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Intramuscular oil injections generating slowly degrading oil-based depots represent a controversial subject in bodybuilding and fitness. However they seem to be commonly reported in a large number of non-medical reports, movies and application protocols for 'site-injections'. Surprisingly the impact of long-term (ab)use on the musculature as well as potential side-effects compromising health and sports ability are lacking in the medical literature. We present the case of a 40 year old male semi-professional bodybuilder with systemic infection and painful reddened swellings of the right upper arm forcing him to discontinue weightlifting. Over the last 8 years he daily self-injected sterilized sesame seed oil at numerous intramuscular locations for the purpose of massive muscle building. Whole body MRI showed more than 100 intramuscular rather than subcutaneous oil cysts and loss of normal muscle anatomy. 2-step septic surgery of the right upper arm revealed pus-filled cystic scar tissue with the near-complete absence of normal muscle. MRI 1 year later revealed the absence of relevant muscle regeneration. Persistent pain and inability to perform normal weight training were evident for at least 3 years post-surgery. This alarming finding indicating irreversible muscle mutilation may hopefully discourage people interested in bodybuilding and fitness from oil-injections. The impact of such chronic tissue stress on other diseases like malignancy remains to be determined. [ABSTRACT FROM AUTHOR]

Copyright of Der Orthopäde is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Orthopäde is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Orthopäde is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Orthopäde is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Chirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Der Chirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: Hip osteoarthritis (OA) affects all components of the osteochondral unit, leading to bone marrow (BM) lesions, and unknown consequences on BM cell functionality. We analyzed the cellular composition in OA-affected acetabula compared to proximal femur shafts obtained of hip OA patients to reveal yet not explored immune and stem cell compartments., Design: Combining flow cytometry, cellular assays and transcription analyses, we performed extensive ex vivo phenotyping of acetabular BM cells from 18 hip OA patients, comparing them with their counterparts from patient-matched femoral shaft BM samples. Findings were related to differences in skeletal sites and age., Results: Acetabular BM had a greater frequency of T-lymphocytes, non-hematopoietic cells and colony-forming units fibroblastic potential than femoral BM. The incidence of acetabular CD45 + CD3 + T-lymphocytes increased (95% CI: 0.1770 to 0.0.8416), while clonogenic hematopoietic progenitors declined (95% CI: -0.9023 to -0.2399) with age of patients. On the other side, in femoral BM, we observed higher B-lymphocyte, myeloid and erythroid cell frequencies. Acetabular mesenchymal stromal cells (MSCs) showed a senescent profile associated with the expression of survival and inflammation-related genes. Efficient osteogenic and chondrogenic differentiation was detected in acetabular MSCs, while adipogenesis was more pronounced in their femoral counterparts., Conclusion: Our results suggest that distinctions in BM cellular compartments and MSCs may be due to the influence of the OA-stressed microenvironment, but also acetabular vs femoral shaft-specific peculiarities cannot be excluded. These results bring new knowledge on acetabular BM cell populations and may be addressed as novel pathogenic mechanisms and therapeutic targets in OA., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Tissue engineering provides the possibility of regenerating damaged or lost osseous structures without the need for permanent implants. Within this context, biodegradable and bioresorbable scaffolds can provide structural and biomechanical stability until the body's own tissue can take over their function. Additive biomanufacturing makes it possible to design the scaffold's architectural characteristics to specifically guide tissue formation and regeneration. Its nano-, micro-, and macro-architectural properties can be tailored to ensure vascularization, oxygenation, nutrient supply, waste exchange, and eventually ossification not only in its periphery but also in its center, which is not in direct contact with osteogenic elements of the surrounding healthy tissue. In this article we provide an overview about our conceptual design and process of the clinical translation of scaffold-based bone tissue engineering applications.

