Due to the importance of the thyroid treatment it was decided to control the lesion in C6 in close intervals. The lumbar tumour was initially treated outside and the first relapse was marginal resected at our department 11 years after the first diagnosis. The bone alterations appeared radiographically lytic and cystic.
Based on paleopathological findings there is evidence that primary malignant bone und probably soft tissue tumours accompanied mankind from the very beginning. Impressive findings of osteosarcomas have been reported from ancient Peru and medieval Hungary. Astonishingly a report exists on a 3rd century AD amputation of a leg affected by “cancer” and, even more amazing, on the successful reconstruction using a homologous limb transplant. This “miracle” has been attributed to Saints Cosmas and Damian. According to the legenda aurea of Jacobo da Varragine the miraculous treatment of took place in 3rd century Rome. The saints amputated the leg of the Deacon Justinian and successfully transplanted the leg of a black African, who had died some hours ago. According to the legend the deacon was able to walk again and glorify his doctors. This legend inspired artists throughout the centuries as can be seen in a famous 16th century oil painting in Stuttgart’s Landesmuseum Württemberg. The twin saints Cosmas and Damian have been praised before for the first homoplastic limb transplant. The cause for amputation, however, was reported to be a “gangrenous leg” or a “diseased leg”. Looking at the original text of the legenda aurea, a different picture emerges, the cause for surgery being “cancer” of the leg – “…cui cancer unum crus totum còsumpserat”. Also astonishing, at their time and in ours, the saints treated patients without taking any payment. It is not surprising that they were the most renowned of all medically inclined saints and were soon regarded as patron saints of medicine. From today’s medical view, neither resection margins according to Enneking nor a follow-up period were provided by the legenda aurea. It therefore remains elusive whether a local or systemic recurrence occurred. Nevertheless, Saints Cosmas and Damian may well be regarded as Europe’s first orthopaedic oncologists.
Epimetaphyseal lesions may occur within congenital dysplasia or can be linked to metabolic, inflammatory and systemic diseases. They can also be caused by trauma or be due to malign or benign neoplasms. Our case-report concerns a 4-year old boy who was x-rayed the day after falling from a chair and twisting his right ankle. X-ray showed an epimetaphyseal lesion of about 2 cm in diameter, located eccentrically in the lateral site of the distal tibia. A unilamellar periostal reaction could be detected in the lateral slices. On MRI, the lesion seemed to be of chondromatous origin and showed smooth borders with no evidence of surrounding oedema. The adjacent epiphyseal plate appeared as untypically fragmented. In CT-scans, the ventrolateral cortical bone was partially perforated and the lesion showed a tender sclerotic border. Due to the benign aspect, we agreed upon radiologic controls in order not to harm the epiphyseal plate by biopsy. MRI follow-ups revealed a slight but continuous growth. The lesion assumed an increasingly eccentric, tongue-shaped configuration with simultaneously increasing calcifications and mineralisations. After 5 years of radiological surveillance, the patient showed no evidence of growth-disturbance and did not report pain, but an increasing feeling of pressure when wearing boots. Traumatic causes as well as metabolic, inflammatory and systemic diseases can, considering the patient’s history and clinical status, be put aside. The benign aspect combined with the long-term follow-up rules out malignancies. A chondroid matrix with increasing areas of mineralisation imply the diagnosis of a chondromatous tumour, although radiomorphology does not support this assumption; especially not, if age, clinical presentation, eccentric epimetaphyseal location and the involvement of the epiphyseal plate are taken into account. Among the entities left for differential-diagnosis, a dysplastic process e.g. Dysplasia hemimelica, must be considered, although doubts remain. For confirmation of diagnosis, further radiological and clinical surveillance will be conducted.
