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Atmospheric nitrate (NO3−Atm) deposition has increased dramatically during the past ~ 150 years and contributes to ecosystem eutrophication. NO3−Atm deposition is widespread, but the role of different landscapes in modulating watershed-scale processing and export of NO3−Atm remains unclear. We measured triple oxygen isotopes (a tracer of NO3−Atm) of NO3− for 832 stream samples collected during baseflow and stormflow from 14 watersheds of varied land use throughout two years in the Chesapeake Bay watershed, and we used these data to assess the influence of land use on NO3−Atm dynamics. Watersheds with more agricultural (> 35%) and developed (> 70%) land exported more NO3−Atm than predominantly forested (> 75%) watersheds. Agricultural lands likely facilitate greater NO3−Atm export because of elevated rates of terrestrial N addition relative to rates of NO3− consumption. In contrast, developed lands likely have limited biotic processing of NO3−Atm because of greater hydrologic connectivity of overland flow pathways to channels. Our results, along with data from prior studies, can be interpreted by extending the conceptual model of kinetic N saturation to NO3−Atm streamwater export across varied land use watersheds. In this framework, elevated rates of terrestrial N inputs overwhelm NO3− sinks, allowing proportionally more NO3−Atm to leak from watersheds. Changes in watershed-scale N inputs that increase stream NO3− concentrations additively affect NO3−Atm, with agricultural watersheds, and their associated large terrestrial N inputs, increasing NO3−Atm export.

A limitation to understanding drivers of long-term trends in terrestrial nitrogen (N) availability in forests and its subsequent influence on stream nitrate export is a general lack of integrated analyses using long-term data on terrestrial and aquatic N cycling at comparable spatial scales. Here we analyze relationships between stream nitrate concentrations and wood

Anthropogenic nutrient inputs have led to nutrient enrichment in many waterbodies worldwide, including Chesapeake Bay (USA). River water quality integrates the spatial and temporal changes of watersheds and forms the foundation for disentangling the effects of anthropogenic inputs. We demonstrate with the Chesapeake Bay Non-Tidal Monitoring Network that machine learning approaches – i.e., hierarchical clustering and random forest (RF) classification – can be combined to better understand the regional patterns and drivers of total nitrogen (TN) trends in large monitoring networks, resulting in information useful for watershed management. Cluster analysis revealed regional patterns of short-term TN trends (2007–2018) and categorized the stations into three distinct trend clusters, namely, V-shape (n = 23), monotonic decline (n = 35), and monotonic increase (n = 26). RF models identified regional drivers of TN trend clusters by quantifying the effects of watershed characteristics (land use, geology, physiography) and major N sources on the trend clusters. Results provide encouraging evidence that improved agricultural nutrient management has resulted in declines in agricultural nonpoint sources, which in turn contributed to water-quality improvement in our period of analysis. Moreover, water-quality improvements are more likely in watersheds underlain by carbonate rocks, reflecting the relatively quick groundwater transport of this terrain. By contrast, water-quality improvements are less likely in Coastal Plain watersheds, reflecting the effect of legacy N in groundwater. Notably, results show degrading trends in forested watersheds, suggesting new and/or remobilized sources that may compromise management efforts. Finally, the developed RF models were used to predict TN trend clusters for the entire Chesapeake Bay watershed at the fine scale of river segments (n = 979), providing fine spatial information that can facilitate targeted watershed management, including unmonitored areas. More broadly, this combined use of clustering and classification approaches can be applied to other regional monitoring networks to address similar water-quality questions.

Human agriculture, wastewater, and use of fossil fuels have saturated ecosystems with nitrogen and phosphorus, threatening biodiversity and human water security at a global scale. Despite efforts to reduce nutrient pollution, carbon and nutrient concentrations have increased or remained high in many regions. Here, we applied a new ecohydrological framework to ~12,000 water samples collected by the U.S. Environmental Protection Agency from streams and lakes across the contiguous U.S. to identify spatial and temporal patterns in nutrient concentrations and leverage (an indicator of flux). For the contiguous U.S. and within ecoregions, we quantified trends for sites sampled repeatedly from 2000 to 2019, the persistence of spatial patterns over that period, and the patch size of nutrient sources and sinks. While we observed various temporal trends across ecoregions, the spatial patterns of nutrient and carbon concentrations in streams were persistent across and within ecoregions, potentially because of historical nutrient legacies, consistent nutrient sources, and inherent differences in nutrient removal capacity for various ecosystems. Watersheds showed strong critical source area dynamics in that 2–8% of the land area accounted for 75% of the estimated flux. Variability in nutrient contribution was greatest in catchments smaller than 250 km2for most parameters. An ensemble of four machine learning models confirmed previously observed relationships between nutrient concentrations and a combination of land use and land cover, demonstrating how human activity and inherent nutrient removal capacity interactively determine nutrient balance. These findings suggest that targeted nutrient interventions in a small portion of the landscape could substantially improve water quality at continental scales. We recommend a dual approach of first prioritizing the reduction of nutrient inputs in catchments that exert disproportionate influence on downstream water chemistry, and second, enhancing nutrient removal capacity by restoring hydrological connectivity both laterally and vertically in stream networks.