The periosteum plays a critical role in bone homeostasis and regeneration. It contains a vascular component that provides vital blood supply to the cortical bone and an osteogenic niche that acts as a source of bone-forming cells. Periosteal grafts have shown promise in the regeneration of critical size defects, however their limited availability restricts their widespread clinical application. Only a small number of tissue-engineered periosteum constructs (TEPCs) have been reported in the literature. A current challenge in the development of appropriate TEPCs is a lack of pre-clinical models in which they can reliably be evaluated. In this study, we present a novel periosteum tissue engineering concept utilizing a multiphasic scaffold design in combination with different human cell types for periosteal regeneration in an orthotopic in vivo platform. Human endothelial and bone marrow mesenchymal stem cells (BM-MSCs) were used to mirror both the vascular and osteogenic niche respectively. Immunohistochemistry showed that the BM-MSCs maintained their undifferentiated phenotype. The human endothelial cells developed into mature vessels and connected to host vasculature. The addition of an in vitro engineered endothelial network increased vascularization in comparison to cell-free constructs. Altogether, the results showed that the human TEPC (hTEPC) successfully recapitulated the osteogenic and vascular niche of native periosteum, and that the presented orthotopic xenograft model provides a suitable in vivo environment for evaluating scaffold-based tissue engineering concepts exploiting human cells., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Background: Many different systems for the management of primary and secondary acetabular defects are available, each with its inherent advantages and disadvantages. The Revisio-System is a press-fit oval mono-block implant that makes a defect-oriented reconstruction and restoration of the center of rotation possible., Material and Methods: In this study, we retrospectively reviewed the outcome of 92 consecutive patients treated with this oval press-fit cup due to periacetabular bone loss. The average follow-up was 58.2 months. Defects were classified according to D'Antonio. There were 39 type II, 38 Type III, and 15 type IV defects. After an average of 4.9 years, the implant survival rate was 94.6% with cup revision as the end point and 89.1% with revision for any reason as the end point. The Harris Hip Score increased from 41.1 preoperatively to 62.3 postoperatively. The mean level of pain measured with the Visual Analogue Scale (VSA) was reduced from 6.9 preoperatively to 3.8 postoperatively., Results: The Revisio-System represents a promising toolbox for defect-orientated reconstruction of acetabular bone loss in revision hip arthroplasty. Our results demonstrate that the implantation of the Revisio-System can result in a good mid-term clinical outcome.

Objective: Regeneration of autologous bone stock and formation of a stable implant bed by impaction of morselized bone allograft., Indications: Bone loss after septic and aseptic loosening or tumour resection., Contraindications: Persistent infection, one-stage septic revision, poor therapeutic compliance, extensive uncontained metaphyseal defects with cortical thinning of the diaphysis., Surgical Technique: Whilst the surgeon removes the loose prosthesis, the assistant prepares the graft. The medullary canal is sealed with a cement restrictor. Graft particles of different sizes are densely impacted around a trial stem. The highest level of stability is achieved by using large particles interspersed with small filler particles. Low-viscosity cement facilitates cement penetration and ensures strong interdigitation with the impacted graft mass after implantation of the prosthesis. Uncontained metaphyseal defects are treated with prosthetic augments., Postoperative Management: Gait training, physiotherapy with isometric quadriceps exercises, partial weight-bearing for 6 weeks, resistance training begins 8 weeks postoperatively., Results: Between 2010 and 2012, 28 patients with large bone defects [Anderson Orthopaedic Research Institute (AORI) grade: 21 × F3, 3 × F2, 13 × T3, 8 × T2] underwent total knee revision with impaction bone grafting. The mean follow-up was 27.7 months (range 21-47 months). On average, patients had undergone 2.5 previous revisions. Implant survival was 82.0 % (95 % CI = 62.5 %-92.1 %) for any reason of revision as the endpoint and 93.1 % (95 % CI = 74.5-98.4 %) for aseptic revision as the endpoint. The mean postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 35.4 (range 3.3-101.6, SD ± 26.2). The mean KSS was 70.6 (range 20-100, SD ± 26.8).

