMMA group. There was no significant difference between groups concerning the occurrence of additional fractures; and no other types of complications or surgery-related adverse events were observed in either the PMMA group or in the VK group., Limitations: The study is only a matched pair analysis of 15 patients for each procedure and the amount of injected filling material was not recorded., Conclusion(s): The study results demonstrate that the clinical outcome of VAS and ODI of using the silicon polymer VK100 is comparable or slightly better than using PMMA. VK 100 shows a trend to minor additional fractures during the follow-up. However, height restoration is not satisfactory in comparison to PMMA, although vertebral height stayed more or less constant in the VK group. To address the augmentation success further, it would be necessary to study a larger patient group over a longer study period and to assess additional parameters such as bone density and injected amount of filling material.

Purpose: This clinical study investigates the use of a radiofrequency ablation system specifically developed for the ablation of spinal metastases. The investigation examines possible temperature-associated risks for the adjacent tissues., Material and Methods: A tumour model was simulated for 8 lumbar and 8 thoracic vertebrae of a human cadaveric spine. The tumour mass was ablated with the SpineSTAR electrode (SpineSTAR, DFINE Inc., CA), which has been specifically developed for the ablation of spinal metastases. During the ablation procedure, the temperatures of the vertebra, the epidural space, and the neural foramen were measured with thermocouples. These temperatures were documented as means with standard deviations. Possible differences between lumbar and thoracic vertebrae were analysed with the Mann-Whitney U test., Results: The maximal temperature of the lumbar vertebrae was 46.4 ± 3.3 °C near to the ablation zone, the temperature of the neural foramen was 37.0 ± 0 °C, and the temperature of the epidural space was 37.3 ± 0.7 °C. In the thoracic vertebrae, the temperature was 44.4 ± 1.7 °C near to the ablation zone, 7.9 ± 1.7 °C in the neural foramen, and 37.25 ± 0.7 °C in the epidural space. There was no significant difference in temperature distribution between treated lumbar and thoracic vertebrae., Conclusion: Ablation of spinal metastases in a cadaveric model using the SpineSTAR electrode was shown to be a safe method with respect to possible temperature-related risks for the adjacent tissues., (Georg Thieme Verlag KG Stuttgart · New York.)

The anterolateral ligament of the knee (ALL) has caused a lot of rumors in orthopaedics these days. The structure that was first described by Segond back in 1879 has experienced a long history of anatomic descriptions and speculations until its rediscovery by Claes in 2013. Its biomechanical properties and function have been examined recently, but are not yet fully understood. While the structure seems to act as a limiter of internal rotation and lateral meniscal extrusion its possible proprioceptive effect remains questionable. Its contribution to the pivot shift phenomenon has been uncovered in parts, therefore it has been recognized that a concomitant anterolateral stabilization together with ACL reconstruction may aid in prevention of postoperative instability after severe ligamentous knee damages. However, there are a lot of different methods to perform this procedure and the clinical outcome has yet to be examined. This concise review will give an overview on the present literature to outline the long history of the ALL under its different names, its anatomic variances and topography as well as on histologic examinations, imaging modalities, arthroscopic aspects and methods for a possible anterolateral stabilization of the knee joint.

