[Acetabular metastatic defect reconstruction using the modular revision support cup MRS-C]

OBJECTIVE

Stabilization of metastatic acetabular defects with a bone cement-augmented revision support cup for remobilization of oncological patients in advanced cancer stages.

INDICATIONS

Metastatic acetabular defects (Metastatic Acetabular Classification, MAC 2-4) in patients with a prognostic medium or long-term survival.

CONTRAINDICATIONS

Highly limited survival due to metastatic disease (< 6 weeks). Local bone or soft tissue infection. Primary bone tumor with curative treatment option. Advanced pelvic discontinuity. Recent wound compromising systemic therapy.

SURGICAL TECHNIQUE

Standard hip approach. Curettage of the metastatic defect and careful reaming of the acetabulum before insertion of the cup. Predrilling of the dome und flange screws before application of the bone cement through the center hole of the implant and filling of the acetabular defect. Complete insertion of the screws for compound osteosynthesis. Implant of a modular inlay or dual mobility system.

POSTOPERATIVE MANAGEMENT

Full weight bearing or mobilization with two crutches according to the level of pain. Adjuvant local radiation therapy after wound consolidation. Continuation of systemic therapy according to tumor board decision.

RESULTS

Between 2012 and 2019, we treated 14 patients with metastatic acetabular defects using the modular revision support cup "MRS-TITAN® Comfort", MRS-C, Peter Brehm GmbH, Weisendorf, Germany) at our institution. Mean Harris Hip Score improvement was 23.2 with a mean patient's survival of 9.7 months due to the reduced cancer-related prognosis; 13 of the 14 implants endured the patient's prognosis. One implant had to be removed due soft tissue defect-related periprosthetic joint infection.

Litigations in orthopedics and trauma surgery: reasons, dynamics, and profiles

BACKGROUND

In recent literature, the increasing number of medical litigations, both in terms of the number of cases being filed and the substantive costs associated with lawsuits, has been described. This study aims to provide an overview of the profile of litigation for orthopedic and trauma surgery to describe the differences and the development of the number of cases over time.

PATIENTS AND MATERIALS

A retrospective review of all litigations between 2000 and 2017 was conducted using the institutional legal database. The causes of litigation were documented and classified into seven major categories. In addition to plaintiff characteristics, the litigation outcomes and the differences between emergency and elective surgery were analyzed.

RESULTS

A total of 230 cases were evaluated. The mean age of the plaintiffs was 44.6 ± 20.1 years, and 56.8% were female. The main reasons for litigation were claimed inappropriate management (46.1%), misdiagnosis (22.6), and poor nursing care (8.3%). Significantly more litigations were filed against surgeons of the orthopedic subspecialty compared with trauma surgeons (78%; p ≤ 0.0001). There were significantly fewer litigations per 1000 cases filed overall in 2009-2017 (65% less; p = 0.003) than in 2000-2008.

CONCLUSION

Our results could not confirm the often-stated trend of having more litigations against orthopedic and trauma surgeons. Although the absolute numbers increased, the number of litigations per 1000 patients treated declined. Patients who underwent elective surgery were more likely to file complaints than emergency patients.

Explant analysis and implant registries are both needed to further improve patient safety

In the early days of total joint replacement, implant fracture, material problems and wear presented major problems for the long-term success of the operation.

Today, failures directly related to the implant comprise only 2–3% of the reasons for revision surgeries, which is a result of the material and design improvements in combination with the standardization of pre-clinical testing methods and the post-market surveillance required by the legal regulation.

Arthroplasty registers are very effective tools to document the long-term clinical performance of implants and implantation techniques such as fixation methods in combination with patient characteristics.

Revisions due to implant failure are initially not reflected by the registries due to their small number.

Explant analysis including patient, clinical and imaging documentation is crucial to identify failure mechanisms early enough to prevent massive failures detectable in the registries.

In the past, early reaction was not always successful, since explant analysis studies have either been performed late or the results did not trigger preventive measures until clinical failures affected a substantial number of patients.

The identification of implant-related problems is only possible if all failures are reported and related to the number of implantations.

A system that analyses all explants from revisions attributed to implant failure is mandatory to reduce failures, allowing improvement of risk assessment in the regulatory process.

[Reconstruction of the extensor apparatus with advanced structural defects in knee revision arthroplasty]

OBJECTIVE

Restoration of the extensor apparatus in the case of advanced tendon defects as part of revision total knee arthroplasty (TKA). Reconstruction and augmentation using vascularized gastrocnemius muscle and tendon.

INDICATIONS

Advanced degeneration of the extensor apparatus (patella tendon; quadriceps tendon) with or without discontinuity, following revision arthroplasty.

CONTRAINDICATIONS

Persistent infection or pending TKA revision. Damaged gastrocnemius or soleus muscle or Achilles tendon.

SURGICAL TECHNIQUE

Extension of the surgical TKA-access medial-distally. Separation of the medial gastrocnemius muscle along the raphe and preparation of the distal tendon from the soleus portion. Transposition into the defect site, augmentation or reconstruction of the defect by double turn of the gastrocnemius tendon. The muscle belly serves to adequately cover the tendon as well as the ventral knee joint. Mesh coverage of the muscle.