Chordomas are rare neoplasms originating from notochordal remnants. They usually affect the midline and the standard treatment consists of surgery and radiotherapy. The present study investigates the expression of survivin, DR4 and DR5 to evaluate potential molecular targets for future therapy-strategies. The study-group included 33 chordomas obtained from 21 male and 9 female patients. At time of diagnosis the patients’ age ranged from 24 to 80 years (51.9 ys.). Tumours were located on the scull-base, in the sacral/coccygeal area and the column in 13, 10, and 7 cases, respectively. Tumour-volume, known in 16 cases, ranged from 3.6 to 668.2 cm3 (mean size 130.7cm3). Immunohistochemistry was performed with antibodies against survivin, DR4, DR5. The staining pattern (cytoplasmic and/or nuclear), percentage of positive tumour-cells and staining-intensity were evaluated. Histologically the tumours were classified as classic, chondroid and dedifferentiated chordomas in 27, 2 and 1 case, respectively. Survivin expression was obtained in 87.5% of the cases. The staining pattern was cytoplasmic in all cases and an additional nuclear staining was detected in two. Staining-intensity was predominantly weak. In 87.9% of cases DR4 staining was investigated in more than 10% of the tumour-cells. The immunoreaction was cytoplasmic (87.9%) and a nuclear staining was additionally detected in two cases. The staining-intensity was predominantly weak. In 81.8% of the chordomas DR5 staining was obtained in more than 10% of the tumour-cells. The staining pattern was cytoplasmic (84.4%) and in one case cytoplasmic and nuclear. The staining-intensity was predominantly moderate. We hypothesise, based on the availability of new chemo- or immunotherapeutic agents like Mapatumumab (agonistic human monoclonal antibody to DR4, tested in solid tumours) and YM155 (new small-molecular inhibitor of survivin, tested in solid tumours and lymphoma), that survivin, DR4 and DR5 may act as potential molecular targets in future therapy of chordomas.
Multifocal osteolytic lesions of the skeletal system are a challenge regarding diagnosis especially when multi-nucleated giant cells which are not specific for a tumour entity are found in the histological specimen. Therefore multiple differential diagnosis have to be considered such as metastases, primary malignant bone tumours, multicentric giant cell tumour of bone and brown tumours of primary hyperparathyroidism. A 49 year old woman underwent medical investigation in an external surgical department due to right hip pain after a fall. The radiologic skeletal status surprised with multiple osteolytic pelvic lesions and one tumour in the left scapula and first histological diagnosis described a giant cell tumour of bone with malignant aspects. After confirmation of this diagnosis by a second histopathological inquiry accomplished by a bone tumor specialist the patient was transferred to our tumour centre. To exclude the differential diagnosis of brown tumours a close look on the parathormon level was done which revealed an exorbitantly high serum amount of 922.7 pg/ml (normal 15–65 pg/ml). Further examination confirmed a parathyroid adenoma. After its extirpation serum levels of parathormon decreased and two months after therapy with high dose calcium substitution radiologic controls show a decline of osteolysis with bone consolidation. Brown tumours of hyperparathyroidism have always to be considered as a rare differential diagnosis of multiple giant cell containing tumours. The disease cannot be distinguished by the histological pattern but can very easily be excluded by normal parathormon levels. First step of therapy in brown tumours should be surgical extirpation of parathyroid adenomas or carcinomas followed by an endocrinological regime. Only failure of this treatment requires further surgical stabilisation of the bone lesions.
Giant cell tumor of the distal radius is associated with a high local recurrence rate. En bloc resection of the distal radius and reconstruction using osteoarticular allograft, curettage with PMMA blomb, and allograft arthrodesis are established methods. The aim of the study was to evaluate the functional outcome of our patients with the DASH-Score and the Mayo Wrist score. In the last 7 years six patients were treated at our department due to a giant cell tumor of the distal radius. Two patients were primary treated with an en bloc resection. The other four were primary treated with curettage packing of the defect with polymethylmethacrylate. In two of these cases a secondary en bloc resection was performed for local recurrence. For evaluation of function in daily live we used the DASH score and the MAYO wrist score. The mean bone resection length was 5,25cm (5–6 cm).All four patients treated with en bloc resection (primary or secondary) had no recurrence but in two out of that cases a re-operation was necessary because of non union. At a mean follow up from 27 months (4–95) there were no recurrences or metastases at all. The flexion/extension of the wrist in currettaged radius was 60°/80° compared with 38°/68° in reconstructed radius. The pronation/suppination was 90°/90° in the currettaged ones versus 77°/77° in the allograft replaced ones. The functional outcome evaluated with Mayo Wrist Score and DASH score showed an excellent outcome for both groups (84/7,7 Allograft <
->
85/10 Currettage) Functional outcome of distal radius resection reconstruction using an allograft is highly satisfactory compared with the literature, however we experienced a high risk for pseudoarthrosis. For prevention of non union simultaneous bone grafting at the index operation could be advisable. Thus allograft reconstruction of the distal radius represents a valuable alternative to arthrodesis.