Little is known about the regional extent and variability of nitrate from atmospheric deposition that is transported to streams without biological processing in forests. We measured water chemistry and isotopic tracers (δ18O and δ15N) of nitrate sources across the Northern Forest Region of the U.S. and Canada and reanalyzed data from other studies to determine when, where, and how unprocessed atmospheric nitrate was transported in catchments. These inputs were more widespread and numerous than commonly recognized, but with high spatial and temporal variability. Only 6 of 32 streams had high fractions (>20%) of unprocessed atmospheric nitrate during baseflow. Seventeen had high fractions during stormflow or snowmelt, which corresponded to large fractions in near-surface soil waters or groundwaters, but not deep groundwater. The remaining 10 streams occasionally had some (

To understand the environmental and anthropogenic drivers of stream nitrogen (N) concentrations across the conterminous US, we combined summer low-flow data from 4997 streams with watershed information across three survey periods (2000-2014) of the US EPA's National Rivers and Streams Assessment. Watershed N inputs explained 51% of the variation in log-transformed stream total N (TN) concentrations. Both N source and input rates influenced stream NO3/TN ratios and N concentrations. Streams dominated by oxidized N forms (NO3/TN ratio > 0.50) were more strongly responsive to the N input rate compared to streams dominated by other N forms. NO3 proportional contribution increased with N inputs, supporting N saturation-enhanced NO3 export to aquatic ecosystems. By combining information about N inputs with climatic and landscape factors, random forest models of stream N concentrations explained 70, 58, and 60% of the spatial variation in stream concentrations of TN, dissolved inorganic N, and total organic N, respectively. The strength and direction of relationships between watershed drivers and stream N concentrations and forms varied with N input intensity. Model results for high N input watersheds not only indicated potential contributions from contaminated groundwater to high stream N concentrations but also the mitigating role of wetlands.

Published reports suggest efforts designed to prevent the occurrence of harmful algal blooms and hypoxia by reducing non-point and point source phosphorus (P) pollution are not delivering water quality improvements in many areas. Part of the uncertainty in evaluating watershed responses to management practices is the lack of standardized estimates of phosphorus inputs and outputs. To assess P trends across the conterminous United States, we compiled an inventory using publicly available datasets of agricultural P fluxes, atmospheric P deposition, human P demand and waste, and point source discharges for 2002, 2007, and 2012 at the scale of the 8-digit Hydrologic Unit Code subbasin (~1,800 km(2)). Estimates of agricultural legacy P surplus accumulated from 1945 to 2001 were also developed. Fertilizer and manure inputs were found to exceed crop removal rates by up to 50% in many agricultural regions. This excess in inputs has led to the continued accumulation of legacy P in agricultural lands. Atmospheric P deposition increased throughout the Rockies, potentially contributing to reported increases in surface water P concentrations in undisturbed watersheds. In some urban areas, P fluxes associated with human waste and non-farm fertilizer use has declined despite population growth, likely due, in part, to various sales bans on P-containing detergents and fertilizers. Although regions and individual subbasins have different contemporary and legacy P sources, a standardized method of accounting for large and small fluxes and ready to use inventory numbers provide essential infromation to coordinate targeted interventions to reduce P concentrations in the nation’s waters.

Ecosystems require access to key nutrients like nitrogen (N) and sulfur (S) to sustain growth and healthy function. However, excessive deposition can also damage ecosystems through nutrient imbalances, leading to changes in productivity and shifts in ecosystem structure. While wildland fires are a known source of atmospheric N and S, little has been done to examine the implications of wildland fire deposition for vulnerable ecosystems. We combine wildland fire emission estimates, atmospheric chemistry modeling, and forest inventory data to (a) quantify the contribution of wildland fire emissions to N and S deposition across the U S, and (b) assess the subsequent impacts on tree growth and survival rates in areas where impacts are likely meaningful based on the relative contribution of fire to total deposition. We estimate that wildland fires contributed 0.2 kg N ha−1 yr−1 and 0.04 kg S ha−1 yr−1 on average across the U S during 2008–2012, with maxima up to 1.4 kg N ha−1 yr−1 and 0.6 kg S ha−1 yr−1 in the Northwest representing over ∼30% of total deposition in some areas. Based on these fluxes, exceedances of S critical loads as a result of wildland fires are minimal, but exceedances for N may affect the survival and growth rates of 16 tree species across 4.2 million hectares, with the most concentrated impacts occurring in Oregon, northern California, and Idaho. Understanding the broader environmental impacts of wildland fires in the U S will inform future decision making related to both fire management and ecosystem services conservation.