POSTOPERATIVE MANAGEMENT

Immobilization of the knee and ankle for 10 days until mesh graft healing. Stepwise increasing flection of the knee with 30°/60°/90° every 2 weeks. Total weight bearing with secured full extended knee, no weight bearing with flexed knee for 6 weeks.

RESULTS

In 9 patients, 3 with complete rupture of the patellar tendon, 5 with destruction of the extensor apparatus, and 1 patient with rupture of the quadriceps tendon following TKA revision, good functional results were achieved with active extension of the knee joint and standing/gait stability 6 months after surgery.

[Reconstruction of tibial metaphyseal defects with artificial components in revision arthroplasty (GenuX MK System)]

OBJECTIVE

Restoration of knee function by using tibial metaphyseal components in advanced metaphyseal bone defects after multiple bone-damaging revision surgery on the knee joint.

INDICATIONS

Advanced tibial metaphyseal bone defects (Anderson Orthopaedic Research Institute [AORI] IIb and III defects) in revision arthroplasty of the knee joint.

CONTRAINDICATIONS

Persistent or current joint infection, general infection (e.g., pneumonia), nonreconstructable insufficient extensor apparatus.

SURGICAL TECHNIQUE

Standard access including existing skin scars, arthrotomy, removal of cement spacer if necessary and removal of multiple tissue samples; preparation of femur first, followed by preparation of the tibia. Referencing the tibial rotation and joint line height. Tibial osteotomy referenced intramedullarily. Determination of the metaphyseal defect size and choice of component size. Positioning of the rasp guide for the preparation of the metaphyseal component (sleeve); gradual preparation of the bed for the metaphyseal component. Afterwards the prepared component at the desired depth (when using augments +5 or +10 mm accordingly 5 or 10 mm above the tibial plateau) is left and the tibial plateau is fixed on the embedded sleeve. Test coupling, control of the implant position and the height of the joint line radiologically. If satisfactory the definitive implants accordingly to the components of used implants before can be implanted.

POSTOPERATIVE MANAGEMENT

Full weight bearing. Regular wound control; limitation of the degree of flexion only with weakened or reconstructed extensor apparatus.

RESULTS

Between May 2018 and August 2019, 14 metaphyseal tibial components were implanted in 14 patients. The mean follow-up was 10.4 months. The follow-up included clinical examination, KSS (Knee Society Score) and an X‑ray and failure analysis. A significant improvement in range of movement from 75 ± 16° to 100 ± 14° (p < 0.01) was achieved. The KSS improved significantly from 78 ± 12 points preoperatively to 137 ± 23 points postoperatively. Two patients complained of persistent pain after exercise (walking distance >200 m) after 6 months; tibial shaft pain was negated by all patients. The group examined afterwards showed an implant survival rate of 100% in the observation interval.

A survey on surgeon practice shows lack of consensus on the management of primary shoulder stiffness

Shoulder stiffness is a condition of painful restriction in active and passive glenohumeral range of motion, which can arise spontaneously or as consequence of a known cause. Numerous therapeutic approaches are available; however, no consensus has been reached on the best algorithm for successful treatment. The aim of this study was to investigate local practice patterns regarding management of primary shoulder stiffness. Randomized controlled trials reporting results of shoulder stiffness treatment were collected and analyzed prior to study begin. Controversial elements in the treatment of primary shoulder stiffness were identified and a survey was created and administrated to clinicians participating at an annual national congress dedicated to shoulder pathologies and their treatment. 55 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 58% and injections of corticosteroids by 60%. Injective therapy with local anaesthetics was considered by 56% of the clinicians and acupuncture by 36%. 38% of the interviewed did never treat shoulder stiffness surgically. Various strategies to manage shoulder stiffness have been proposed and high-level evidence has been published. Numerous controversial points and a substantial lack of consensus emerged both from literature reviews and from this survey. The treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology, aiming primarily at identifying risk factors for recurrence, reducing pain, restoring range of motion and function and shortening the duration of symptoms.

[Periprosthetic fractures of the proximal femur]

The incidence of periprosthetic fractures of the proximal femur is increasing due to the growing numbers of hip replacements in old age. The treatment of these fractures is a challenge for the treating physician and standardized procedures are necessary. The unified classification system (UCS) is a suitable tool to establish treatment strategies: On the basis of the fracture localization and extent, bone quality, stability of the prosthesis and the presence of further implants, the fractures can be classified according to the UCS and a treatment algorithm can be derived. This article gives an overview of the diagnostics, classification and characteristics of the various periprosthetic fracture types as well as the treatment.

[Challenges of discharge management in geriatric traumatology : Example of an integrated orthogeriatric service]

BACKGROUND

Geriatric patients are currently responsible for almost one third of all emergency hospital admissions. An increase of 50% is expected in the next decade. This age redistribution poses new challenges for inpatient care and discharge management. The requirements of an orthopedic trauma surgery clinic in the care of this patient group can be clarified with the help of this first collaboratively created geriatric orthopedic trauma surgery complex treatment unit of a university hospital.

