Search

Wiederherstellung einer schmerzfrei belastbaren Extremitat mit einem modularen Kniearthrodesesystem. Arthrodese auf Grundlage eines zementfreien modularen Revisionsschafts zur rotationsstabilen, diaphysaren Verankerung. Verlust oder Funktionsunfahigkeit des Kniestreckapparats; ausgepragte Knochen- und Weichteildestruktion nach zweizeitigem Prothesenwechsel, der die Implantation einer Knieendoprothese nicht mehr erlaubt. Ausgedehnte Osteolysen, die eine diaphysare Prothesenverankerung unmoglich machen. Kontralateral versteiftes Kniegelenk und/oder ipsilateral versteiftes Huftgelenk. Gegenseitige Oberschenkelamputation. Entfernen des ggf. noch einliegenden gelockerten Knieprothesensystems oder Spacers und – im zementierten Fall – des Knochenzements. Entfernen des intramedullaren Granulationsgewebes. Aufbohren der Markraume mit Reibahlen und flexiblen Markraumbohrwellen. Uberprufen der Beinlange und Rotation mittels Probeimplantaten. Formschlussige, zementfreie Implantation der sternformigen, modularen femoralen und tibialen Verankerungsschafte mit diaphysarem „Press-fit“. Aufsetzten und Verspannen der rotationsgerecht ausgerichteten Kopplungselemente. Mobilisation an Unterarmgehstutzen ab dem 1. postoperativen Tag. Entfernen der Redondrainagen nach 48 h. Teilbelastung mit 20 kg fur 6 Wochen postoperativ. Bei nativradiologisch unverandertem Prothesensitz nach 6 Wochen Steigerung der Belastung um wochentlich 10 kg bis zur Vollbelastung. Zwischen 2007 und 2012 untersuchten wir 27 Patienten, die mit dem Kniearthrodesesystem TITAN (KAM-TITAN) versorgt wurden. Der Nachuntersuchungszeitraum lag bei 30,9 ± 12,0 Monaten. Die mit dem Oxford Knee Score (OKS) gemessenen klinischen Ergebnisse ergaben im Mittel Werte von 39,2 ± 8,3 Punkten. Die Schmerzintensitat wurde mittels Visueller Analog Skala (VAS) bestimmt und lag bei den Patienten bei durchschnittlich 2,9 ± 1,3. Im Nachuntersuchungszeitraum lag bei 85,2 % der Patienten ein infektfreier Status vor.

Periprosthetic loosening, either aseptic or induced by periprosthetic joint infection remains a major long term complication and challenge in orthopedics and trauma surgery. Sensitivity of potential loosening of the material and other causes of a painful prosthesis is essential for choosing the respective treatment option and providing the needed resources. 18F-Fluoride is a radiopharmaceutical which shows a high affinity to bone and a rapid blood clearance. The objective of this study was to assess 18F-Fluoride PET/CT´s sensitivity and specificity in diagnosing periprosthetic loosening in total hip and knee arthroplasty. We included 26 patients with 24 hip and 13 knee prostheses in our retrospective study with radiological or clinical suspicion of peri-prosthetic loosening at least one year after implantation. Results of 18F-Fluoride PET/CT imaging were compared with surgical results or clinical follow-up if surgery was not performed. On the basis of our data we found a sensitivity of 95.00 %, a specificity of 87.04 % and an accuracy of 89.19 % for 18F-Fluoride PET/CT. The results of our study show that 18F-Fluoride PET/CT is a useful and promising technique in diagnosing periprosthetic loosening of total hip and knee arthroplasties. Further investigation should focus on different uptake patterns of the isotope in periprosthetic joint infection and therefore distinguishing aseptic from septic loosening and enhancing the diagnostic value of this imaging method.

Soft tissue sarcomas are a heterogeneous group of neoplasias that due to their often clinically silent appearance often remain undetected or experience delayed treatment. Especially soft tissue swelling is often misinterpreted by patients and doctors and trivialized or verified with an incorrect biopsy technique. The hereby evoked complications for the patients are serious and may be reduced by simply following the available guidelines. The treatment of soft tissue sarcomas requires a close interdisciplinary coordination between specialists in tumor orthopedics, oncology, radiology, pathology and radiotherapy. On the basis of a selective literature review, the following article points out the current evidence on the treatment and illustrates a treatment algorithm.Weichteilsarkome sind eine heterogene Gruppe von seltenen Neoplasien, die aufgrund ihrer anatomischen Lage und ihres oft inapparenten klinischen Erscheinungsbildes eine häufig zu spät diagnostizierte Tumorentität darstellen. Gerade weichteilige Schwellungen werden initial oft fehlinterpretiert und im Gegensatz zu den gängigen Behandlungsleitlinien bagatellisiert oder inkorrekt biopsiert. Die daraus resultierenden Komplikationen sind für den Patienten gravierend und können durch Befolgen gewisser Behandlungsgrundsätze minimiert werden. Die Behandlung der Weichteilsarkome kann nur im interdisziplinären Kontext unter Einbeziehung von chirurgischen Fächern, Onkologie, Pathologie und Strahlentherapie gelingen und sollte beginnend mit der Biopsie an Tumorzentren durchgeführt werden. Dieser Übersichtsartikel versucht, anhand einer selektiven Literaturrecherche eine Übersicht über die aktuelle Evidenzlage zur Behandlung dieser Tumorentität aufzuzeigen und einen Behandlungsalgorithmus darzustellen.