Understanding drivers of water quality in local watersheds is the first step for implementing targeted restoration practices. Nutrient inventories can inform water quality management decisions by identifying shifts in nitrogen (N) and phosphorus (P) balances over space and time while also keeping track of the likely urban and agricultural point and nonpoint sources of pollution. The Chesapeake Bay Program’s Chesapeake Assessment Scenario Tool (CAST) provides N and P balance data for counties throughout the Chesapeake Bay watershed, and these data were leveraged to create a detailed nutrient inventory for all the counties in the watershed from 1985–2019. This study focuses on three primary watershed nutrient balance components—agricultural surplus, atmospheric deposition, and point source loads—which are thought to be the leading anthropogenic drivers of nutrient loading trends across the watershed. All inputs, outputs, and derived metrics (n=53) like agricultural surplus and nutrient use efficiency, were subjected to short- and long-term trend analyses to discern how sources of pollution to surface water have changed over time. Across the watershed from 1985–2019, downward trends in atmospheric deposition were ubiquitous. Though there are varying effects, long-term declines in agricultural surplus were observed, likely because nutrients are being managed more efficiently. Multiple counties’ point source loads declined, primarily associated with upgrades at major cities that discharge treated wastewater directly to tidal waters. Despite all of these positive developments, recent increases in agricultural surpluses from 2009–2019 highlight that water quality gains may soon be reversed in many agricultural areas of the basin. Besides tracking progress and jurisdictional influence on pollution sources, the nutrient inventory can be used for retrospective water quality analysis to highlight drivers of past improvement/degradation of water quality trends and for decision makers to develop and track their near- and long-term watershed restoration strategies.

The composition of forests in the northeastern United States and the ecosystem services they provide to future generations will depend on several factors. In this paper, we isolate the effects of two environmental drivers, nitrogen (N) deposition and climate (temperature and precipitation) change, through an analysis of a single cohort of 24 dominant tree species. We assembled a tree database using data from U.S. Forest Service Forest Inventory and Analysis monitoring plots. Applying observed species-specific growth and survival responses, we simulated how forest stands in a 19-state study area would change from 2005 to 2100 under 12 different future N deposition-climate scenarios. We then estimated implications for three selected forest ecosystem services: merchantable timber, aboveground carbon sequestration, and tree diversity. Total tree biomass (for 24 species combined) was positively associated with both increased N deposition and temperatures; however, due to differences in the direction and magnitude of species-specific responses, forest composition varied across scenarios. For example, red maple (Acer rubrum) trees gained biomass under scenarios with more N deposition and more climate change, whereas biomass of yellow birch (Betula alleghaniensis) and red pine (Pinus resinosa) was negatively affected. Projections for ecosystem services also varied across scenarios. Carbon sequestration, which is positively associated with biomass accumulation, increased with N deposition and increasing climate change. Total timber values also increased with overall biomass; however, scenarios with increasing climate change tended to favor species with lower merchantable value, whereas more N deposition favored species with higher merchantable value. Tree species diversity was projected to decrease with greater changes in climate (warmer temperatures), especially in the northwestern, central, and southeastern portions of the study area. In contrast, the effects of N deposition on diversity varied greatly in magnitude and direction across the study area. This study highlights species-specific and regional effects of N deposition and climate change in northeastern U.S. forests, which can inform management decision for air quality and forests in the region, as well as climate policy. It also provides a foundation for future studies that may incorporate other important factors such as multiple cohorts, sulfur deposition, insects, and diseases. US Environmental Protection Agency [EP-C-11-036, EP-W-11-029] We would like to thank Alan Talhelm and Christine Davis for their thoughtful review and comments on the draft manuscript, as well as Jamie Cajka, Marion Deerhake, Justine Allpress, Lindsay Aramayo, and Christina Van Winkle for their key contributions to the project. Financial support for this research was provided by the US Environmental Protection Agency under Contract EP-C-11-036 and Contract EP-W-11-029. The views expressed in this manuscript are those of the authors and do not necessarily represent the views or policies of the U.S. Environmental Protection Agency.

Ongoing water quality degradation tied to nitrogen and phosphorus pollution results in significant economic damages by diminishing the recreational value of surface water and compromising fisheries. Progress in decreasing nitrogen and phosphorus pollution to surface water over the past two decades has been slow. Limited resources need to be leveraged efficiently and effectively to prioritize watersheds for restoration. Leveraging recent nitrogen and phosphorus inventories for the years 2002, 2007, and 2012, we extracted relevant flux and demand terms to help identify US subbasins that are likely contributing a disproportionate amount of point and non-point source nutrient pollution to surface water by exploring the mean spatial distribution of terrestrial anthropogenic surplus, agricultural surplus, agricultural nutrient use efficiency, and point source loads. A small proportion of the landscape, 50% of point source loads into surface water. Point source loads are mainly concentrated in urban areas across the country with point source loading rates often exceeding >10.0 kg N ha−1 yr−1 and >1.0 kg P ha−1 yr−1. However, the ability for future upgrades to wastewater treatment plant infrastructure alone is unlikely to drive further improvement in water quality, outside of local water ways, since point source loads only account for ~4% of anthropogenic N and P surplus. As such, further progress in boosting nutrient use efficiency in agricultural production, usually lowest in areas of intensive livestock production, would likely contribute to the biggest gains to water quality restoration goals. This analysis and the corresponding database integrate multiple streams of information to highlight areas where N and P are being managed inefficiently to give decision makers a succinct platform to identify likely areas and sources of water quality degradation.