OBJECTIVE

What influence do age and delirium have on discharge management, length of inpatient stay and discharge destination in a geriatric cohort?

MATERIAL AND METHODS

All patients who received inpatient treatment as part of the orthopedic trauma surgery geriatric complex treatment (GKB) between May 2017 and December 2019 were evaluated. An analysis of the demographics, length of inpatient stay, discharge destinations and evaluation of the Barthel index collected on admission and discharge, the mini-mental state examination (MMSE) and the geriatric depression scale (GDS) were carried out.

RESULTS

Out of 312 patients, 110 men and 193 women with a median age of 81 years, 77 patients (24.6%) showed delirium when enrolled in the GKB and 39 (12.5%) dementia. Older patients presented more often with delirium than younger people (p = 0.013), especially those aged 70-79 years (p = 0.037). Dementia patients suffered more frequently from postoperative delirium (p < 0.01). The mean hospital stay was 17.79 days (±4.6 days). The GKB was regularly completed in 60.7% of all cases and 39.3% patients dropped out early. Patients with delirium were discharged significantly less often into their own home but into short-term care or nursing homes (p = 0.038). A general correlation between delirium development and the discharge destination was noticeable (p = 0.004).

CONCLUSION

Patients with dementia are more likely to develop delirium postoperatively, which leads to an increase in the length of inpatient stay, an increase in treatment costs and more work for the discharge management team. In addition, the discharge to the patients' home is impaired by delirium, which means that the growing need for places in short-term care and nursing homes also creates socioeconomic burdens.

[Endoprosthetic replacement of the proximal humerus in revision shoulder arthroplasty]

OBJECTIVE

Reconstruction of proximal humeral bone defects in the setting of shoulder revision arthroplasty by implantation of a modular humeral component.

INDICATIONS

Severe segmental humeral bone defects in revision total shoulder arthroplasty, after tumor resection, trauma, pathological fractures, post-infectious or after failed osteosynthesis.

CONTRAINDICATIONS

Acute or chronic local infections, large diaphyseal bone defects preventing adequate anchorage of the prosthesis, very short life expectancy (<3 months).

SURGICAL TECHNIQUE

Removal of the implant using an extended deltopectoral approach. Periarticular arthrolysis with preservation of neurovascular structures. Resection of the meta-diaphyseal bone and reconstruction of the humeral length with the help of different extension sleeves and a modular humeral component. Soft tissue management is crucial, especially with reverse shoulder arthroplasty.

POSTOPERATIVE MANAGEMENT

Three weeks postoperatively immobilization in a shoulder sling, active assisted movement therapy by gradual pain-adapted increase of movement, muscle coordination, and strength.

RESULTS

The results of 11 consecutive patients treated with a modular humeral component due to a failed shoulder arthroplasty between 2008 and 2016 were evaluated retrospectively. Mean length of reconstruction was 100 mm. Due to recurrent dislocations one patient required revision and conversion to a reverse component. No cases of aseptic loosening or periprosthetic infection were observed.

Erratum to: Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction

Erratum to:Oper Orthop Traumatol 2018 https://doi.org/10.1007/s00064-018-0559-3 The article was wrongly published under the article type "Review". Please note that the article is an "Original Paper".The publisher apologizes to authors and ….

Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction

OBJECTIVE

The aim is to stabilize the thoracolumbar spine with a thoracoscopically implanted vertebral body replacement (VBR). To improve intraoperative depth perception and orientation, implantation is performed under three-dimensional (3D) thoracoscopic vision.

INDICATIONS

Vertebral burst fractures at the thoracolumbar junction (A4 AOSpine classification), pseudarthrosis, and posttraumatic instability with increasing kyphosis.

CONTRAINDICATIONS

Severe pulmonary dysfunctions, pulmonary or thoracic infections, previous thoracic surgery, and pulmonary adhesions.

SURGICAL TECHNIQUE

The patient is lying in a right lateral decubitus position. Localization of the fractured vertebra. Minimally invasive transthoracic approach. Perform single lung ventilation and insert the 3D thoracoscope two intercostal spaces above the working portal. Utilization of special binocular glasses for 3D vision of the operation field and secure resection of the fractured vertebra. Measurement of the bony defect and insertion of the expandable cage. Control of correct cage position under fluoroscopy. Insertion of a chest tube and inflate the left lung.

POSTOPERATIVE MANAGEMENT

Chest × ray Remove chest tube when output is <500 ml/24 h Early mobilization on the ward 6 weeks no weight-bearing >5 kg RESULTS: Between 2012 and 2017, 12 patients received a VBR under 3D thoracoscopic vision. After a mean follow up of 26 months, no cage dislocation was noticed and all patients recovered from the initial back pain. Complications were notable in two cases (17%) with a small pneumothorax after removal of the chest tube and postoperative pneumonia in one patient (8%). All responded to conservative treatment. Revision surgery was not necessary.