Ziel der Operation ist die Wiederherstellung einer beschwerdearmen Schulterfunktion durch Implantation eines modularen, proximalen Humerusersatzes in der Revisionsendoprothetik bei ausgepragtem segmentalem humeralem Knochenverlust. Segmentale humerale Knochendefekte in der Revisionsendoprothetik des Schultergelenks nach Tumorresektion, Trauma, pathologischen Frakturen, postinfektios oder fehlgeschlagener Osteosynthese. Lokale floride Infektionen, ausgedehnte diaphysare Knochendefekte mit ausgedunnter Kortikalis und weitem diaphysarem Markraum, die eine diaphysare Prothesenverankerung nicht erlauben. Relative Kontraindikationen: Sehr kurze Lebenserwartung (

The second part of this review deals with the several options for the surgical therapy of bone metastases according to their anatomical site and the patient's individual prognosis. Although metastases to the bone - with few exceptions - are normally given palliative therapy, patients nowadays reach survival times of several months to years, depending on the underlying tumour entity. Scoring systems are suitable to estimate the patient's prognosis and fracture risk. The indication for operation has to be adapted to these parameters. In order to preserve a high quality of life, a limb saving procedure has to be aimed at. The options include the resection of the metastasis with stabilisation, the sole stabilisation of the affected bone, and wide resection with limb reconstruction using a modular tumor endoprosthesis. With today's anaesthesiological peri- and intraoperative care, a vast number of surgical implants and bone augmentations are available. However, what is important is not the practicability of the procedure, but the oncological justification and patient-adapted selection of surgical therapy.Der vorliegende 2. Teil dieser Übersichtsarbeit befasst sich mit den unterschiedlichen operativen Therapiemöglichkeiten von Skelettmetastasen in Abhängigkeit von deren Lokalisation und der individuellen Prognose des Patienten. Obwohl im Falle der ossären Metastasierung mit wenigen Ausnahmen von einem palliativen Therapieschema ausgegangen wird, erreichen die Patienten dennoch Überlebensraten von mehreren Monaten bis Jahren in Abhängigkeit von der zugrunde liegenden Tumorentität. Zur Abschätzung der Prognose und Frakturgefährdung stehen verschiedene Scores zur Verfügung. Die Operationsindikation ist immer im Zusammenhang mit der Prognose und patientenindividuell zu stellen. Im Sinne des Erhaltens einer hohen Lebensqualität ist prinzipiell eine extremitätenerhaltende Therapie anzustreben. Diese lässt sich unterteilen in eine Resektion der Metastase mit Stabilisierung der Extremität, der alleinigen Stabilisierung sowie der weiten Resektion mit ossärer und funktioneller Defektrekonstruktion mittels einer Tumorendoprothese. Mit den heutigen Möglichkeiten der intra- und perioperativen Patientenversorgung ist eine Vielzahl von Implantaten und Möglichkeiten der Augmentation von metastatischen Knochendefekten verfügbar. Im Vordergrund steht jedoch nicht die chirurgische Durchführbarkeit, sondern die onkologisch sinnvolle und patientengerechte Wahl der Therapie und des operativen Vorgehens.

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 2.2 cm. The mean VAS for pain was three, the mean Oxford Knee Score was 38 ± 9. Total implant survival at a 74 month 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.

ZusammenfassungMaligne Neoplasien sind in Deutschland nach den kardiovaskulären Erkrankungen weiterhin die zweithäufigste Todesursache. Obwohl sich die 5-Jahres-Überlebensraten der meisten malignen Tumoren in Deutschland in den letzten 30 Jahren signifikant verbessert haben, gilt eine ossäre Metastasierung mit wenigen Ausnahmen weiterhin als Zeichen der Inkurabilität. Neben den seltenen primären Knochentumoren macht die Behandlung von ossären Absiedlungen von Karzinomen einen großen Teil der tumororthopädischen Tätigkeit aus, die zudem eine enge interdisziplinäre Abstimmung mit der inneren Medizin, Radiologie und der entsprechenden Fachdisziplin der zugrunde liegenden Entität erfordert. Durch die Fortschritte in der onkologischen Therapie des Primärtumors wird z. T. ein sehr langes Überleben erreicht, sodass das Management von SRE („skeletal related events“) auch bei palliativen Situationen an Relevanz gewinnt. Die vorliegende Übersichtsarbeit geht in ihrem 1. Teil auf der Grundlage einer aktuellen selektiven Literaturübersicht auf die zuvor erwähnten pathophysiologischen Zusammenhänge der ossären Metastasierung ein und stellt im Folgenden einzelne Diagnostika und deren Relevanz dar.

Zusammenfassung Hintergrund Das multiple Myelom (MM) ist als maligne hämatologische Systemerkrankung nach Einteilung der Weltgesundheitsorganisation (WHO) dem Formenkreis der Plasmazellneoplasien zuzuordnen. Die weltweite Inzidenzrate des MM liegt etwa bei 6 – 7/100 000 Einwohnern/Jahr und macht somit etwa 1% aller Krebserkrankungen der Welt aus. In Deutschland sind ca. 6000 Neuerkrankungen pro Jahr zu verzeichnen. Im Zeitalter der sog. neuen Therapiesubstanzen wie Immunmodulatoren, Proteasomeninhibitoren und Antikörpern haben sich in der Behandlung des MM enorme Fortschritte ergeben. Auf dem Fachgebiet der Orthopädie und Unfallchirurgie ist es von großer Bedeutung, die Leitsymptome des MM im klinischen Alltag sicher zu erkennen und durch eine zielgerichtete Basisdiagnostik weiter abzuklären. Die operative Versorgung von myelomassoziierten Skelettläsionen, wie etwa die Stabilisierung von pathologischen Frakturen, ist Aufgabe der orthopädischen Chirurgie. Methoden Auf Grundlage einer umfassenden Literaturrecherche, die selektiv in PubMed mit den Stichworten „multiple myeloma“ and „diagnostic“ or „therapy“ erfolgte, wurde die verfügbare Primär- und Sekundärliteratur zu aktuellen Standards in der Diagnostik und Therapie des MM beurteilt. Eingeschlossen wurden systematische Reviews, Metaanalysen, klinischen Studien und internationale Therapieempfehlungen bis Frühjahr 2016. Ergebnisse Es existieren heute sehr sensitive Nachweismethoden in der Diagnostik des MM, die neben der bildgebenden Skelettdiagnostik und histologischen Knochenmarkuntersuchung insbesondere die klinisch-chemische Serum- und Urindiagnostik, einschließlich eines 24-h-Sammelurins umfassen. Nach heutigem Kenntnisstand besteht das therapeutische Grundkonzept aus der Kombination einer Hochdosischemotherapie (HDT) und einer autologen Blutstammzelltransplantation (ASCT). Die einzelnen Therapiesäulen der meist multimodalen Behandlungsstrategie sind in enger fachübergreifender Zusammenarbeit patientengerecht abzuwägen. Hierbei ist für die Bewertung des Risikoprofils des Patienten das Lebensalter, die Komorbiditäten sowie der individuelle Krankheitsverlauf (Rezidivneigung oder therapierefraktäre Krankheitsprogression) zu berücksichtigen. Bei Patienten > 70. – 75. Lebensjahr und/oder schweren Komorbiditäten, für die eine HDT und ASCT i. d. R. ungeeignet ist, müssen Indikationen für konventionelle Therapieoptionen gestellt werden. Darüber hinaus sind supportive Behandlungsmaßnahmen wie die Gabe von Bisphosphonaten zur Knochenprotektion, stabilisierende Operationen von pathologischen Frakturen oder eine lokale Strahlenbehandlung von schmerzhaften Osteolysen in das gesamtheitliche Therapiekonzept des MM einzubinden. Schlussfolgerung In aktuellen Studienuntersuchungen konnte gezeigt werden, dass neue Wirkstoffgruppen wie Proteasomenhemmer, immunmodulatorische Substanzen und Antikörper bereits vielversprechend in der Behandlung des MM eingesetzt werden können, um die Prognose und Lebensqualität von Myelompatienten in Zukunft weiter zu verbessern. Hierbei werden die Therapiealgorithmen komplexer und kostenintensiver.