Reducing nutrient pollution of surface and coastal waters in the U.S. and elsewhere remains a major environmental and engineering challenge for the 21st century. In the case of the Chesapeake Bay restoration, we still lack scientific proof that watershed-based management actions have been effective at reducing nonpoint-source nutrient loads from the land to this estuary in accordance with restoration goals. While the conventional wisdom is that implementation of best management practices (BMP’s) and wastewater treatment have turned the tide against nutrient pollution, we examined long-term (1986-present) nitrate-N trends in streams and major tributaries of the Upper Potomac River Basin (UPRB) and found that: 1) dramatic reductions in annual discharge-weighted mean nitrate-N concentrations and yields across the UPRB can be almost universally attributed to reductions in atmospheric N deposition as opposed to on-the-ground management actions such as implementation of BMP’s; 2) observed water quality changes generally comport with a modified kinetic N saturation model (MKNSM); 3) the MKNSM can separate the nitrate-N yield that is responsive to atmospheric deposition from a “non-responsive” yield; and 4) N saturation from atmospheric N deposition appears to be an inherently reversible process across most of the landscape. These unanticipated region-wide water quality benefits can be attributed to NOx emission controls brought about by the 1990 Clean Air Act Amendments (and subsequent U.S. NOX control programs) and reflect a water quality “success story” in the Chesapeake Bay restoration.

Excess nitrate in drinking water is a human health concern, especially for young children. Public drinking water systems in violation of the 10 mg nitrate-N/L maximum contaminant level (MCL) must be reported in EPA's Safe Drinking Water Information System (SDWIS). We used SDWIS data with random forest modeling to examine the drivers of nitrate violations across the conterminous U.S. and to predict where public water systems are at risk of exceeding the nitrate MCL. As explanatory variables, we used land cover, nitrogen inputs, soil/hydrogeology, and climate variables. While we looked at the role of nitrate treatment in separate analyses, we did not include treatment as a factor in the final models, due to incomplete information in SDWIS. For groundwater (GW) systems, a classification model correctly classified 79% of catchments in violation and a regression model explained 43% of the variation in nitrate concentrations above the MCL. The most important variables in the GW classification model were % cropland, agricultural drainage, irrigation-to-precipitation ratio, nitrogen surplus, and surplus precipitation. Regions predicted to have risk for nitrate violations in GW were the Central California Valley, parts of Washington, Idaho, the Great Plains, Piedmont of Pennsylvania and Coastal Plains of Delaware, and regions of Wisconsin, Iowa, and Minnesota. For surface water (SW) systems, a classification model correctly classified 90% of catchments and a regression model explained 52% of the variation in nitrate concentration. The variables most important for the SW classification model were largely hydroclimatic variables including surplus precipitation, irrigation-to-precipitation ratio, and % shrubland. Areas at greatest risk for SW nitrate violations were generally in the non-mountainous west and southwest. Identifying the areas with possible risk for future violations and potential drivers of nitrate violations across U.S. can inform decisions on how source water protection and other management options could best protect drinking water.

A limitation to understanding drivers of long-term trends in terrestrial nitrogen (N) availability in forests and its subsequent influence on stream nitrate export is a general lack of integrated analyses using long-term data on terrestrial and aquatic N cycling at comparable spatial scales. Here we analyze relationships between stream nitrate concentrations and wood δ 15N records (n = 96 trees) across five neighboring headwater catchments in the Blue Ridge physiographic province and within a single catchment in the Appalachian Plateau physiographic province in the eastern United States. Climatic, acidic deposition, and forest disturbance datasets were developed to elucidate the influence of these factors on terrestrial N availability through time. We hypothesized that spatial and temporal variation of terrestrial N availability, for which tree-ring δ 15N records serve as a proxy, affects the variation of stream nitrate concentration across space and time. Across space at the Blue Ridge study sites, stream nitrate concentration increased linearly with increasing catchment mean wood δ 15N. Over time, stream nitrate concentrations decreased with decreasing wood δ 15N in five of the six catchments. Wood δ 15N showed a significant negative relationship with disturbance and acidic deposition. Disturbance likely exacerbated N limitation by inducing nitrate leaching and ultimately enhancing vegetative uptake. As observed elsewhere, lower rates of acidic deposition and subsequent deacidification of soils may increase terrestrial N availability. Despite the ephemeral modifications of terrestrial N availability by these two drivers and climate, long-term declines in terrestrial N availability were robust and have likely driven much of the declines in stream nitrate concentration throughout the central Appalachians.