Upper ankle joint prostheses in haemophilia patients

Secondary arthrosis of the upper ankle joint (talocalcanean joint) is one of the most frequent forms of haemophilic arthropathy. It is a secondary form of arthrosis not only because of chronic synovitis and cartilage injury resulting from chronic recurrent intraarticular bleeds, but also due to the misalignment of the joint and abnormal joint stress. The consequences are manifest even in young patients and finally lead to subtalar joint ankylosis with the biomechanical disorder of foot drop (talipes equinus). In such clinical situations, implantation of a subtalar joint endoprosthesis is a viable alternative to arthrodesis. Case report:A man (age: 52 years), suffering from severe haemophilia A (residual FVIII activity < 1 %), no inhibitor formation. The patient has a history of several years of painful ankylosis of the right ankle joint and minor talipes equinus, and suffers from symptomatic talonavicular arthrosis. Open joint cleansing considerably improved mobility in the upper ankle joint and alleviated the pain in the talonavicular joint. However, the recovered mobility of the arthrotic upper ankle joint also activated the patient’s arthrosis, associated with severe pain. As there was no contraindication to upper ankle joint replacement, a cement-free prosthesis was implanted. Three months after surgery, the patient was mobile, with good foot rolling properties without orthopedic aids, and without pain in his upper joint ankle. Conclusion: In terms of biomechanics an upper ankle joint endoprosthesis is a superior alternative to arthrodesis in haemophilia patients. In order to minimize the complication rate, the treatment of haemophilia patients should be restricted to specially equipped interdisciplinary treatment centers with adequately trained and experienced surgeons as well as haemo -staseologists.

Comparison of radiofrequency kyphoplasty and balloon kyphoplasty in combination with posterior fixation for the treatment of vertebral fractures

BACKGROUND

In case of complex vertebral fractures, posterior fixation is often required for correction of deformity and instability. Fixation is commonly supported by balloon kyphoplasty (BKP) anterior. A development of BKP is radiofrequency-targeted vertebral augmentation (RF-TVA), which leads to comparable results for augmentation and pain relief.

OBJECTIVE

This prospective study evaluates the outcome of posterior fixation combined with RF-TVA or BKP, respectively.

METHODS

VAS, ODI, kyphosis angle and vertebral height of 44 patients were evaluated preoperatively, 3 and 12 months postoperatively.

RESULTS

Both treatments improved vertebral height and kyphosis angle. At 12 months, vertebral height restoration was still significantly better in the BKP group (p < 0.001) and the improvement of kyphosis angle was comparable between both groups (p = 0.71). VAS and ODI improvements were significantly better in the RF-TVA group (p < 0.001). 8% of BKP patients had cement extravasations, compared to 10.5% in the RF-TVA group (p = 1.0).

CONCLUSIONS

Combining posterior fixation with RF-TVA leads to better results of VAS and ODI, whereas the vertebral height restoration was favorable for patients treated with BKP. Cement leakage was comparable between both groups. It was asymptomatic and within reported ranges. Limitations of this study are the patient number and different stabilization instrumentation.

Radiofrequency-activated PMMA-augmentation through cannulated pedicle screws: A cadaver study to determine the biomechanical benefits in the osteoporotic spine

INTRODUCTION

PMMA-augmentation of pedicle screws strengthens the bone-screw-interface reducing cut-out risk. Injection of fluid cement bears a higher risk of extravasation, with difficulty of application because of inconsistent viscosity and limited injection time.

OBJECTIVE

To test a new method of cement augmentation of pedicle screws using radiofrequency-activated PMMA, which is suspected to be easier to apply and have less extravasations.

METHODS

Twenty-seven fresh-frozen human cadaver lumbar spines were divided into 18 osteoporotic (BMD ≤ 0.8 g/cm2) and 9 non-osteoporotic (BMD > 0.8 g/cm2) vertebral bodies. Bipedicular cannulated pedicle screws were implanted into the vertebral bodies; right screws were augmented with ultra-high viscosity PMMA, whereas un-cemented left pedicle screws served as negative controls. Cement distribution was controlled with fluoroscopy and CT scans. Axial pullout forces of the screws were measured with a material testing machine, and results were analyzed statistically.

RESULTS

Fluoroscopy and CT scans showed that in all cases an adequately big cement depot with homogenous form and no signs of extravasation was injected. Pullout forces showed significant differences (p < 0.001) between the augmented and non-augmented pedicle screws for bone densities below 0.8 g/cm2 (661.9 N ± 439) and over 0.8 g/cm2 (744.9 N ± 415).

CONCLUSIONS

Pullout-forces were significantly increased in osteoporotic as well as in non-osteoporotic vertebral bodies without a significant difference between these groups using this standardized, simple procedure with increased control and less complications like extravasation.

[Biological downsizing : Acetabular defect reconstruction in revision total hip arthroplasty]

BACKGROUND

Periacetabular bony defects remain a great challenge in revision total hip arthroplasty. After assessment and classification of the defect and selection of a suitable implant the primary stable fixation and sufficient biological reconstitution of a sustainable bone stock are essential for long term success in acetabular revision surgery. Biological defect reconstruction aims for the down-sizing of periacetabular defects for later revision surgeries.