Background: Resection of diaphyseal bone tumors for local tumor control and stabilization often results in an intercalary skeletal defect and presents a reconstructive challenge for orthopaedic surgeons. Although many options for reconstruction have been described, relatively few studies report on the functional outcomes and complications of patients treated with modular intercalary endoprostheses., Questions/purposes: The objectives of this study were to examine clinical outcomes after reconstruction with a modular intercalary endoprosthesis with a specific focus on (1) the rate of complication or failure; (2) differences in complication rates by anatomic site; (3) functional results as assessed by the Musculoskeletal Tumor Society System (MSTS); and (4) differences in complication rate between patients treated with cemented versus noncemented fixation., Methods: We conducted a retrospective chart review of patients treated with a modular intercalary endoprosthesis from three musculoskeletal oncology centers from 2008 to 2013. The indication for use of this intercalary endoprosthesis was segmental bone loss from aggressive or malignant tumor with sparing of the joint above and below and deemed unsuitable for biologic reconstruction. No other implant was used for this indication during this period. During this period, 41 patients received a total of 44 intercalary implants, which included 18 (40%) humeri, 5 (11%) tibiae, and 21 (48%) femora. There were 27 (66%) men and 14 (34%) women with a mean age of 63 years (range, 18–91 years). Eight patients (20%) had primary bone tumors and 33 (80%) had metastatic lesions. Thirty-five (85%) patients were being operated on as an initial treatment and six (15%) for revision of a previous reconstruction. Twenty-nine (66%) procedures had cemented stem fixation and 15 (34%) were treated with noncemented fixation. The overall mean followup was 14 months (range, 1–51 months). Patients with primary tumors had a mean followup of 19 months (range, 4–48 months) and patients with metastatic disease had a mean followup of 11 months (range, 1–51 months). Causes of implant failure were categorized according to Henderson et al. [19] into five types as follows: Type I (soft tissue failure), Type II (aseptic loosening), Type III (structural failure), Type IV (infection), and Type V (tumor progression). At 2 years of followup, 38 (93%) of these patients were accounted for with three (7%) lost to followup. MSTS functional assessment was available for 39 of 41 patients (95%)., Results: At latest followup of these 41 patients, 14 (34%) patients were dead of disease, two patients (5%) dead of other causes, seven (17%) are continuously disease-free, one (2%) shows no evidence of disease, and 17 (41%) are alive with disease. There were 12 (27%) nononcologic complications. Five (11%) of these were Type II failures occurring in noncemented implants between the stem and bone, and six (14%) were Type III failures occurring in cemented implants at the clamp-rod implant interface. One patient developed a deep infection (2%, Type IV failure) and underwent removal of the implant. Additionally, one patient (2%, Type V failure) was treated by amputation after local progression of his metastatic disease. Complications were more common in femoral reconstructions than in tibial or humeral reconstructions. Twelve of 21 patients (57%) with femoral reconstructions had complications versus 0% of tibial or humeral reconstructions (0 of 23; odds ratio [OR], 62; 95% confidence interval [CI], 3–1154; p < 0.0001). The mean overall MSTS score was 77%. Implants with cemented fixation (29) had higher mean MSTS scores when compared with implants with noncemented (15) fixation (84% versus 66%, p = 0.0017). The complication rate was 33% in noncemented cases and 21% in cemented cases (p = 0.39); however, Type II failure at the bone-stem interface was associated with noncemented fixation and Type III failure at the clamp-rod interface was associated with cemented fixation (OR, 143; 95% CI, 2.413–8476; p = 0.0022)., Conclusions: The results of this study indicate that this modular intercalary endoprosthesis yields equivalent results to other studies of intercalary endoprostheses in terms of MSTS scores. We found that patients treated with intercalary endoprostheses in the femur experienced more frequent complications than those treated for lesions in either the humerus or tibia and that the femoral complication rate of this endoprosthesis is higher when compared with other studies of intercalary endoprostheses for femoral reconstruction. Further studies are still needed to determine the long-term outcomes of this endoprosthesis in patients with primary tumors where longevity of the implant is of more importance than in the metastatic setting. We recommend cemented fixation for this intercalary modular endoprostheses because this provides improved MSTS scores and allows immediate return to weightbearing, which is of advantage to metastatic patients with limited lifespans. Level of Evidence: Level III, therapeutic study.