It remains difficult to assess the timing and amount of atmospherically deposited and microbial nitrate (NO3-NAtm and NO3-NMicro, respectively) reaching streams. To elucidate temporal variation of NO3-NAtm and NO3-NMicro, we measured nitrate concentrations, δ17O-NO3−, and δ18O-NO3− in a stream draining a gaged, forested watershed in the central Appalachian Mountains throughout a range of hydrological conditions during two water years. From the isotopic data we calculated Δ17O-NO3− values, which were used to calibrate a statistical load model to estimate export of NO3-NAtm and NO3-NMicro. A hydrograph separation was used to estimate loss of NO3-NAtm and NO3-NMicro through base flow and direct runoff pathways. NO3-NAtm contributed 7–11% of the total nitrate yields and paralleled seasonal patterns of NO3-NMicro. Yields of NO3-NAtm and NO3-NMicro in streamflow during the study period were dominated (61 and 85%, respectively) by base flow transport, suggesting that base flow is a major loss pathway for both nitrate species from this watershed.

Die Arthrodese des oberen Sprunggelenkes (OSG) ist ein sicheres Verfahren zur Behandlung der fortgeschrittenen, konservativ nicht mehr ausreichend beeinflussbaren Arthrose des OSG. Zwar wird die Bewegungsfunktion gegenuber den konkurrierenden Verfahren, der OSG-Endoprothese und den periartikularen Achskorrekturen dabei geopfert; vorteilhaft ist aber die sehr gute Belastbarkeit der Versteifung bei korperlich beanspruchenden Tatigkeiten, die Moglichkeit zur Defektrekonstruktion, die Anwendbarkeit bei Bandinstabilitaten und die sehr gute Vorhersagbarkeit der Beschwerdereduzierung. Vorteile fur eine Versorgung mittels Endoprothetik konnten bisher nicht belegt werden. Die Osteosynthese erfolgt typischerweise mittels grosvolumigen Osteosyntheseschrauben, winkelstabilen Formplatten oder bei zusatzlicher Pathologie des USG mittels retrogradem Arthrodesenagel.

We evaluated long-term surface water nitrate and atmospheric nitrogen (N) deposition trends for a group of nine predominantly forested Appalachian Mountain watersheds during a recent multidecadal period (1986-2009) in which regional NOx emissions have been progressively reduced. Statistical analysis showed unexpected linear declines in both annual surface water nitrate-N concentrations (mean =46.4%) and yields (mean =47.7%) among the watersheds corresponding to comparable declines in annual wet N deposition (mean =34.4%) resulting from U.S. NOx emission control programs during the same time period. Nitrate-N concentration trends were robust across a large geographical region and appeared insensitive to watershed size across several orders of magnitude-suggesting that the improvements in water quality are probably propagated to surface and estuarine waters downstream. Surface waters are thus responding to declining atmospheric N deposition in much the same way they responded to declining sulfur deposition-although only one watershed showed a 1:1 relationship. Application of a kinetic N saturation model indicated that all nine forested watersheds are exhibiting signs of N saturation as evidenced by a limited, but variable, efficiency of demand for N. Further reductions in N deposition would be expected to produce additional reductions in streamwater N loads.

The diabetic foot syndrome (DFS) is an important complication of diabetes mellitus resulting in severe undesired consequences, such as amputation, disability and reduced quality of life. In Germany there are approximately 300,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years of diagnosis. To achieve a reduction of the amputation rate it is necessary to identify the main causes. The use of the Wagner-Armstrong wound classification is well accepted in Germany. Therapy and diagnosis of the diabetic foot syndrome are almost standardized and all procedures are well established. In addition a professional stage-adjusted wound therapy has to take place in an interdisciplinary collaboration at a centre for wound care.

An analysis of the MR-images of 75 patients with calcifying tendinitis of the shoulder was performed. The aim of the study was to recognize characteristic findings of the calcific deposits and their relation to the involved tendons as well as the coincidence with additional degenerative alterations of the rotator cuff. The calcifications can be demonstrated with high accuracy (> 95%) in T1-weighted images as areas of decreased signal intensity. It is possible to characterize the calcifications similar to Gartner's radiologic classification differentiating form and density of the calcific deposits as well as their delimitation to the tendon structure. In T2-images there frequently is a perifocal band of increased signal intensity which can be identified as an oedema around the calcification. Analysing two perpendicular planes the calcifications can be assigned to the corresponding anatomical structure. 83 percent were located in the supraspinatus tendon above the humeral head or in the superior part of the subscapularis tendon. Degenerative areas of the rotator cuff are demonstrated as small zones of increased signal intensity, abnormal morphology or discontinuity of the tendon. Only in one patient a partial tear could be found; 11 percent showed variable signs of degenerative alteration of the involved tendon.