TECHNIQUE

In the field of biological augmentation several methods are currently available. Autologous transplants feature a profound osseointegrative capacity. However, limitations such as volume restrictions and secondary complications at the donor site have to be considered. Structural allografts show little weight bearing potential in the long term and high failure rates. In clinical practice, the usage of spongious chips implanted via impaction bone grafting technique in combination with antiprotrusio cages for the management of contained defects have shown promising long time results. Nevertheless, when dealing with craniolateral acetabular and dorsal column defects, the additional implantation of macroporous metal implants or augments should be considered since biological augmentation has shown little clinical success in these particular cases.

PROSPECT

This article provides an overview of the current clinically available biological augmentation methods of peri-acetabular defects. Due to the limitations of autologous and allogeneic bone transplants in terms of size and availability, the emerging field of innovative implantable tissue engineering constructs gains interest and will also be discussed in this article.

[Preoperative, neuropathic component in patients with back pain]

BACKGROUND

The objectification of pain is essential for evaluation, treatment plan and follow-up; therefore, it is necessary to find reliable clinical parameters.

OBJECTIVE

The goal of the study was the preoperative screening of a neuropathic component in patients with vertebral compression fracture (WKF), herniated disc (NPP) or spinal cord compression (SKS).

MATERIAL AND METHODS

Depending on the preoperative condition on admittance, patients were classified into three groups: group 1 WKF, group 2 NPP and group 3 SKS. To characterize the pain we used the painDETECT questionnaire, the Oswestry questionnaire and further questionnaires. All patients were surgically treated according to the diagnosis, e.g. radiofrequency kyphoplasty, nucleotomy or spondylodesis.

RESULTS

We evaluated the data from 139 patients (45% WKF, 34% NPP and 21% SKS). There were no differences in preoperative pain intensity (median ordinal scale 0-10) with a mean preoperative score of 7 for all groups. The total score of the painDETECT questionnaire showed significantly higher results in group 2 (median 18) and in group 3 (median 14) than in group 1 (median 9). There was even a significant difference between groups 2 and 3 (p = 0.03). The highest pain intensity was detected in group 1 with a median visual analog scale (VAS) of 71 mm. The total scores in the painDETECT questionnaire and the scores in the Oswestry questionnaire correlated in groups 2 and 3.

CONCLUSION

The painDETECT questionnaire was shown to be a very suitable instrument for evaluating the neuropathic pain component in patients with dorsalgia. This could be very useful in planning further therapy.

[The Role of a Modular Universal Tumour and Revision System (MUTARS®) in Lower Limb Endoprosthetic Revision Surgery - Outcome Analysis of 25 Patients]

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

[Clinical Trial to Test the iFuse Implant System® in Patients with Sacroiliac Joint Syndrome: One Year Results]

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

Radiofrequency Ablation: Temperature Distribution in Adjacent Tissues

PURPOSE

This clinical study investigates the use of a radiofrequency ablation system specifically developed for the ablation of spinal metastases. The investigation examines possible temperature-associated risks for the adjacent tissues.

MATERIAL AND METHODS

A tumour model was simulated for 8 lumbar and 8 thoracic vertebrae of a human cadaveric spine. The tumour mass was ablated with the SpineSTAR electrode (SpineSTAR, DFINE Inc., CA), which has been specifically developed for the ablation of spinal metastases. During the ablation procedure, the temperatures of the vertebra, the epidural space, and the neural foramen were measured with thermocouples. These temperatures were documented as means with standard deviations. Possible differences between lumbar and thoracic vertebrae were analysed with the Mann-Whitney U test.

RESULTS

The maximal temperature of the lumbar vertebrae was 46.4 ± 3.3 °C near to the ablation zone, the temperature of the neural foramen was 37.0 ± 0 °C, and the temperature of the epidural space was 37.3 ± 0.7 °C. In the thoracic vertebrae, the temperature was 44.4 ± 1.7 °C near to the ablation zone, 7.9 ± 1.7 °C in the neural foramen, and 37.25 ± 0.7 °C in the epidural space. There was no significant difference in temperature distribution between treated lumbar and thoracic vertebrae.

CONCLUSION

Ablation of spinal metastases in a cadaveric model using the SpineSTAR electrode was shown to be a safe method with respect to possible temperature-related risks for the adjacent tissues.

[Intra-articular Sampling with Novel Biopsy Forceps: a Simple and Reliable Diagnostic Procedure for Patients with Periprosthetic Infections of the Knee Joint]

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

[Antimicrobial prosthesis coatings]

BACKGROUND

Antimicrobial coatings have a great potential in the treatment and prevention of periprosthetic joint infection.

OBJECTIVE

To present established and novel concepts of antimicrobial coatings.

METHODS

A literature review and discussion of published concepts in basic research, pre-clinical animal studies, and clinical practice were carried out.