Objective: Problematic tissue defects in the distal one-third of the lower leg represent a special challenge for the operative therapy. The distally based adipofascial sural artery flap is a safe and effective modification of the classical fasciocutaneous sural artery flap technique and makes the reconstruction in this problematic area more feasible. The surgical aim is soft tissue reconstruction with local tissue avoiding free tissue transfer., Indications: Complex or chronic wounds (maximum width of 8 cm) of the distal lower leg with exposed bone, joints, tendons, and/or neurovascular structures, especially in cases of missing skin perforators., Contraindications: Arterial vascular disease (stage III-IV), especially peroneal artery occlusion. Postthrombotic syndrome with occlusion of the small saphenous vein. Chronic lymphedema., Surgical Technique: Preparation of the vascular pedicle of the distally based flap (including small saphenous vein, sural artery and nerve), the adjacent crural fascia and the subcutaneous fat without a skin island. The pivot point is about 6 cm cranial to the malleolus lateralis. The flap can be raised proximally up to the heads of the gastrocnemius muscle. After harvesting the flap there will be a change in blood flow direction in the small saphenous vein. The donor site can be closed primarily. The flap is covered with meshed split skin graft at the end of surgery., Postoperative Management: Strict elevation of the extremity for 5 days, then flap conditioning., Results: Between 1997 and 2012, this technique was used in 104 consecutive patients with soft tissue defects in the distal one-third of the lower leg. Flap survival was achieved 91 patients. In 2 patients amputation of the lower leg was necessary at the mid tibia level. In 3 cases flap necrosis occurred, requiring free tissue transfer.

Objective: The objective of an open biopsy is to obtain a sufficient amount of representative tumor tissue in terms of adequate quality and quantity, without adverse effects on later therapy., Indications: Suspected malignancy after non-invasive diagnostic procedures. Histopathologic evaluation of tumor entity and grading. Planning of the definitive tumor resection and initiation of neoadjuvant therapeutic regimen. Obtaining unfixed, fresh-frozen tumor samples for molecular/genetic analyses or tumor tissue bank., Contraindications: Hemorrhagic diathesis. Tumor is only accessible with a surgical approach leading to a significant damage of the surrounding tissue. High probability of tumor cell contamination with incisional biopsy. Poor physical status. Poor therapeutic compliance., Surgical Technique: The biopsy tract should be carefully planned according to oncological principles. The operation begins with a small incision in longitudinal direction to the extremity. The shortest path between skin and lesion that avoids contamination of other compartments is selected. The biopsy tract should be located within the surgical approach which is later used for definitive tumor resection. During the definitive procedure it should be possible to resect the biopsy approach with adequate surgical margins because it is considered to be contaminated with tumor cells. In principle, a wide resection of the biopsy tract should be possible. During the operation meticulous hemostasis has to be performed because any hematoma around a tumor may contaminate the entire extremity. In cases of an intraosseous tumor a cortical window should be made to obtain intramedullary tumor tissue. Drains should be located in continuity with the skin incision or in direct extension of the wound. Wound closure with intracutaneous suture technique. Excisional biopsy in terms of marginal resection should be performed only in the presence of small, epifascial lesions that are assumed to be benign after completion of basic diagnostic procedures. In cases of larger or subfascial tumors an incisional biopsy should be conducted., Postoperative Management: Compressive dressing to prevent postoperative hematoma. In cases of tumors affecting load-bearing bones, weight-bearing should be prohibited after biopsy, if there is any fracture risk. Upon receipt of the histopathological results the definitive tumor resection is planned.

Despite the compact anatomy with thin soft tissue coverage, diagnosis of both benign and malignant tumors of the foot is often delayed. Diagnostic errors are more common than in other body regions, as neoplasias are rarely considered. Barring a few exceptions the foot is not a typical predilection site for malignant musculoskeletal tumors, although, basically any tumor entity of the musculoskeletal system can affect the foot. Delays in specific diagnostic and therapeutic procedures of these lesions can entail serious consequences for patients as tumor size is a major prognostic factor for recurrence-free survival. In cases of an indistinct persistent swelling or bone lesion a tumorous process should always be considered to ensure early diagnosis and therapy of foot tumors.