The purpose of the study was to examine the accuracy of MRI in distinguishing between the cartilage of the femoral head and the acetabulum in vivo. In 20 healthy and 41 arthrotic hips an MRI was performed, using a special traction on the hips. With T1-weighted 3-dimensional gradient-echo sequence it is possible to distinguish between the high-signal femoral head and acetabular cartilage by having a low signal of the joint space. In the horizontal position of the phase encoding parameters a reduction of the chemical-shift artefact can be achieved mainly in the ventro-lateral areas. In addition it is possible to discriminate between four qualities of cartilage. The extent and localisation of degenerative cartilage in the hip joint can influence the indication of osteotomies for the hip joint.

UNLABELLED Since 1979 prenatal ultrasonography is a screening method in Germany. The examination of head, thorax and femur is now established as a routine method. AIM OF THE STUDY The evaluation of the effectiveness and the consequences of an early prenatal diagnosis of foetal limb deficiencies. METHOD From 1989-1994 we had 403 children with 207 minor or 196 major limb deficiencies. Questionnaires were sent to those 196 parents of children with major diseases 134 cases (68%) of children with limb deficiencies could be analysed. The average age of the mother at birth was 27.5 years and the age of the father was 30.5 years. RESULTS 61 children had deficiencies of the upper limb. another 61 of the lower limbs and 12 had combined defects of the limbs. The mothers had 5.6 (1-15) prenatal ultrasounds examinations. In 63% (n = 82) these were performed by the obstetric practitioners, in 30% in departments of obstetrics and 7% in a university hospital. In 5.2% only, the limb deficiency was diagnosed antenataly. CONCLUSION If there are any unclear findings the women should be sent to a centre of prenatal diagnostics. In cases of congenital deficiencies of the limbs there is the possibility] for the parents to combined to combined consultation of the obstetrician, the human genetic and the orthopaedic to plan the treatment and talk about all consequences.

Subject We analysed the periprosthetic bone mineral density (BMD) in a prospective longitudinal study over two years after operation and in a separate cross-sectional study more than five years after implantation of cementless total hip arthroplasty (CLS-stem, Mecron threaded acetabular cup) by using dual-energy X-ray absorptiometry (DEXA). Materials and methods In n = 53 patients (29 women, 24 men) we analysed the periprosthetic BMD prospectively in certain periods. All patients had an uncomplicated postoperative course and good clinical outcome (Merle d'Aubigne score > 12). In the cross-sectional study we analysed 23 patients (13 women, 10 men). Regions of Interest (ROI) were defined according to Gruen et al. for the periprosthetic femur and to De Lee and Charnley for the periprosthetic acetabulum. Results BMD significantly decreases in the periprosthetic femur as well as in the periprosthetic acetabulum during the first three months. In men BMD reaches its lowest values between six months (femur) and one year (acetabulum) after operation and then increases to 96.2% at the femur and 93.8% at the acetabulum. In women BMD decreases during the entire follow-up to 89.4% at the periprosthetic femur and 80.0% at the periprosthetic acetabulum. In the proximal zones 1 and 7 of the femur and the cranial-medial zone II of the acetabulum we observed the highest decrease of mineralisation. More than five years after implantation of the prosthesis BMD in the femur showed only little changes. On the other side BMD around the threaded acetabular cup significantly decreased to 67.4% in women and 79.1% in men. Conclusion The results reflect the different stress on the periprosthetic bone after implantation of the prosthesis and fit to earlier reported good clinical results of the CLS-stem and to increased loosening rate of threaded acetabular cups after five years. Analysing changes of mineralisation in cementless total hip arthroplasty DEXA together with the analization scheme according to Gruen at the femur and to De Lee and Charnley at the acetabulum is a useful method and has been reliable in clinical practise.

The osteotomy of the first phalanx of the great toe has been described by Akin as early as in 1925. Since that time this technique and its modifications have been widely in clinical use and were mostly described as additional correction manoeuvre combined with standard metatarsal osteotomies like scarf or chevron osteotomies. As the so-called Akin osteotomy mostly is used as a surplus procedure scientific evaluation of this osteotomy itself can rarely be found. Different fixation techniques like k-wire-, wire, staple-thermo-staple-or screw-fixations are in use. The result are the follow up of 135 patients out of more than 200 operated patients treated with forefoot realignemant procedure because of hallux valgus with a follow up of at least 1 year.

We report on the orthopaedic treatment of a patient with the very rare Ito syndrome and congenital hemihypertrophy. The leading symptom is the lamellar depigmentation of the skin for which it is synonymously called incontinantia pigmenti acromians. Further anomalies are found in the central nervous system, as well as the ocular and the musculoskeletal systems. The treatment of the hemihypertrophy and the coexistent dysplasia of the hip with a combination of intertrochanteric shortening osteotomy and a triple osteotomy are specified and further methods are discussed.