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.

SummaryThe objective of this study was to define fall rates and to identify possible fall risk factors in adult patients with severe haemophilia. Patients, material, methods: 147 patients with severe haemophilia A and B were evaluated using a standardized test battery consisting of demographic, medical and clinical variables and fall evaluation. Results: 41 (27.9 %) patients reported a fall in the past 12 months, 22 (53.7 %) of them more than once. Young age, subjective gait insecurity and a higher number of artificial joints seem to be risk factors for falling. Conclusion: Falls seem to be a common phenomenon in patients with severe haemophilia. Fall risk screening and fall prevention should be implemented into daily practice.

Einleitung: Bei grosen und gelenknahen knochernen Defektsituationen nach vorangegangenen revisionsendoprothetischen Eingriffen besteht im Fall des erneuten Versagens die Moglichkeit der Versorgung durch modulare Implantatsysteme aus der tumorendoprothetischen Versorgung als sog. „Salvage Procedure“. Das Ziel der vorliegenden retrospektiven Studie ist die Evaluation von Patienten, die aufgrund groser und gelenknaher knocherner Defektsituationen, welche nicht mit konventionellen Implantatsystemen versorgt werden konnten, hinsichtlich des klinisch-funktionellen Outcomes und der Komplikationsrate nach Implantation eines modularen Tumor- und Revisionssystems (MUTARS®, Firma Implantcast, Buxtehude, Deutschland). Methodik: In unserer Klinik wurden im Zeitraum von 2005 bis 2014 insgesamt 25 Patienten mittels des MUTARS-Systems aufgrund einer konventionell nicht zu versorgenden ossaren Defektsituation operativ revidiert. Der mittlere Nachbeobachtungszeitraum lag bei 16 Monaten (Spannweite: 12–72 Monate). Folgende Indikationen fuhrten zum Revisionseingriff: Ein Patient stellte sich aufgrund einer gelockerten Kappenprothese mit Bildung eines Metallgranuloms vor, 2 Patienten mit einer Pseudarthrose nach Implantation eines Femurnagels, ein Patient mit einem „Cut-Out“ eines Femurnagels. Vier Patienten mussten aufgrund einer aseptischen und ein Patient aufgrund einer septischen Lockerung einer zuvor implantierten Endoprothese revidiert werden. Insgesamt wurden 6 Patienten aufgrund einer periprothetischen Fraktur revidiert. Weitere 10 Patienten wurden bei einer infektkonsolidierten Girdlestone-Situation nach Explantation einer Endoprothese aufgrund eines periprothetischen Infekts versorgt. Alle Patienten wurden in regelmasigen Intervallen klinisch und radiologisch reevaluiert. Es wurden neben den Komorbiditaten der Patienten klinisch funktionelle-Parameter wie der Harris Hip Score erfasst. Des Weiteren wurde eine Outcome-Analyse bezuglich peri- und postoperativer Komplikationen und eine nativradiologische Verlaufsbeurteilung durchgefuhrt. Ergebnisse: Insgesamt wurden 23 Patienten mit einem proximalen Femur versorgt. Drei Patienten erhielten zusatzlich zur Tumorprothese einen Beckenteilersatz aufgrund einer Beckendiskontinuitat. Ein Patient wurde mit einem distalen Femur, und bei einem weiteren Patienten wurde das ganze Femur durch einen totalen Femurersatz endoprothetisch ersetzt. Die mittlere Krankenhausverweildauer lag bei 25 Tagen (Spannweite: 11–47 Tage). Wir verzeichneten eine Komplikationsrate von 24 %. Der Harris Hip Score stieg von 28 Punkten praoperativ auf 81 Punkte postoperativ. Schlussfolgerung: Bei hohergradigen, knochernen und gelenknahen Defektsituationen nach vorangegangener, gescheiterter endoprothetischer oder osteosynthetischer Versorgung, bietet das MUTARS-System eine suffiziente Versorgungsmoglichkeit mit modularer Adaptation an die jeweilige individuelle Defektkonstellation des Patienten. Die klinischen Ergebnisse sind im kurz- bis mittelfristigen Verlauf vielversprechend.

Introduction Besides the target joints (elbow, knee and ankle), the hip is one of the commonly affected joints in haemophilic arthropathy. Hip arthroplasty is the therapy of choice after failure of conservative treatment. There are only limited data on long-term results after primary total hip arthroplasty (THA). Aim The aim of this retrospective study was to analyse clinical outcome and complication rate after total hip replacement in patients with severe haemophilic arthropathy. Methods Forty-three patients with haemophilia (PWH), one patient with von Willebrand disease and one patient with a Factor-VII-deficiency undergoing 49 total hip arthroplasties, were evaluated in a retrospective study. Harris hip score (HHS), range of motion (ROM), pain status (visual analogue scale, VAS) complication rate and patient satisfaction were assessed at a mean follow-up of 11.5 years (range: 3–32). Results HSS, ROM and VAS improved significantly combined with high patient satisfaction. In total, three (6.1%) periprosthetic infections and five (10.2%) aseptic implant loosenings occurred after THA leading to revision arthroplasty. In two (4.1%) cases, a pseudotumour and one (2.0%) periarticular ossification had to be resected after THA. Conclusion Total hip replacement in PWH leads to a significant increase of function, reduction of pain and a high satisfaction. Due to the relatively high complication rate (infections and aseptic loosening) compared to patients without haemophilia, an individual assessment of the risk–benefit ratio from surgical and haemostaseological point of view is needed.