Objective: Treatment of tumors of the pelvic girdle by resection of part or all of the innominate bone with preservation of the extremity. Implantation and stable fixation using a custom-made megaprosthesis to restore painless joint function and loading capacity. The surgical goal is to obtain a wide surgical margin and local tumor control., Indications: Primary bone and soft tissue sarcomas, benign or semi-malignant aggressive lesions, metastatic disease (radiation resistance and/or good prognosis)., Contraindications: Limited life expectancy and poor physical status, extensive metastatic disease, persistent deep infection or recalcitrant osteomyelitis, poor therapeutic compliance, local recurrence following a previous limb-sparing resection, extensive infiltration of the neurovascular structures and the intra- and extrapelvic soft tissues., Surgical Technique: Levels of osteotomy are defined preoperatively by a CT-controlled manufactured three-dimensional 1:1 model of the pelvis. Using these data, the custom-made prosthesis and osteotomy templates are then constructed by the manufacturer. The anterior (internal, retroperitoneal) and posterior (extrapelvic, retrogluteal) aspects of the pelvis are exposed using the utilitarian incision surgical approach. The external iliac and femoral vessels are mobilized as they cross the superior pubic ramus. The adductor muscles, the rectus femoris and sartorius muscle are released from their insertions on the pelvis and the obturator vessels and nerve are transected. If the tumor extends to the hip joint, the femur is transected at a level distal to the intertrochanteric line to ensure hip joint integrity and to prevent tumor contamination. A large myocutaneous flap with the gluteus maximus muscle is retracted posteriorly. The pelvitrochanteric and small gluteal muscles are divided near their insertion in the upper border of the femur. To release the hamstrings and the attachment of the sacrotuberous ligament, the ischial tuberosity is exposed. After osteotomy using the prefabricated templates, the pelvis is released and the specimen is removed en bloc. The custom made prosthesis can either be fixed to the remaining iliac bone or to the massa lateralis of the sacrum. The released muscles are refixated on the remaining bone or the implant., Postoperative Management: Time of mobilization and degree of weight-bearing depends on the extent of muscle resection. Usually partial loading of the operated limb with 10 kg for a period of 6-12 weeks, then increased loading with 10 kg per week. Thrombosis prophylaxis until full weight bearing. Physiotherapy and gait training. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination, and radiographic studies., Results: Between 1994 and 2008, 38 consecutive patients with periacetabular tumors were treated by resection and reconstruction with a custom-made pelvic megaprosthesis. The overall survival of the patients was 58% at 5 years and 30% at 10 years. One or more operative revisions were performed in 52.6% of the patients. The rate of local recurrence was 15.8%. Deep infection (21%) was the most common reason for revision. In two of these cases (5.3%), a secondary external hemipelvectomy had to be performed. There were four cases of aseptic loosening (10.5%) in which the prosthesis had to be revised. Six patients had recurrent hip dislocation (15.8%). In four of them a modification of the inserted inlay and an implantation of a trevira tube had to be performed respectively. Peroneal palsy occurred in 6 patients (15.8%) with recovery in only two. There were 4 operative interventions because of postoperative bleeding (10.5%). The mean MSTS score for 12 of the 18 living patients was 43.7%. In particular, gait was classified as poor and almost all patients were reliant on walking aids. However, most patients showed good emotional acceptance.