The aim of this study was to assess bone mineral density (BMD) and degenerative changes in the lumbar spine in male former elite athletes participating in different track and field disciplines and to determine the influence of body composition and degenerative changes on BMD. One hundred and fifty-nine former male elite athletes (40 throwers, 97 jumpers, 22 endurance athletes) were studied. Anthropometric (age, body mass index [BMI]) and sport-specific data (personal best, intensity, duration, and time since termination of competitive sports career as well as current sporting activity) were collected. Degenerative changes of the lumbar spine in lateral view were evaluated by using the Kellgren and Lawrence Score. Bone mineral density of the lumbar spine was measured in an anterior-posterior view with dual energy X-ray absorptiometry (DEXA, T-score). Throwers had a higher body mass index than jumpers and endurance athletes. Throwers and jumpers had higher BMD (T-LWS) than endurance athletes. Bivariate analysis revealed a negative correlation of BMD (T-score) with age and a positive correlation with BMD and Kellgren score (p

AIM This study evaluates the pressure distribution, the radiological and clinical results in patients before surgery and 6 months after scarf osteotomy for hallux valgus. METHODS 29 patients were examined before surgery and 6 months after surgery for symptomatic hallux valgus. Pedographic analysis was performed by dividing the footprint of the patients into 8 regions of interest. For each region the maximum mean pressure and the peak pressure were evaluated. Moreover, clinicofunctional results (AOFAS score) and radiological results were evaluated. RESULTS 6 months postoperatively, maximum mean pressure increased significantly under the medial forefoot where as the peak pressure in this region revealed indifferent results. Significant improvement of clinicofunctional results and a significant reduction of the intermetatarsal and metatarsophalangeal angle could be seen. CONCLUSION These results confirm the clinical and radiological findings of other studies, but this study shows for the first time an increase of pressure under the first ray of the foot after hallux valgus surgery and an adaptation to the pressure distribution of normal feet.

Background We describe the surgical treatment, outcome and long-term survival of patients with multiple myeloma (MM) in response to conventional (CC) or high-dose (HDT) chemotherapy. Patients and methods Eighty-four patients diagnosed with MM were recruited for the study (51 male, 33 female; median age 62 years) and consecutively surgically treated in a single institution during a 12-year period. The main end point of the study was overall survival after surgery. Cox regression analysis was used to estimate the effect of factors that may predict survival. Results Spinal surgery was performed in 54 cases, and 30 patients were surgically treated at the extremities. The post-surgical complication rate was low (17%; 14/84 patients). The median overall survival time was 47 months. Patients receiving HDT had a longer 5-year overall survival rate than patients receiving CC (51% versus 33%). Univariate predictors of mortality included age >65 years [risk ratio (RR) 1.62; P = 0.023], osteolyses in long weight-bearing bones (RR 2.23; P = 0.007) and an elevated C-reactive protein level >5 mg/l (RR 1.82; P = 0.016); the latter remained significant as a predictor in multivariate analysis (RR 2.66; P = 0.0209). Conclusions Given the high number of patients reaching 5-year overall survival and the low post-surgery complication rate, surgery should pursue a long-term stable reconstruction of the affected bone.

Aim The purpose of this study was to evaluate the clinical outcome of patients with metastatic tumors of the spine after surgical and non-surgical treatment. Methods The charts of 259 patients with metastatic tumors of the spine were reviewed retrospectively to define predictors of outcome. Our data included patient demographics, primary tumor, location of the metastatic tumor within the spine, indication for surgical or non-surgical treatment, type of surgical and non-surgical intervention, post-treatment outcome in terms of neurology, use of adjuvant radiation therapy or systemic therapy. Results The most frequent indication for surgical treatment was the combination of neurological deficit (ND), pathological vertebral fracture, and pain (50 %). Surgical intervention was performed by the posterior approach in 67 %, by the anterior approach in 13 %, and by an anterior/posterior approach in 10 %. The post-surgical outcome, depending on the type of surgical approach in terms of ND, was for the posterior approach 29 % improved, for the anterior approach 53 % improved, and for the anterior/posterior approach 15 % improved. Discussion Our data suggest that the indications for metastatic tumor surgery in the spine depend on the location of the metastatic tumor in the spine, clinical symptoms, and prognosis.

Um die haufig komplexe Fusdeformitat des sogenannten Hallux valgus-Syndroms sicher operativ therapieren zu konnen, hat sich das „harmonisierende“ Vorfusrealignement, bestehend aus Scarf-Osteotomie, Akin-Osteotomie und Weil-Osteotomie, etabliert. Die Operationsmethode ist technisch anspruchsvoll und erfordert eine gute chirurgische Operationsschule. Sorgfaltiges Weichteilbalancing und prazise Osteotomietechniken sind unabdingbar fur den Erfolg dieser kombinierten Korrektur. Die Analyse von 135 Scarf-Osteotomien ergibt ein uberwiegend positives Ergebnis mit einer Erfolgsrate von 77%.