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. The aim of this retrospective study was to evaluate the mid- to long-term survival of a cementless femoral stem (Zweymuller® SL stem) and a threaded cup (Bicon SL®) in patients younger than 50 years of age. 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. 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. Our study demonstrates excellent long-term survival of cementless femoral stem in combination with a threaded cup in young patients undergoing total hip arthroplasty.

Multiple myeloma is a haematological blood cancer in elderly patients, in which neoplastic cell populations cause osteolytic destruction in the bone skeleton. More than 50% of all patients sustain pathological fractures during the course of their disease. Of all malignant lesions of the spine, multiple myeloma is the most frequent spinal tumour and accounts for approximately 15% of all cases. 8 - 10% of the patients develop neurological deficits. In addition to systemic antineoplastic therapy, surgical treatment is often required in order to reconstruct and stabilise bone defects associated with multiple myeloma, as well as to address tumour-related complications.A comprehensive literature search was performed in PubMed using the keywords "multiple myeloma" and "surgery" or "fracture". This served to evaluate the available primary and secondary literature on the current status of the surgical therapy of multiple myeloma. Systematic reviews, meta-analyses and clinical studies and international recommendations for therapy were included - from 1975 until the spring of 2018.Stabilising surgery is essential in order to retain and restore function and mobility in bone sections affected by myeloma and for tumour-related osseous defects due to pathological fracture or instability. Absolute and relative indications for surgical treatment are distinguished and are based on the extent and localisation of bone lesions, manifest fractures, accompanying side effects and complications such as neurological deficits and bone pain that is intractable to conservative treatment. The range of options in surgical treatment of myeloma-related bone damage within the upper and lower extremities ranges from hybrid stabilisation procedures combining bone cement and various implants, to conventional and modular tumour prostheses systems. In spinal surgery, minimally invasive procedures such as kyphoplasty or vertebroplasty, as well as selective decompressive operations, dorsal spinal fusion and vertebral replacement are performed in cases of osseous defects and related fractures or instabilities. The surgical treatment and time of operation is determined by the general individual risk profile and prognosis of the patient with multiple myeloma. The surgical approach should have the objective of a final and load stable solution for the patient, which takes into account the frequent long-term course of the disease. Radiotherapy is often recommended after surgery.In therapy of multiple myeloma, surgical treatment is often required in order to reduce distress and retain the function and flexibility of myeloma affected bone sections and the mobility and quality of life of the cancer patient. The range of surgical strategies is complex and demanding.Das multiple Myelom (MM) stellt eine maligne hämatologische Plasmazellerkrankung des meist älteren Patienten dar, bei der es durch neoplastische Zellpopulationen im Knochenskelett zu osteolytischen Knochendestruktionen kommt. Über 50% aller Myelompatienten erleiden im Krankheitsverlauf pathologische Frakturen. Mit rund 15% ist das MM der am häufigsten auftretende maligne Tumor der Wirbelsäule, wobei 8 – 10% eine tumorbedingte neurologische Ausfallsymptomatik aufzeigen. Die operative Therapie stellt bei Patienten mit MM neben der onkologischen, antineoplastischen Systemtherapie eine wesentliche supportive Behandlungsmaßnahme dar und dient der Rekonstruktion und Stabilisierung betroffener Skelettabschnitte nach myelomassoziierten Knochendestruktionen und der Behandlung begleitender Komplikationen.Auf Grundlage einer umfassenden Literaturrecherche, die selektiv in PubMed mit den Stichworten „multiple myeloma“ and „surgery“ or „fracture“ erfolgte, wurde die verfügbare Primär- und Sekundärliteratur zur Beurteilung der aktuellen operativen Therapieverfahren beurteilt. Eingeschlossen wurden deutsch- und englischsprachige systematische Reviews, Metaanalysen, klinische Studien und internationale Therapieempfehlungen von 1975 bis Frühjahr 2018.Bei Auftreten von pathologischen Frakturen oder Instabilitäten des Skelettapparats aufgrund von tumorbedingten Knochendestruktionen sind stabilisierende Operationen für die Erhaltung und Wiederherstellung von Funktion und Beweglichkeit unumgänglich. Es werden absolute und relative Indikationsstellungen für eine operative Therapie des MM unterschieden, die sich nach Ausmaß und Befund stabilitätsgefährdender Knochenläsionen oder manifester pathologischer Frakturen sowie begleitender Komplikationen wie neurologische Ausfallserscheinungen und konservativ therapierefraktäre Knochenschmerzen richten. Das Spektrum operativer Versorgungsmöglichkeiten reicht im Bereich der Extremitäten von Verbundosteosynthesen mit verschiedenen Kraftträgern bis hin zu modularen Tumorendoprothesensystemen. Zur Stabilisierung von tumorbedingten Wirbelsäulendestruktionen kommen minimalinvasive Verfahren wie Kypho- und Vertebroplastien, aber auch selektive Dekompressionen sowie Fusionsspondylodesen und Wirbelkörperersatzverfahren zum Einsatz. Operationsmethode und Versorgungszeitpunkt sind individuell und in Abhängigkeit vom Risikoprofil und Prognose des Myelompatienten zu wählen. Grundsätzliches Ziel und Anspruch operativer Stabilisierungseingriffe sollte eine definitive und belastungsstabile Versorgung sein, die bei meist langem Krankheitsverlauf des Myelompatienten eine Restitutio ad Integrum gewährleistet. Postoperativ ist eine adjuvante Strahlentherapie zu empfehlen.Die operative Therapie des MM nimmt eine Schlüsselrolle in der ganzheitlichen Behandlung des Myelompatienten ein, um Leidensdruck zu reduzieren und Funktion und Beweglichkeit der betroffenen Skelettabschnitte wiederherzustellen und damit Mobilität und Lebensqualität für den Tumorpatienten zu erhalten. Das Spektrum der operativen Versorgungsstrategien ist dabei komplex und anspruchsvoll.