Background: Malnutrition in geriatric patients is very common and an important outcome factor when treating injuries and fractures. There is actually no clear definition of the term malnutrition or recommendation for a screening method., Objective: The purpose of this study was to determine the nutritional status of geriatric trauma patients using different screening procedures. We tested whether the body mass index (BMI) gives indication for malnutrition or if there is a correlation with more specific test procedures., Methods: The BMI and the data of three specific screening procedures, Subjective Global Assessment (SGA), Nutritional Risk Screening (NRS) and Mini Nutritional Assessment (MNA) were calculated; clinical parameters were registered., Results: There was proof of correlation (p< 0.001) between BMI and SGA; also between BMI and NRS was a significant correlation (p= 0.0004). There was less significant correlation between BMI and MNA (p= 0.05). All three screening methods correlated (p< 0.01)., Conclusions: BMI and subjective statements provide first important information. The SGA not only correlates well with the BMI, but also complements the overall picture with individual information regarding medical history and clinical findings. Other more extensive methods, such as the NRS and the MNA, also show correlation and complement the overall picture with individual information.

The incidence of fractures among epileptics is frequent and mostly occurs by direct trauma due to falls caused by seizures. The risk of fractures is estimated to be 50 % higher in epileptics than in the general population. Most of the fractures affect the proximal femora and the hip joint. Dorsal shoulder dislocations occur frequently in epileptics. If they occur bilaterally, this is pathognomonic for seizuring. Besides this, shoulder dislocation and bilateral dislocation fractures of the humeral head, however, are far more rare even among epileptics but pathognomonic for seizure. In this case report we present a female patient with bilateral dislocation fracture of the humeral head due to first clinical manifestation of a tonic-clonic seizure without direct trauma., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Antimicrobial coatings have a great potential in the treatment and prevention of periprosthetic joint infection., Objective: To present established and novel concepts of antimicrobial coatings., Methods: A literature review and discussion of published concepts in basic research, pre-clinical animal studies, and clinical practice were carried out., Results: To date there has been a wide range of technical solutions (anti-adhesive surfaces, bioactive surfaces with antimicrobial effects, surfaces releasing antimicrobial substances, nanostructures, bioactive surfaces affecting biofilm development) demonstrating a high potential in pre-clinical studies. Only a few with the bactericidal activity of silver ions have been prepared for the market. Conclusive results with regard to biocompatibility and toxicity are lacking., Discussion: Despite the great potential of antimicrobial coatings, no conclusive decisions can be made because of the limited data and the lack of evidence of their clinical efficacy on the basis of prospective controlled clinical studies. In addition to their unlimited biocompatibility, innovative concepts have to be feasible in everyday clinical routine.

Background: The clinical presentation of spondylsodiscitis/spondylitis are manifold. This commonly leads to a period of several months from initial symptoms to final diagnosis. A standardised treatment is difficult. The purpose of this study is to investigate the treatment carried out for patients with spondylodiscitis or spondylitis to develop an individualised standard care for better treatment., Patients and Methods: Data of 90 patients were retrospective analysed. In particular documented data of the initial examination and the following treatments concerning identification of causes and systematically control of pathogens were examined., Results: In 91 % of patients a diagnostically conclusive MRI was conducted. The degree of spondylidiscitis/spondylitis was mainly ASA criteria I or II (86 %). In 96 % of patients different diagnostic methods for identification of pathogens were conducted and documented. RESULTS confirmed the most common pathogens mentioned in the literature. 75 % of patients were treated by surgery. In 93 % of patients an antibiotic treatment was documented. 