Methodik. Perioperative sowie subjektive, klinisch-funktionelle und radiologische Langzeitergebnisse mit einer durchschnittlichen Nachuntersuchungszeit von 9 Jahren nach OSG-Arthrodese bei posttraumatischer Arthrose wurden in 2 Gruppen mit auserer (Fixateur externe) oder interner (Schrauben-)Kompressionsarthrodese bei insgesamt 55 Patienten miteinander verglichen. Ergebnisse. In der Fixateur-externe-Gruppe traten signifikant haufiger tiefe Weichteilinfekte auf, die konservativ behandelt werden konnten, wahrend die Pseudarthroserate, die Infektrevisionsrate und auch die Gesamtrevisionsrate keine signifikanten Unterschiede in den beiden Gruppen aufwiesen. Schlussfolgerung. Beide Fixationsmoglichkeiten gewahrleisten eine sichere und stabile Arthrodese des OSG und zeigen uberzeugende Langzeitergebnissse ohne signifikanten Unterschied im Vergleich.

Study design: Case report. Objective: To describe a patient with a large tumor lesion of the 6th vertebrae affecting surrounding soft tissue, and symptoms of cord compression. Histologic diagnosis indicated a destructive osteoblastoma following dorsal and anterior resection and internal fixation. Setting: University Hospital, Germany. Methods: A 23-year old male patient was admitted with a 2-month history of increasing upper extremity weakness and pain. X-ray and MRI indicated massive involvement of the anterior and posterior elements of the 6th vertebrae with a large soft tissue mass. Following emergency decompression and dorsal stabilization, the pathologic investigation revealed a destructive osteoblastoma. Subsequent dorsal and anterior resection with internal fixation were performed. Results: The patient initially presented with symptoms of beginning paraplegia of C6/7. According to the neurologic classification of spinal cord injury, motor function score was 56 and sensory function score 83. After emergency dorsal decompression and internal fixation with Luque-Instrumentation® he showed increasing neurological recovery. Complete neurological recovery was achieved at 2 and 12-months postoperatively, following secondary dorsal and anterior resection of the tumor and internal fixation with bone cement (PalacosR®) and Harms-cage®. Radiologic signs of local recurrence were identified 1 year postoperatively. Conclusion: Osteoblastoma of the cervical spine is rare. Patients often present with severe neurological symptoms due to significant tumor mass. Complete resection is necessary to regain full recovery, to prevent recurrence and, in some cases, malignant transformation.

12 Patienten wurden nach der von Capanna et al. [7] erstmalig beschriebenen Technik des Manteltransplantats operativ versorgt. Dieses Verfahren dient der Defektrekonstruktion durch die Kombination eines uberbruckenden Allograft mit der korpereigenen Fibula. Die Indikation wurde in einem Fall aufgrund eines Enchondromrezidives sowie in 11 Fallen aufgrund primar maligner Knochentumoren gestellt [malignes fibroses Histiozytom (3-mal), Adamantinom (2-mal), Ewing-Sarkom (2-mal), Osteosarkom (2-mal), Chondrosarkom (1-mal), Hamangioperizytom (1-mal)]. Die mittlere Defektlange nach Tumorresektion betrug 15,7 cm, die autologe Fibula wurde in 8 Fallen gefasgestielt verwendet. Im bisherigen Nachuntersuchungszeitraum von durchschnittlich 29,2 Monaten traten 5 operationspflichtige Komplikationen auf, in 3 dieser Falle war im weiteren Verlauf eine Amputation erforderlich. In den ubrigen Fallen wurden gute bis sehr gute funktionelle (Enneking-Score) und radiologische (ISOLS-Score) Verlaufe beobachtet. Die bisherigen Ergebnisse deuten daraufhin, dass sich die kombinierte Anwendung von Allograft und autologer Fibula zur Defektrekonstruktion nach Resektion maligner Knochentumoren bei guter Funktionalitat eignet.

Retrospective analysis of 30 patients with pathological fracture out of 336 patients with primary malignant bone tumors should demonstrate the influence a pathologic fracture and the form of surgical therapy have on the survival rate. In 25 out of 30 patients a fracture led to diagnosis of the disease. Pathological fractures occurred cumulatively by malignant fibrous histiocytoma of the bone and in tumor stages IIb and III. Surgery was performed on 26 out of 30 patients (12 ablative therapies, 14 reconstructive therapies). The mortality risk for patients with pathological fractures was more than double the risk for patients without pathological fractures (P = 0.0062). When performed correctly, reconstructive therapy does not influence the survival rate.