Das Auftreten von Frakturen bei Epileptikern ist nicht ungewohnlich und haufig auf direkte Traumata durch Sturze zuruckzufuhren. Gegenuber der Normalbevolkerung wird das Risiko des Auftretens einer Fraktur als um 50 % hoher beziffert. Am haufigsten sind diesbezuglich auftretende Frakturen des proximalen Femurs und des Huftgelenks. Im Bereich der Schulter werden bei Epileptikern haufig dorsale Luxationen beobachtet. Treten diese beidseits auf, ist dies sehr wahrscheinlich auf einen Krampfanfall zuruckzufuhren. Beidseitige Humeruskopfluxationsfrakturen sind wiederum deutlich seltener. Wir beschreiben in unserem Bericht einen Fall der klinischen Erstmanifestation eines Grand-Mal-Anfalls bei einer Patientin, welcher durch beidseitige Humeruskopfluxationsfrakturen ohne direktes Trauma evident wurde.

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

Prosthetic joint infections (PJI) are a serious and challenging complication after total joint arthroplasty. According to the literature, most PJI are monomicrobial infections caused by gram-positive cocci. The number of polymicrobial PJI might be underrepresented in the literature and only limited data are available regarding the outcome of polymicrobial PJI. Our hypothesis was that polymicrobial PJI are associated with a reduced cure rate compared with monomicrobial PJI. Routine clinical data were collected and analysed retrospectively as anonymised, aggregated data. A total of 77 consecutive patients with 77 confirmed PJI and proven infectious organism of the hip and knee joint treated within a two-stage exchange concept and a follow-up ≥ two years were investigated. Detection of the infectious organism was based on multiple microbiological cultures taken intra-operatively. Superficial wound swabs or swabs from sinus tracts were not taken into account. Data were grouped into polymicrobial and monomicrobial PJI. The main outcome variable was “definitively free of infection after two years” as published. Second, we considered several variables as potential confounders or as risk factors. A total of 42 men and 35 women with 46 infected total hip arthroplasties and 31 infected total knee arthroplasties were evaluated. In 37 (46.6 %) of our 77 patients a polymicrobial PJI could be detected. We found a significant association between polymicrobial PJI and the outcome parameter definitively free of infection after two years with an odds ratio (OR) of 0.3 [95 % confidence interval (CI) 0.1–1.0]. The rate of patients graded as definitively free of infection after two years was 67.6 % for polymicrobial infections vs. 87.5 % for monomicrobial infections. The American Society of Anesthesiologists (ASA) score (OR 0.4, 95 % CI 0.2–1.0, p = 0.062) was identified as a borderline significant covariable. Our data suggest that polymicrobial PJI might be underrepresented in the current literature. Additionally, the presence of multiple infectious organisms is associated with a reduced rate after two years with 67.6 vs 87.5 % for monomicrobial infections. Special attention and extra care should be considered for these patients.

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). 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. 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. 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. 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.

Introduction Advanced haemophilic arthropathy of the knee is associated with progressive joint stiffness. Results after total knee arthroplasty (TKA) in stiff knees are considered to be inferior compared to those with less restricted preoperative range of motion (ROM). There is only very limited data on the results of primary TKA in haemophilic patients with stiff knees. Aim The purpose of this retrospective study was to evaluate the clinical outcome after TKA performed in haemophilic patients with preoperative ROM of 50° or less. Methods Twenty one patients (23 knees) undergoing TKA with stiff knees were retrospectively evaluated. Mean follow-up was 8.3 years (range, 2–25). Clinical assessment included ROM, degree of flexion contracture and complication rate. Functional evaluation and pain status were assessed using the Knee Society's Scoring System (KSS). Results Range of motion improved from 26.7° preoperatively to 73.0° postoperatively. Flexion contracture decreased from 21.7° to 8.3°. KSS increased from 22.9 to 72.9 points. Evaluation of pain revealed a decrease from 8.4 points preoperatively to 2.1 points postoperatively. All these differences were statistically significant (P

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.Maligne Neoplasien sind in Deutschland nach den kardiovaskulären Erkrankungen weiterhin die zweithäufigste Todesursache. Obwohl sich die 5-Jahres-Überlebensraten der meisten malignen Tumoren in Deutschland in den letzten 30 Jahren signifikant verbessert haben, gilt eine ossäre Metastasierung mit wenigen Ausnahmen weiterhin als Zeichen der Inkurabilität. Neben den seltenen primären Knochentumoren macht die Behandlung von ossären Absiedlungen von Karzinomen einen großen Teil der tumororthopädischen Tätigkeit aus, die zudem eine enge interdisziplinäre Abstimmung mit der inneren Medizin, Radiologie und der entsprechenden Fachdisziplin der zugrunde liegenden Entität erfordert. Durch die Fortschritte in der onkologischen Therapie des Primärtumors wird z. T. ein sehr langes Überleben erreicht, sodass das Management von SRE („skeletal related events“) auch bei palliativen Situationen an Relevanz gewinnt. Die vorliegende Übersichtsarbeit geht in ihrem 1. Teil auf der Grundlage einer aktuellen selektiven Literaturübersicht auf die zuvor erwähnten pathophysiologischen Zusammenhänge der ossären Metastasierung ein und stellt im Folgenden einzelne Diagnostika und deren Relevanz dar.