RESULTS

To date there has been a wide range of technical solutions (anti-adhesive surfaces, bioactive surfaces with antimicrobial effects, surfaces releasing antimicrobial substances, nanostructures, bioactive surfaces affecting biofilm development) demonstrating a high potential in pre-clinical studies. Only a few with the bactericidal activity of silver ions have been prepared for the market. Conclusive results with regard to biocompatibility and toxicity are lacking.

DISCUSSION

Despite the great potential of antimicrobial coatings, no conclusive decisions can be made because of the limited data and the lack of evidence of their clinical efficacy on the basis of prospective controlled clinical studies. In addition to their unlimited biocompatibility, innovative concepts have to be feasible in everyday clinical routine.

[Bilateral Dislocation Fracture of the Humeral Head (Right AO 11C3.3; Left AO 11A1.3) without Direct Trauma Due to First Clinical Manifestation of Seizure - a Case Report and Review of the Literature]

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

[Impact of Preoperative Knee Stiffness on the Postoperative Outcome after Total Knee Arthroplasty in Patients with Haemophilia]

INTRODUCTION

Total knee arthroplasty (TKA) is an effective treatment option for patients with end-stage haemophilic arthropathy of the knee. However, the procedure is technically challenging, as knee motion is often restricted before the operation and complication rates are then thought to be higher than for patients with a normal range of motion (ROM). There is very limited information on the outcome of TKA in haemophilic patients presenting with stiff knees. The objective of the present study was to retrospectively analyse and compare the clinical results after TKA in haemophiliacs with stiff and non-stiff knees.

PATIENTS AND METHODS

The results of 50 TKA procedures in 41 haemophilic patients were retrospectively evaluated at a mean follow-up of 7.2 ± 4.9 years (range 2-25 years). 20 patients presenting with 23 stiff knees - defined by a preoperative ROM of 50° or less - were compared with 21 patients with 27 non-stiff knees. Knee motion (ROM, flexion, extension), Knee Society Score (KSS/KSS function), pain status (visual analogue scale, VAS), number of bleedings and patient satisfaction were evaluated.

RESULTS

The complication rate was 12 %, including two haematomas, one aseptic loosening, and three periprosthetic infections. The overall mean ROM increased from 58.6 ± 34.2° (range 0-120°) preoperatively to 85.9 ± 23.4 (35-130°) postoperatively (p < 0.005). Mean KSS and KSS function improved from 30.6 ± 11.0 points (range 10-49) and 43.4 ± 9.3 points (range 15-65) to 79.3 ± 9.6 points (range 49-95) and 68.9 ± 11.0 points (45-90), respectively (p < 0.005). The mean VAS score decreased significantly from 7.9 ± 0.8 points (range 6-9) to 1.8 ± 1.1 points (range 0-4; p < 0.005). In comparison to the non-stiff group, patients with stiff knees showed a significantly greater mean improvement in ROM (46.3 ± 21.8° [range - 10-85°] vs. 9.4 ± 16.9° [range - 30-35°]), flexion (32.8 ± 19.6° [range - 10-85°] vs. 5.2 ± 16.2° [range - 40-35°]), and flexion contracture (13.5 ± 9.6° [range 5-30°] vs. 5.9 ± 6.7° [range 5-20°]). Both KSS and KSS function were significantly inferior in stiff knees than with non-stiff knees. Nine patients with knee stiffness who underwent additional v-y quadricepsplasty to lengthen the extensor mechanism developed a mean extensor lag of 7-0° ± 4-8° (range 5-15°). At final follow-up, 37/41 patients were satisfied or very satisfied with the surgical result.

CONCLUSION

TKA in haemophilic patients presenting with haemophilic arthropathy of the knee results in significant improvements in function and reduced pain. Although the ultimate clinical outcome in stiff knees is inferior to that with non-stiff knees, joint replacement surgery can be successfully performed in patients with restricted preoperative range of motion. Vy-quadricepsplasty for to facilitate exposure is associated with the development of a postoperative extensor lag and should therefore be performed restrictively. Patient satisfaction after TKA was equally high in the two groups.

[Diagnosis and Treatment of Spondylodiscitis/Spondylitis in Clinical Practice]

BACKGROUND

The clinical presentation of spondylsodiscitis/spondylitis are manifold. This commonly leads to a period of several months from initial symptoms to final diagnosis. A standardised treatment is difficult. The purpose of this study is to investigate the treatment carried out for patients with spondylodiscitis or spondylitis to develop an individualised standard care for better treatment.

PATIENTS AND METHODS

Data of 90 patients were retrospective analysed. In particular documented data of the initial examination and the following treatments concerning identification of causes and systematically control of pathogens were examined.

RESULTS

In 91 % of patients a diagnostically conclusive MRI was conducted. The degree of spondylidiscitis/spondylitis was mainly ASA criteria I or II (86 %). In 96 % of patients different diagnostic methods for identification of pathogens were conducted and documented. RESULTS confirmed the most common pathogens mentioned in the literature. 75 % of patients were treated by surgery. In 93 % of patients an antibiotic treatment was documented. 50 patients (81 %) were successfully healed.