Objective: The goal of the operation is limb-sparing resection of tumors arising from the proximal tibia with adequate surgical margins and local tumor control. Implantation of a constrained tumor prosthesis with an alloplastic reconstruction of the extensor mechanism to restore painless joint function and loading capacity of the extremity., Indications: Primary bone and soft tissue sarcomas. Benign or semimalignant aggressive lesions. Metastatic disease (radiation resistance and/or good prognosis)., Contraindications: Poor physical status. Extensive metastatic disease with life expectancy <6 months. Tumor penetration through the skin. Local infection or recalcitrant osteomyelitis. Poor therapeutic compliance. Large popliteal extraosseous tumor masses with infiltration of neurovascular structures., Surgical Technique: A single incision is made from the anteromedial aspect of the distal femur to the distal one third of the medial lower leg. Preparation of large medial and lateral fasciocutaneous flaps. The popliteal vessels are explored through a medial approach by releasing the pes anserinus and semimembranosus tendon, mobilizing the medial gastrocnemius muscle and detaching the soleus muscle from the tibial margo medialis. The anterior tibial artery and vein are ligated. If the knee joint is free of tumor, circumferential dissection of the knee capsule is performed and the patellar ligament is dissected. An osteotomy of the tibia shaft is performed with safety margins according to preoperative planning. In order to obtain adequate surgical margins, in some cases an en bloc resection of the tibiofibular joint becomes necessary. Therefore, the peroneal nerve is exposed. Parts of the M. tibialis anterior, a portion of the M. soleus and the entire M. popliteus are left on the resected tibial bone. After implantation of the prosthesis and coupling of the femoral and tibial component, the extensor mechanism is reconstructed using an alloplastic cord. It is passed transversely through the distal end of the quadriceps tendon looping the proximal margin of the patella. Both ends are passed distally through a subsynovial tunnel and are fixed under adequate pretension in a metal block of the tibial component. The detached hamstrings and remaining ligaments can be fixed on preformed eyes of the prosthesis. A medial gastrocnemius muscle flap is used to provide soft tissue coverage of the tibial component., Postoperative Management: Immobilization and elevation of the extremity for 5 days, then flap conditioning. Mobilization in a hinged knee brace locked in extension for 6 weeks without weight bearing. During this time active flexion with a stepwise progress, isometric quadriceps training. Then beginning of straight leg raising exercises, stepwise unlocking of the brace with 30° every 2 weeks. Weight-bearing is increased by 10 kg/week. Thrombosis prophylaxis until full weight-bearing. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination and radiographic studies., Results: Between 1988 and 2009, endoprosthetic replacement and alloplastic reconstruction of the extensor mechanism after resection of tibial bone tumors was performed in 17 consecutive patients (9 females and 8 males) with a mean age of 31.1 years (range 11-65 years). There were no local recurrences. Until now, 5 patients have died of tumor disease. One or more operative revisions were necessary in 53.9% of the patients. According to Kaplan-Meier survival analysis, the implant survival at 5 years was 53.6% and 35.7% at 10 years, respectively. In 2 cases, a distal transfemoral amputation had to be performed due to deep infection. There were 3 cases of tibial stem revision due to implant failure and aseptic loosening, respectively. In 3 patients, the hinge of the prosthesis had to be revised. Impaired wound healing occurred in 2 cases. Peroneal nerve palsy was observed in 3 patients with recovery in only one. The mean Oxford knee score for 9 of the 12 living patients was 30.7 ± 7.5 (24-36). No patient had a clinically relevant extension lag. The mean range of motion at the last follow-up was 90.2° ± 26.7 (range 35-130°). All patients were well satisfied with their postoperative outcomes.

The minimally invasive direct anterior approach for total hip arthroplasty (THA) was first published in 1985. Since then the technique has been further improved and the indications have been extended. The approach utilizes the muscle gap between the tensor fasciae latae muscle on the lateral side and the sartorius muscle on the medial side. This muscle gap allows a direct and quick approach to the hip joint with good muscle preservation. During preparation of the femur the tensor fasciae latae muscle is at risk of being damaged. The lateral cutaneous nerve of the thigh (NCFL) and its branches are also in danger of being damaged during skin incision and dissection of the subcutaneous tissue. In this article the technique, risks and current clinical results of THA using the minimally invasive direct anterior approach are described. The results from the literature, as well as own results are compared to the traditional transgluteal lateral Bauer approach and discussed. Reviewing the literature, special attention has been given to the incidence of NCFL lesions, damage of the tensor fasciae latae muscle and positioning of the cup. Especially for the latter, the general view is hindered in the minimally invasive technique.

Although there is no clear evidence, minimally invasive hip arthroplasty seems to be associated with slightly higher complication rates compared to standard procedures. Major nerve palsy is one of the least common but most distressing complications. The key for minimizing the incidence of nerve lesions is to analyze preoperative risk factors, accurate knowledge of the anatomy and minimally invasive techniques. Once clinical signs of nerve injury are evident, the first diagnostic steps are localization of the lesion and quantification of the damage pattern. Therefore, clinical assessment of the neurological deficits should be performed as soon as possible. Apart from rare cases of isolated transient conduction blockade or complete transection, the damage pattern is mostly combined. Thus, there can be evidence for dysfunction of nerve conduction (neuropraxia) and structural nerve damage (axonotmesis or neurotmesis) simultaneously. Because the earliest signs of denervation are detectable via electromyography after 1 week, it is not possible to make any reliable prognosis within the first days after nerve injury using electrophysiological methods. This review article should serve as a guideline for prevention, diagnostics and therapy of neural lesions in minimally invasive hip arthroplasty.