Presenting the implantation of the PediatrOS™ FlexTack™ (Merete, Berlin, Germany) for growth guidance and a modified explantation procedure to facilitate explantation and prevent bone and soft tissue damage. Implantation: Genua vara and valga, coxa vara, varus and valgus deviation of the ankle joint, the elbow joint and the wrist Modified Explantation: Removal of the implant after successful limb correction or dislocation of the implant. Implantation: Closed growth plates, insufficient remaining growth potential, acute or chronic infection, insufficient osseous structures, severe muscular, nervous or vessel diseases endangering the respective limb Explantation: General inoperability of the patient. Implantation: Localization of the growth plate. Insertion of K‑wire parallel to joint line on the joint side. Setting of the implant. Insertion of second K‑wire and insertion with the implantation instrument and hammer. Modified Explantation: Cutting of the implant bridging part. Both ends of the bridging part are bent vertically to prevent soft tissue damage. Dissection of both implant arms from the bone with the chisel. Extraction in 360° motion using tooth extraction pliers. Implantation: Full weight bearing. X‑ray controls every 3 months to control growth correction. Explantation: Full weight bearing. Complications such as breaking of the k‑wires, breaking of the chisel or extraction of adhering bone tissue occurred in 14 of the 64 (21.9%) explanted FlexTack implants. Complication-free removal using the original instruments provided by the manufacturer was possible for five implants. The modified explantation procedure as described above was applied in 45 explanted implants (70.3%) with complete removal of the implant without further complications within the follow up period.

Phosphaturic mesenchymal tumor (PMT) is a rare neoplasm of uncertain histogenesis that has been linked to tumor-induced osteomalacia (TIO) since 1959. The neoplastic cells produce increased amount of FGF23 which results in TIO via uncontrolled renal loss of phosphate (phosphaturia), and consequently diminished bone mineralization. To date, ∼300 cases have been reported. Although there is increasing evidence that PMT can be diagnosed by reproducible histopathologic features, firm diagnosis has been often restricted to cases associated with TIO and, hence, diagnosis of "nonphosphaturic variants" remained challenging. Recently, FGFR1/FN1 gene fusions were detected in roughly half of cases. We herein reviewed the clinicopathologic features of 22 PMTs (15 cases not published before), stained them with an extended immunohistochemical marker panel and examined them by fluorescence in situ hybridization for FGFR1 gene fusions. Patients were 12 males and 9 females (one of unknown sex) aged 33 to 83 years (median: 52 y). Lesions affected the soft tissues (n=11), bones (n=6), sinonasal tract (n=4), and unspecified site (n=1). Most lesions originated in the extremities (9 in the lower and 4 in the upper extremities). Acral sites were involved in 10 patients (6 foot/heel, 3 fingers/hands, and 1 in unspecified digit). Phosphaturia and TIO were recorded in 10/11 and 9/14 patients with detailed clinical data, respectively. Limited follow-up (5 mo to 14 y; median: 16 mo) was available for 14 patients. Local recurrence was noted in one patient and metastasis in another patient. Histologically, 11 tumors were purely of conventional mixed connective tissue type, 3 were chondromyxoid fibroma-like, 2 were hemangio-/glomangiopericytoma-like with giant cells, and 1 case each angiomyolipoma-like and reparative giant cell granuloma-like. Four tumors contained admixture of patterns (predominantly cellular with variable conventional component). Immunohistochemistry showed consistent expression of CD56 (11/11; 100%), ERG (19/21; 90%), SATB2 (19/21; 90%), and somatostatin receptor 2A (15/19; 79%), while other markers tested negative: DOG1 (0/17), beta-catenin (0/14), S100 protein (0/14), and STAT6 (0/7). FGFR1 fluorescence in situ hybridization was positive in 8/17 (47%) evaluable cases. These results add to the phenotypic delineation of PMT reporting for the first time consistent expression of SATB2 and excluding any phenotypic overlap with solitary fibrous tumor or sinonasal glomangiopericytoma. The unifying immunophenotype of the neoplastic cells irrespective of the histologic pattern suggests a specific disease entity with diverse morphotypes/variants rather than different neoplasms unified by TIO.

Revision of failed total hip arthroplasty with severe acetabular bone loss represents a rare but challenging problem. Anatomic reconstruction with biological defect augmentation as solid bone transplants or cancellous bone restores bone stock while providing good component stability. The objective of this study was to present short- to mid-term results of revision total hip arthroplasty with a modular ring system in a consecutive series of patients with severe acetabular bone loss. We retrospectively reviewed 39 consecutive patients (39 hips) with severe acetabular bone loss (Paprosky type 3 A and 3 B) reconstructed with revision total hip arthroplasty using the cementless modular ring system MRS-Titan®. The MRS-Titan® consists of independent ring systems that are adapted modularly to the defect situation. Combined with acetabular defect reconstruction by using cancellous bone in impaction grafting technique, the MRS-Titan® system offers a cement-free revision system that enables defect-adapted customization to individual anatomic matters, bridging of the acetabular bone defect and reconstruction of the centre of rotation. Initial stability of the implant was obtained by screw fixation. Harris hip score and sequential radiographs were used to evaluate clinical and radiographic results. At an average follow up of 31 months (range 12–69 months) 33 of 39 (84.6 %) of the implants were considered radiographically stable without signs of acetabular migration of more than 2 mm in the horizontal or vertical direction, implant rotation or screw breakage. Complications included six implant failures (15 %). We recorded one aseptic loosening of the MRS prosthesis after 20 months. Five patients (12.8 %) had to undergo revision surgery because of periprosthetic joint infection. Two patients had a dislocation postoperatively. The mean Harris hip score improved from 27 ± 14 points preoperatively to 76 ± 15 points at the time of last follow up. By achieving stable implant fixation and providing potential for biological fixation, treatment of severe acetabular bone loss in revision total hip arthroplasty with the modular ring system MRS-Titan provides a durable solution with good clinical and radiographic results and allows us to accomplish major goals of reconstruction.