CONCLUSION

It is important to identify and treat spondylodiscitis/spondylitis as early as possible. Diagnosis by means of blood culture and MRI and treatment of the infection with antibiotics and possibly surgical interventions seem be very suitable, but need to be individualised to each and every patient.

Elective total knee arthroplasty in haemophilic patients. Proposal for a clinical pathway

Total knee arthroplasty (TKA) provides significant pain relief and better function in patients with end-stage haemophilic knee arthropathy. Peri- and postoperative care tends to be more complex than in non-haemophilic patients undergoing TKA and requires a multidisciplinary team approach.

AIM

The implementation of standardized clinical pathways in non-haemophilic patients undergoing TKA has been shown to increase quality of care and to reduce postoperative complication rates. Consequently, the use of clinical pathways in haemophilic patients undergoing TKA may be beneficial to this particular subpopulation of patients.

METHODS

A clinical pathway for TKA for haemophilic patients was designed in a consensus process involving all participating departments.

RESULTS

We propose a specifically adjusted clinical pathway for TKA for haemophilic patients to show that standardization of elective orthopaedic surgery in haemophilia is feasible.

CONCLUSION

The authors emphasize that there are limitations on categorizing haemophilic patients and stress that individual interdisciplinary treatment should take precedence over a standardized approach.

[Influence of Parkinson's Disease on the Perioperative Course of Patients after Lumbar Fusion Surgery]

BACKGROUND

The incidence of Morbus Parkinson (MP) increases with age. An increasing number of patients with MP in the orthopaedic patient population is expected. In the case of general surgery and trauma surgery MP in patients was identified as an important factor for perioperative morbidity. This study investigates the influence of MP on the perioperative course of patients after elective lumbar fusion.

PATIENTS AND METHODS

A retrospective matched-pairs analysis with 17 patients in each group was conducted with patients treated in the department of spinal surgery in an orthopaedic university hospital for symptomatic degenerative lumbar spine disease without improvement after conservative therapy. The analysis compared the perioperative courses of patients with MP (MP) and patients without MP (no MP) concerning duration of hospital and intensive care treatment, duration for mobilisation, rehabilitation and occurrence of complications.

RESULTS

The mean duration of inpatient treatment (MP 18.4 ± 11.6 d; no MP 14.7 ± 5.4 d), duration of intensive care (MP 1.7 ± 4.2 d; no MP 1,0 ± 1,9 d) and duration for mobilisation (MP 8.8 ± 12.46 d; no MP 5.0 ± 4.2 d) tend to be longer for MP patients. There was no statistically significant difference between both patient groups. A rehabilitative inpatient follow-up treatment was more frequent in patients with MP (MP n = 4; no MP n = 2). None of the two groups showed an increased occurrence of complications.

CONCLUSION

While general surgery and trauma surgery patients show significant differences regarding duration of inpatient treatment, more frequent falls and more frequent rehabilitative inpatient follow-up treatments, patients after elective lumbar fusion show only a trend. Possibly the result is due to the underlying degenerative disease of the lumbar spine with spinal stenosis and gait disturbance in the MP group and as well in the control group. Therefore both groups suffered from impaired mobility. Additionally there was a high incidence of other comorbidities in the control group, which could have affected the results of this study. Another limitation is the number of the included patients. Although, this study showed no increased occurrence of complications, typical risk factors, like increased risk for airway complications, urinary tract infection and falls, should be considered for the treatment of MP patients.

[Surgical treatment of sternoclavicular joint instability with tenodesis]

BACKGROUND

Instability of the sternoclavicular joint is a very uncommon disorder of the shoulder girdle. Acute traumatic dislocations are commonly treated nonoperatively. But severe displacement or chronic instability with recurrent symptomatic subluxation may require surgical intervention. We present our results with open reduction and internal fixation through an autologous gracilis tendon transplant or fiber tape in 8 patients treated surgically. The operative stabilisation of the sternoclavicular joint reduces pain level and improves function of the shoulder. This technique provides an effective surgical procedure for treatment of symptomatic sternoclavicular joint instability.

OBJECTIVE

Restoration of the function and aspect of the sternoclavicular joint.

INDICATIONS

Chronic and painful instabilities.

CONTRAINDICATIONS

Local infection, tumor.

SURGICAL TECHNIQUE

The gracilis tendon graft is harvested as previously described by Petersen. Direct incision over the sternoclavicular joint. Sharp dissection of the periostal sleeve and partial release of sternocleidomastoideus and pextoralis muscle. Resection of osteophytes. Careful placement of a raspatorium under the proximal clavicle and sternum to protect the mediastinal structures. Application of 2.5 or 3.2 mm drill holes to the sternum and the proximal clavicle. The gracilis tendon or the fiber tape is pulled through the drill holes in a figure of eight and then sutured. Recontruction of the joint capsule, closure of the wound.

POSTOPERATIVE MANAGEMENT

Gilchrist brace for 3-5 days, functional physiotherapy with a maximum abduction of 90° for 6 weeks. No carrying or lifting of weights greater than 5 kg for 3 months.