Objective: Operative technique of propeller flap reconstruction of soft tissue defects in the distal lower extremity. Soft tissue reconstruction of the distal third of the lower extremity with local, reliable perforator flaps avoiding free tissue transfer., Indications: Complex wounds (maximum width of 6 cm) of the distal lower extremity with exposed bones, joints, tendons, and neurovascular structures., Contraindications: Arterial vascular disease (stage III or IV), diabetes mellitus, postthrombotic syndrome, venous ulcers, chronic lymphedema, contusion of adjacent soft tissue, previous radiation, and lack of perforators, Surgical Technique: The perforator represents the pivot point around which rotation of up to 180º of the subfascially harvested flap allows closure of the defect. The proximal donor site can be closed primarily up to a width of 6 cm., Postoperative Management: Strict elevation of the extremity for 5 days, then flap conditioning., Results: This technique was used for soft tissue reconstruction in 17 patients. In one patient with diabetes, complete flap necrosis occurred, requiring amputation of the extremity. One case of epidermolysis healed without further surgery.

Total hip arthroplasty is the procedure of choice for most patients with advanced, symptomatic osteoarthritis due to congenital dysplasia of the hip. However, the complexity of arthroplasty is significantly increased because of anatomic abnormalities associated with dysplasia of the hip. In addition the relatively young age of patients may affect survival of the implant. From a biomechanical standpoint the primary surgical objective is reconstruction of the anatomical center of rotation. Independent of the pelvic bone stock the socket should be located as near as possible to the anatomical acetabular location. There are various operative strategies to ascertain sufficient stability of the socket. The anterolateral deficiency of the acetabulum can be reconstructed by bulk femoral autografting or bone impaction grafting. Furthermore controlled perforation of the medial wall or implantation of reinforcement rings and oval sockets have been described. Cementless, biological socket fixation shows superior long-term results compared to cemented cups, especially in these young patients. The location of the reconstructed acetabulum and the desired leg length influence the type of femoral reconstruction and in some cases femoral shortening is required. In this article endoprosthetic reconstructive options for developmental dysplasia of the hip are discussed depending on the femoral and acetabular deformity.

The number of implantations of hip prostheses in Germany is now approximately 190,000 per year. By improving the implants and the development of modern surgical techniques and instruments the revision rate has been significantly reduced. The survival rate of the implants could be further increased in recent years, however, up to 22% of patients complain about persistent pain after hip arthroplasty. The diagnosis of existing pain after total joint replacement of the hip joint to achieve a causal therapy needs a systematic approach because of the heterogeneity of the symptoms and diseases. The etiology of the pain can be joint-associated and also hip joint independent. Often the causes of pain are multifactorial so that a standardized assessment should be conducted using an algorithm. The clarification of pain begins with the history, inspection and palpation followed by a clinical examination. It is then useful to perform radiological imaging followed by invasive procedures if necessary. The exploratory revision is nowadays considered to be obsolete in the literature.

Out of all skeletal metastases 30% are located in the spine as are 10% of primary bone tumors, whereby 52% of metastases occur in the lumbar region, 36% in the thoracic spine and 12% in the cervical spine. Patients suffer from local pain caused by irritation of the periosteum due to rapid growth of the tumor or subsequent pathologic fractures which may lead to compression and neurological impairment with paresthesia, paresis and paraplegia. If the diagnosis cannot be confirmed exactly by radiological imaging and laboratory tests, a biopsy should be performed. A precise diagnosis of the tumor entity as well as an estimation of the prognosis provides an important basis for further decision-making. The aim of therapy is pain relief and stabilization by operative and non-operative measures. Therapy is palliative with the aim of pain relief and preservation of mobility. In cases of solitary metastasis a curative operative treatment should be performed.