50 patients (81 %) were successfully healed., Conclusion: It is important to identify and treat spondylodiscitis/spondylitis as early as possible. Diagnosis by means of blood culture and MRI and treatment of the infection with antibiotics and possibly surgical interventions seem be very suitable, but need to be individualised to each and every patient., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Total knee arthroplasty (TKA) is an effective treatment option for patients with end-stage haemophilic arthropathy of the knee. However, the procedure is technically challenging, as knee motion is often restricted before the operation and complication rates are then thought to be higher than for patients with a normal range of motion (ROM). There is very limited information on the outcome of TKA in haemophilic patients presenting with stiff knees. The objective of the present study was to retrospectively analyse and compare the clinical results after TKA in haemophiliacs with stiff and non-stiff knees., Patients and Methods: The results of 50 TKA procedures in 41 haemophilic patients were retrospectively evaluated at a mean follow-up of 7.2 ± 4.9 years (range 2-25 years). 20 patients presenting with 23 stiff knees - defined by a preoperative ROM of 50° or less - were compared with 21 patients with 27 non-stiff knees. Knee motion (ROM, flexion, extension), Knee Society Score (KSS/KSS function), pain status (visual analogue scale, VAS), number of bleedings and patient satisfaction were evaluated., Results: The complication rate was 12 %, including two haematomas, one aseptic loosening, and three periprosthetic infections. The overall mean ROM increased from 58.6 ± 34.2° (range 0-120°) preoperatively to 85.9 ± 23.4 (35-130°) postoperatively (p < 0.005). Mean KSS and KSS function improved from 30.6 ± 11.0 points (range 10-49) and 43.4 ± 9.3 points (range 15-65) to 79.3 ± 9.6 points (range 49-95) and 68.9 ± 11.0 points (45-90), respectively (p < 0.005). The mean VAS score decreased significantly from 7.9 ± 0.8 points (range 6-9) to 1.8 ± 1.1 points (range 0-4; p < 0.005). In comparison to the non-stiff group, patients with stiff knees showed a significantly greater mean improvement in ROM (46.3 ± 21.8° [range - 10-85°] vs. 9.4 ± 16.9° [range - 30-35°]), flexion (32.8 ± 19.6° [range - 10-85°] vs. 5.2 ± 16.2° [range - 40-35°]), and flexion contracture (13.5 ± 9.6° [range 5-30°] vs. 5.9 ± 6.7° [range 5-20°]). Both KSS and KSS function were significantly inferior in stiff knees than with non-stiff knees. Nine patients with knee stiffness who underwent additional v-y quadricepsplasty to lengthen the extensor mechanism developed a mean extensor lag of 7-0° ± 4-8° (range 5-15°). At final follow-up, 37/41 patients were satisfied or very satisfied with the surgical result., Conclusion: TKA in haemophilic patients presenting with haemophilic arthropathy of the knee results in significant improvements in function and reduced pain. Although the ultimate clinical outcome in stiff knees is inferior to that with non-stiff knees, joint replacement surgery can be successfully performed in patients with restricted preoperative range of motion. Vy-quadricepsplasty for to facilitate exposure is associated with the development of a postoperative extensor lag and should therefore be performed restrictively. Patient satisfaction after TKA was equally high in the two groups., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Reconstruction and long-term stabilization of segmental diaphyseal bone defects of the humerus, femur, and tibia., Indications: Segmental bone defects due to aggressive benign or primary malignant bone tumors, trauma, pathological fractures, osteomyelitis, or failed osteosynthesis., Contraindications: Acute or chronic local infections, large metadiaphyseal bone defects preventing adequate anchorage of the prosthesis, very short life expectancy (<3 months)., Surgical Technique: Exposure and resection of the bony defect according to the preoperative planning. Reaming of the intramedullary canals proximally and distally followed by implantation of the stems (cemented or noncemented). Reducing sleeves can be used to bridge the difference in diameter between the nail and the spacer. Mounting of the spacer half shell with the threaded holes from underneath after adjusting for alignment and rotation. Assembling of the other half shell by guided pins to ensure proper alignment. Tightening of the clamping screws using a torque screwdriver. Connection of two spacers is possible., Postoperative Management: Active physiotherapy and full weight bearing; antibiotic prophylaxis., Results: The results of 14 consecutive patients treated with 15 modular intercalary endoprostheses (Osteobridge™, Merete, Berlin, Germany) between January 2007 and January 2012 with a mean follow up of 24 ± 12 months (range 12-51 months) were evaluated retrospectively. One patient had a primary malignant bone tumor, while all the other patients underwent resection for metastatic disease. The mean age at surgery was 65.9 ± 15.7 years (range 25-83 years). The mean diaphyseal reconstruction length was 110 ± 50 mm (range 50-190 mm). Three patients (20%) required revision of the distal stem due to aseptic loosening. Evaluation of the functional outcome using the MSTS score by Enneking revealed 3 very good (22%), 7 good (50%), 4 fair (28%), and no poor results.