Einleitung: Minimalinvasive Zugangswege zum Huftgelenk bei der primaren Endoprothetik stehen seit einigen Jahren im Fokus einer kontroversen Diskussion. Minimalinvasive Zugange versprechen eine weichteilschonende Implantation mit Vorteilen in den postoperativen funktionellen Ergebnissen und reduziertem intraoperativem Blutverlust. Methodik: Auf Grundlage einer umfassenden Literatursuche (Einschlusskriterien: Prospektiv randomisierte klinische Studien, systematische Reviews, Metaanalysen) wird die verfugbare Primar- und Sekundarliteratur beurteilt, Vor- und Nachteile minimalinvasiver Zugange zum Huftgelenk werden im Vergleich zu traditionellen Zugangen diskutiert. Ergebnisse: Die verfugbare Primar- und Sekundarliteratur belegt Vorteile minimalinvasiver Zugange zum Huftgelenk im funktionellen Outcome in der fruhen postoperativen Phase. Nach 1 Jahr postoperativ bestehen keine funktionellen Unterschiede mehr zum Standardzugang. Des Weiteren werden eine verminderte Operationsdauer, ein verminderter Blutverlust und ein kurzerer stationarer Aufenthalt belegt. Studien der Evidenzgrade I und II zu mittel- und langfristigen Ergebnissen minimalinvasiver Zugange im Vergleich zu den etablierten Standardzugangen sind nicht verfugbar. Die verfugbaren Systematic Reviews und Metaanalysen lassen lediglich eine globale Beurteilung der Primarliteratur zu minimalinvasiven Zugangswegen zu, ohne dabei zwischen den etablierten Standardzugangen und dem nach minimalinvasiven Kriterien modifizierten Pendant zu differenzieren. Es existieren zurzeit wenig bildmorphologische In-vivo-Hinweise (MRT) fur eine Reduktion des muskularen Traumas durch Verwendung von MIS-Zugangen. Fazit: Die verfugbare Literatur erlaubt derzeit kein abschliesendes Urteil zur Wertigkeit minimalinvasiver Zugangswege zum Huftgelenk. Weiterfuhrende prospektiv randomisierte kontrollierte Studien sind notwendig, um die sehr guten (Langzeit-)Ergebnisse der etablieren Standardzugange mit den nach minimalinvasiven Kriterien modifizierten Huftzugangen zu vergleichen. Solange keine ausreichenden Langzeitergebnisse zu Komplikations- und Revisionsraten minimalinvasiver Zugangswege vorliegen, konnen minimalinvasive Zugangswege nicht als Goldstandard empfohlen werden.

Primarstabile Uberbruckung azetabularer Knochendefekte vom Typ Paprosky IIa und IIb und Rekonstruktion des anatomischen Rotationszentrums. Begleitende Defektrekonstruktion mit homologer Spongiosa in „Impaction-Grafting“-Technik zur Wiederherstellung eines tragfahigen Implantatlagers und „down grading“ der knochernen Defektsituation im erneuten Revisionsfall. Azetabulare Defektsituationen des Pfannenbodens/-erkers bei verbliebener Resttragfahigkeit des Pfannenerkers bei intaktem kaudalem Pfannenrand (Paprosky-Typ IIa, IIb). Bestehender Huftgelenksinfekt. Azetabulare Knochendefekte oder eine nichttragfahige Knochensubstanz, die eine sichere Auflage des metallischen Abstutzrings in der Pfanneneingangsebene verhindern. Transglutealer, lateraler Huftgelenkzugang. Entfernung der gelockerten, azetabularen Prothesenkomponente. Auffrasen des Implantatlagers unter Erhalt des mechanisch stabilen Restknochens. Praparation der homologen Spongiosachips und Impaktierung in die azetabularen Knochendefekte. Einbringen der Pfannendachschale nach Verankerung des kaudalen Hakens in der Inscisura acetabuli. Primarstabile Verankerung mit Platzierung von 1–2 Domschrauben im Kraftvektorverlauf sowie Spongiosaschrauben im Pfannendachbereich. Einzementierung des Polyethyleninlays. Mobilisation an 2 Unterarmgehstutzen ab dem 1. postoperativen Tag. Teilbelastung mit 20 kg fur 6 Wochen postoperativ. Bei nativradiologisch unverandertem Implantatsitz Belastungssteigerung nach 6 Wochen um 10 kg/Woche bis zur Vollbelastung unter Fortfuhren der Thromboseprophylaxe. Limitation der Huftflexion auf 90°. Adduktionsvermeidung unter gleichzeitiger Ausenrotation in den ersten 6 postoperativen Wochen sowie von Freizeit- und Sportaktivitaten mit Sprung- und axialen Stosbelastungen fur 12 Monate postoperativ. Rontgenkontrollen nach 3, 6 und 12 Monaten und 2-jahrliche Verlaufskontrolle. Zwischen 2008 und 2011 wurden 22 konsekutive Patienten mit 23 Implantaten versorgt und uber 38 ± 11 Monate nachuntersucht. Pra- vs. postoperativ zeigte sich eine signifikante Steigerung im Harris-Hip-Score (82,2 ± 8,7 vs. 44,7 ± 10,7) und im Merle-d’Aubigne-Score (14,6 ± 1,9 vs. 7,5 ± 1,3). In 21 Fallen radiologischer Nachweis einer Osseointegration; 2 partielle Lysesaume (9 %) in den Zonen I–III nach DeLee und Charnley. Zunehmende trabekulare Zeichnung im Sinne einer Wiederherstellung der trabekularen Mikroarchitektur im augmentierten Areal zeigten 20 Abstutzschalen (87 %), eine stabile Integration bei unveranderter Positionierung des anatomischen Rotationszentrums 21 Abstutzschalen (92 %) und eine Implantatmigration 2 Implantate (9 %). Operative Revision im Follow-up bei 3 Prothesen (13 %).

Increased articular 99mTc MDP uptake on blood pool imaging (BPI) of patients with rheumatologic conditions is indicative of active inflammatory changes, and has been suggested as a strong predictor of response to radiosynoviorthesis (RSO). In this study, we aimed to assess the value of pretreatment BPI positivity (i.e. scintigraphic-apparent hyperemia) for successful RSO in hemophilic arthropathy. Thirty-four male patients with painful hemophilic arthropathy underwent RSO after failure of conservative treatment. Treated joints comprised the knee in eight, elbow in five, and ankle in 21 patients. Pretreatment triple-phase bone scintigraphy showed hyperemic joints (pathologic BPI) in 17 patients, whereas 17 patients had no increased tracer uptake on BPI. Response to RSO was evaluated 6 months post-treatment by measuring changes in intensity of arthralgia according to the visual analog scale (VAS), bleeding frequency, and range of motion. The association between hyperemia (pathologic BPI) and treatment outcome was examined using nonparametric tests for independent samples. Clinically evident pain relief occurred in 26 patients (76.5 %), and the mean VAS decreased from 7.7 ± 1.1 to 4.6 ± 2.7 (p

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.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.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 infection4 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.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.