RESULTS

During the period from January 2006 to December 2010, 8 patients with sternoclavicular instability were treated. Four patients were treated with fiber tape and four were treated with a gracilis tendon autograft. Postoperative all patients described a reduction of pain and improved shoulder function. The Constant score was 72 points, the DASH 58 points.

[Treatment of isolated fractures of the olecranon: percutaneous double-screw fixation versus conventional tension band wiring]

BACKGROUND

Isolated fractures of the olecranon account for 7-10% of all osseous injuries in adults. These fractures are usually treated surgically by conventional tension band wiring. The percutaneous double-screw fixation is an optional treatment in patients with two fragment olecranon fractures with some postoperative advantages.

PATIENTS AND METHODS

A total of 13 patients with isolated fractures of the olecranon (Schatzker-Schmelling type A) treated by percutaneous double-screw fixation were included in this prospective study. The mean age of patients was 43.6 ± 11.0 years. Intraoperative and postoperative complications were recorded. Functional results were assessed after a mean follow-up of 38.2 ± 11.5 months using the Quick-DASH score. The results were compared with those obtained in the control group including 26 patients treated by conventional tension band wiring.

RESULTS

No intraoperative complications were observed in both groups. In the group with percutaneous double-screw fixation the scar length was significantly shorter (2.4 ± 0.4 cm vs. 11.0 ± 1.8 cm, p < 0.001) and the hardware removal was substantially less frequent that in the group with conventional tension band wiring with 38.5 % and 73.1 %, respectively. At the minimum follow-up of 2 years comparable functional results were obtained in both groups (Quick-DASH score 2.3 vs. 0.0 points, respectively, p = 0.155); however, the range of elbow motion was significantly higher in the group with percutaneous double-screw fixation (extension/flexion 145° vs. 130°, p < 0.001; pronation/supination 165° vs. 155°, p < 0.001).

CONCLUSIONS

The percutaneous double-screw fixation is a safe and viable treatment option in patients with isolated fractures of the olecranon (Schatzker-Schmelling type A). The functional results regarding DASH scores obtained using this technique were comparable with those observed in patients with conventional tension band wiring; however, range of elbow motion and cosmetic results were significantly better in the patient group with percutaneous double-screw fixation.

Total ankle replacement in patients with von Willebrand disease: mid-term results of 18 procedures

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

[Soft tissue tumor near the joint: hibernoma]

Joint associated tumors must undergo histological analysis, since not only inflammatory, but also benign and malign tumors exist in this location. We report a well circumscribed tumor, located in the elbow that histologically turned out to be a hibernoma. Complete surgical excision is the therapy of choice and recurrences are rare. To rule out liposarcoma with hibernoma like changes, fluorescence in-situ hybridisation has been performed and showed no MDM-2 amplification. Hibernomas are tumors of brown adipose tissue that may be localized next to joints.

[Evaluation of radiation exposure of personnel in an orthopaedic and trauma operation theatre using the new real-time dosimetry system "dose aware"]

AIM

There is a positive correlation between operation time and staff exposure to radiation during intraoperative use of C-arm fluoroscopy. Due to harmful effects of exposure to long-term low-dose radiation for both the patient and the operating team it should be kept to a minimum. AIM of this study was to evaluate a novel dosimeter system called Dose Aware® (DA) enabling radiation exposure feedback of the personal in an orthopaedic and trauma operation theatre in real-time.

METHOD

Within a prospective study over a period of four month, DA was applied by the operation team during 104 orthopaedic and trauma operations in which the C-arm fluoroscope was used in 2D-mode. During ten operation techniques, radiation exposure of the surgeon, the first assistant, the theatre nurse and the anaesthesiologist was evaluated.

RESULTS

Seventy-three operations were analysed. The surgeon achieved the highest radiation exposure during dorsolumbar spinal osteosynthesis, kyphoplasty and screw fixation of sacral fractures. The first assistant received a higher radiation exposure compared to the surgeon during plate osteosynthesis of distal radius fractures (157 %), intramedullary nailing of pertrochanteric fractures (143 %) and dorsolumbar spinal osteosynthesis (240 %). During external fixation of ankle fractures (68 %) and screw fixation of sacral fractures (66 %) radiation exposure of the theatre nurse exceeded 50 % of the surgeon's radiation exposure. During plate osteosynthesis of distal radius fractures (157 %) and intramedullary splinting of clavicular fractures (115 %), the anaesthesiologist received a higher radiation exposure than the surgeon.

CONCLUSION

The novel dosimeter system DA provides real-time radiation exposure feedback of the personnel in an orthopaedic and trauma operation theatre for the first time. Data of this study demonstrate that radiation exposure of the personnel depends on the operation type. The first assistant, the theatre nurse and the anaesthesiologist might be exposed to higher radiation doses than the surgeon. DA might help to increase awareness concerning irradiation in an orthopaedic and trauma operation theatre and might enhance staff compliance in using radiation protection techniques.