von Willebrand disease (VWD) is a recognized cause of secondary ankle osteoarthritis (OA). Few studies have examined orthopaedic complications and outcomes in VWD patients treated for end-stage ankle OA with total ankle replacement (TAR). To determine the clinical presentation, intraoperative and postoperative complications and evaluate the mid-term outcome in VWD patients treated with TAR. Eighteen patients with VWD with mean age 47.3 years (range = 34.0-68.7) were treated for end-stage ankle OA with TAR. The mean duration of follow-up was 7.5 years (range = 2.9-13.2). Intraoperative and perioperative complications were recorded. Component stability was assessed with weight-bearing radiographs. Clinical evaluation included range of motion (ROM) tests using a goniometer and under fluoroscopy using a lateral view. Clinical outcomes were analysed by a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score and Short Form (36) Health Survey (SF-36) health survey. One patient sustained an intraoperative medial malleolar fracture. In two patients delayed wound healing was observed. Two secondary major surgeries were performed. Pain level decreased from 8.2 ± 0.9 (range = 7-10) preoperatively to 1.1 ± 1.2 (range = 0-4) postoperatively. Significant functional improvement including ROM was observed. All categories of SF-36 score showed significant improvement in quality of life. Mid-term results of TAR in patients with VWD are encouraging. The total rate of intraoperative and postoperative complications was 33.3%. However, longer term outcomes are necessary to fully understand the clinical benefit of TAR in patients with VWD., (© 2015 John Wiley & Sons Ltd.)

Purpose: The Charlson comorbidity index (CCI) was developed to quantify the influence of comorbidities on survival. The age-related CCI respects patients' age as an additional risk factor. There are several studies available based on administrative data regarding functional outcome, implant survival, resource use and length of hospital stay in patients undergoing primary total hip arthroplasty (THA). To date, there is a lack of knowledge regarding the correlation of the CCI and the age-related CCI in case of revision total hip arthroplasty (RTHA)., Objective: Our objective was to validate the influence of the CCI and age-related CCI in patients undergoing RTHA regarding complication rate, resource use implant survival and mortality rate., Methods: Between October 2007 and November 2012, 142 consecutive patients undergoing RTHA were included in this retrospective study. Routine clinical data were collected and analysed as anonymized aggregated data. In accordance to CCI and age-related CCI the rate of complications (internal medical and surgical complications), the length of hospital stay and the need for ICU treatment and the mortality rate was evaluated. Kaplan-Meier survivorship was used to determine implant survival., Results: Twenty-one patients (15%) had a low risk CCI, 59 patients (41%) a moderate risk CCI and 62 patients (44%) a high risk CCI. The mean follow-up was 27 months (range 24-70 months). In total, we recorded 57 complications (40%), of which 45 were surgical (79%) and 12 were internal medical complications (21%). Twenty-four patients (17%) had to undergo revision surgery. CCI and age-related CCI had no influence regarding implant survival. We recorded a significant influence of the age-related CCI in regard to the necessity of postoperative intensive care unit stay and the length of total hospital stay. Further we recorded a significant influence of the CCI and the age-related CCI regarding postoperative complications and internal complications, postoperative dislocation and the need for surgical revision., Conclusion: In summary, we conclude that the CCI and the age-related CCI are strong predictors regarding complication rate in patients undergoing RTHA. In a short- to mid-term follow-up, no influence on implant survival is detectable.