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. 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. 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. 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 3, retrospective comparative study

Gelenknahe Tumoren mussen histologisch abgeklart werden, da neben entzundlichen Veranderungen auch benigne und maligne Tumoren auftreten. Wir berichten uber einen glatt begrenzten Tumor, der in der Ellenbeuge lokalisiert war und sich histologisch als Hibernom erwies. Die Therapie erfolgt chirurgisch durch komplette Resektion, Rezidive treten sehr selten auf. Es lag keine MDM-2-Genamplifikation vor, somit war ein Liposarkom mit hibernomahnlichen Arealen auszuschliesen. Hibernome sind Tumoren des braunen Fettgewebes, die selten auch in der Nachbarschaft von Gelenken auftreten konnen.

Osteoarthritis is a common and progressive joint disorder. Despite its widespread, in clinical practice only late phases of osteoarthritis that are characterized by severe joint damage are routinely detected. Since osteoarthritis cannot be cured but relatively well managed, an early diagnosis and thereby early onset of disease management would lower the burden of osteoarthritis. Here we evaluated if biophysical parameters of small synovial fluid samples extracted by single molecule microscopy can be linked to joint damage. In healthy synovial fluid (ICRS-score 2/s, N = 5) than in samples from patients with joint damage (ICRS-score > 2) (4.5 μm2/s, N = 16). More strikingly, the diffusion coefficient of hyaluronan in healthy synovial fluid was on average 30% slower than expected by sample viscosity. This effect was diminished or missing in samples from patients with joint damage. Since single molecule microscopy needs only microliters of synovial fluid to extract the viscosity and the specific diffusion coefficient of hyaluronan this method could be of use as diagnostic tool for osteoarthritis.

Introduction Fractures in persons with haemophilia (PWH) are not uncommon and require an interdisciplinary approach to maintain haemostasis during surgical treatment. Aim The aim of this study was to evaluate the perioperative management and outcome in PWH following fracture fixation compared to a matched non-haemophilic control group. Methods A cohort of 44 PWH who underwent 46 surgical fracture fixations was retrospectively compared to 46 non-haemophilic patients (matched-pair controls). Patients were classified according to the fracture localization: (i) proximal upper extremity (PrUEx; n = 7), (ii) distal upper extremity (DiUEx; n = 12), (iii) proximal lower extremity (PrLEx; n = 13) and (iv) distal lower extremity (DiLEx; n = 14). Both groups were assessed for length of hospital stay, duration of surgery, drainage use and complication rates. Results There was no significant difference regarding the duration of the preoperative hospital stay between PWH and controls. Only PWH who were operated at the DiUEx stayed significantly longer in hospital (4.8 ± 3.7 days) than controls (2.2 ± 2.3 days; P = 0.039). Operation time was significantly longer in PWH with fractures treated at the DiLEx (64.9 ± 26.6 min) compared to the controls (49.8 ± 37.9 min; P = 0.035). Neither frequency nor duration of surgical drainage placement differed significantly between the two groups. The overall complication rate in both groups was low without a statistically significant difference. Conclusion An optimal interdisciplinary perioperative management provided the surgical treatment of fractures in PWH can be performed safely with a low complication rate.

Revision of failed total hip arthroplasty with massive acetabular bone loss resulting in pelvic discontinuity represents a rare but challenging problem. The objective of this study was to present short to mid-term results of revision total hip arthroplasty with a custom-made acetabular implant in a consecutive series of patients with pelvic discontinuity. We retrospectively reviewed 18 consecutive patients with massive acetabular bone loss (Paprosky Type 3B) resulting in pelvic discontinuity reconstructed with revision total hip arthroplasty using a custom-made acetabular component. The prosthesis was created on the basis of a thin-cut 1-mm computed tomography (CT) scan of the pelvis. Initial stability of the implant was obtained by screw fixation. Harris hip score and sequential radiographs were used to evaluate the clinical and radiographic results. At an average follow up of 30 months (range 17–62 months) 16 of 18 (88.9 %) custom-made implants were considered radiographically stable without signs of acetabular migration of more than 2 mm in the horizontal or vertical direction, implant rotation or screw breakage. Complications included two periprosthetic joint infections treated with explantation of the implant. Three patients had recurrent dislocations postoperatively. The mean Harris hip score improved from 28 ± 12 points preoperatively to 69 ± 13 points at the time of last follow up. Treatment of acetabular bone loss and pelvic discontinuity with a custom-made acetabular component can provide a durable solution with good clinical and radiographic results.

Background Periprosthetic joint infections (PJI) are often treated by two stage exchange with the use of an antibiotic impregnated spacer. Most of the two-stage exchange algorithms recommend the implantation of an antibiotic-impregnated spacer during the first stage for a period of 2–24 weeks before reimplantation of the new prosthesis. For the spacer to have a therapeutic effect, the local antibiotic concentration must be greater than the minimal inhibition concentration (MIC) against the pathogens causing the PJI. It must remain so for the entire spacer period, otherwise recurrence of infection or resistances might occur. The question as to whether a sufficient concentration of antibiotics in vivo is reached for the entire spacer period has not been answered satisfactorily. Case presentation We here present a case of a histologically confirmed chronic PJI 20 month after primary arthroplasty. The primary knee arthroplasty was performed due to osteoarthritis of the joint. Initial assessment did not detect a causative pathogen, and two stage exchange with a vancomycin-gentamycin impregnated spacer was performed. At the time of reimplantation, sonication of the explanted spacer revealed a multi-resistant strain of staphylococcus epidermidis on the device and in the joint. Adaption of the therapy and prolonged treatment successfully eradicated the infection. Conclusion According to the authors’ knowledge, the case presented here confirms for the first time the surface contamination (proven through sonication) of a vancomycin-/gentamicin- impregnated Vancogenx®-spacer with a MRSE after ten weeks of implantation. This case study demonstrates the difficulties still associated with the diagnostics of PJI and the published different two stage treatment regimes with the use of antibiotic impregnated spacers.