Extensive bone loss, as encountered in both revision arthroplasty of the hip and after resection of malignant tumors of the pelvis, is a major challenge for the surgeon as well as for the revision implant. The aims are, despite extensive acetabular defects, to achieve a primary and load-stable fixation of the revision prosthesis in the pelvic bone as well as restoring the physiological joint biomechanics. At present, a large number of different alloarthroplastic revision implants and complex techniques are available for reconstruction of acetabular deficiencies. According to D'Antonio's classification of acetabular defects, particularly high-grade defects with loss of the posterior column or a pelvic discontinuity require special attention regarding implant selection and surgical planning. The object of this paper is to highlight the most important tools and techniques of endoprosthetic reconstruction for grade III and IV defects (D'Antonio) of the acetabulum by means of a classification-oriented therapeutic concept and to discuss the pros and cons of the particular implant.

Aim: An interdisciplinary approach plays an important role in orthopaedic rheumatology. The aim of this study was to test the quality of an interdisciplinary consultation, which analyzed a pool of orthopaedic patients in terms of rheumatological disease., Method: Orthopaedic patients (n=100) were transferred to a multidisciplinary team of experts in a two-stage selection process. Patient data were examined with regard to diagnosis and therapy. A patient interview analyzed the course of disease and effects of the consultation. Patients were questioned on the development of pain, diagnostics and therapy as well as their general satisfaction., Results: Rheumatological disease was diagnosed in 42% of patients, while specific anti-rheumatic therapy was started in 41%. An improvement in symptoms as a result of treatment was seen in 63% of cases. Patient examinations revealed an above-average level of satisfaction in 63% of patients., Conclusion: Interdisciplinary consultation led to improved and faster diagnosis and therapy of rheumatological diseases, which was positively evaluated by the pool of patients treated.

The number of periprosthetic fractures following hip replacement is increasing due to longer life expectancy and the rising number of joint replacements. The main causes of periprosthetic fractures include trauma, implant specific factors or loosening of the endoprosthesis. When planning therapy, surgeons should consider specific and general implant- and patient-related risk factors to ensure the best possible treatment. Established classification systems can facilitate preoperative planning. At present, the Vancouver classification system probably comes closest to the ideal, as it considers fracture configuration, stability of the implant and quality of the bone stock. Depending on these factors, therapeutic options include conservative treatment, fracture stabilisation or replacement of the endoprosthesis. The problems associated with periprosthetic fractures of varying etiology and the available treatment options are discussed against the background of the established classification systems.

Femoral revision of total hip arthroplasty is a technically demanding procedure. Therefore, accurate preoperative planning is essential for good clinical results. With many reconstruction methods available, the decision-making process can be complex. Well established classification systems can facilitate preoperative planning. At the time of revision surgery appropriate implants and instruments have to be available ensuring the possibility of managing operative complications. Primary goals of revision arthroplasty are restoration of the physiological joint biomechanics and primary stable fixation of the revision implant. In consideration of possible repeat revision surgery, cementless stem fixation should be preferred. Modular stems provide significant flexibility in restoring the center of rotation. Depending on the pre-existing femoral defect, osseous grafts can be necessary.The scope and classification systems of femoral osseous defects in revision arthroplasty will be discussed and different treatment options will be outlined, which guide the surgeon in selecting an appropriate method of reconstruction.

Approximately 18,000 hip revision procedures of the acetabular component are performed annually in Germany with rising incidence. The aims of acetabular revision are reconstruction of the anatomic hip center, reconstruction of bone stock, cement-free primary stability of the revision implant in autochthonous bone and permanent secondary integration.Precise planning of the revision surgery is necessary with analysis and classification of the bone defects and reconstruction following a concise therapeutic concept. Cup loosening without bone loss as well as segmental bone defects can usually be reconstructed with standard implants. Cavity defects, especially the common craniolateral defects, require the implantation of oval cups or augments to achieve anatomic reconstruction of the hip center. Combined segmental and cavity defects can be reconstructed using oval cups with craniolateral plates, whereas acetabular discontinuity requires stable fixation within the iliac wing by means of an intramedullary stem combined with an extramedullary plate. Middle and long term survival greater than 90% can be realized with the use of this therapeutic concept.