Periprosthetic osteolysis after total joint replacement is a well described complication. This normal slowly increasing process is caused by infection, implant loosening or more special, debris induced. However malignant processes may rarely occur at exact this location too. Based on clinical presentation and imaging it is sometimes difficult to exclude a local malignant process. We report two cases of extensive osteolysis after total hip replacement, including their follow up and a review of the relevant literature. Two female patients developed massive osteolysis in periprosthetic areas (pelvic area and proximal femur as well as distal femur) after being treated by total hip arthroplasty 14 and 18 years ago. In both cases a tumorous process was suspected after imaging and they were therefore referred to our clinic. In one case a rapidly progressing soft tissue swelling with extensive peri-articular osteolysis was considered to be a malignant tumour. After an incisional biopsy, an embolisation had to be performed due to continuous massive bleeding. Histology revealed a superinfected polyethylene disease, treated with a two stage revision surgery. The second patient presented with an impending fracture due an unusual osteolysis at the tip of the stem. Here again polyethylene debris was found at biopsy. Extensive osteolysis and/or soft tissue swelling caused by polyethylene debris may sometimes be difficult to differ from a tumorous process. As a guideline presented by Min WK. et al in 2008 a reactive bone-destroying process normally proceeds slowly in contrast to a more rapid progression in malignant disease. However, as presented in the first of our cases, exemptions may occur. In these cases a biopsy or at least a frozen section at operation should be obtained in order to exclude a real neoplasm.
Increasing incidence rates of soft tissue sarcomas (STS) have been reported. In the present study the authors have analysed the incidence of STS in Austria in a population-based study for the period 1984–2004 in comparison with seven international studies. Age-adjusted incidence rates, gender- and age-predilection and geographic differences were analysed, comprising data from the Austrian National Cancer Registry, including all cases of STS in Austria between 1984 and 2004. A total of 5333 cases was registered, male to female ratio was 0.8. The most common histotypes were sarcoma NOS (36%), leiomyosarcoma (24%), liposarcoma (12%), malignant fibrous histiocytoma (MFH) (9%) and fibrosarcoma (5%). Age-adjusted incidence rate was 2.4 per 100,000 per year. Analysis of annual incidence rates and three-year-periods showed no increasing trend (annual increasing gradient = −0.0025). This study analysed the most recent data from a European population in comparison with seven other studies. An increase of incidence of STS as postulated elsewhere could not be confirmed. The incidence rate of STS in Austria (2.4 per 100 000 per year) ranges in the lower half of international incidence rates (1.8–5.0 per 100 000 per year). Different inclusion criteria (Kaposi’s sarcoma and dermatofibrosarcoma) and classificationsin the various studies could be seen. These findings are more likely to cause the increase of incidence in some studies than true increase of STS due to new or accumulated risk factors.
High-dose methothrexate, a standard agent in the therapy protocols for osteosarcoma, has long been suspected to have a negative long-term effect on bone metabolism and bone mineral density, especially in children and young adults. Recent literature questioned this association as also the BMD of Ewing‘s sarcoma patients treated without methothrexate is known to be decreased. We therefore wanted to screen our patients treated for Ewing‘s sarcoma and osteosarcoma for osteopenia/osteoporosis-associated fractures. Between 1994 and 2008 107 patients below 50y of age were treated for bone malignancies including 51 Ewing’s sarcomas – 31 male and 20 female – with a mean age at diagnosis of 17y(±11SD) and 56 osteosarcomas – 36 male and 20 female – with a mean age of 23y(±12SD). We screened the patients‘ files for fractures after chemotherapy. We found five patients with not trauma-associated fractures – one Ewing‘s sarcoma(1/51;2%) and four osteosarcoma patients(4/56;7%). They presented one fracture of the proximal femur 107 months after tumour diagnosis, three fractures of the distal femur after 29, 51, and 72 months and two fractures of the proximal tibia after 29 and 32 months (one patient suffered from fractures affecting both – the distal femur and the proximal tibia). As presented in our case series fractures due to an osteoporotic process after chemotherapy for bone sarcomas are well known late effects. Although described in several studies therapeutic recommendations for pro-phylaxis are sparse. Furthermore the fact that fractures occurred in both types of sarcoma casts MTX as the main cause of chemotherapy-induced osteoporosis into doubt. Additionally we estimate a high number of unreported cases of premature osteoporosis because sarcoma patients are usually not tested for their BMD-levels. Therefore further studies using DEXA (dual-energy-x-ray-absorptiometry) to measure the patients BMDs after chemotherapy are needed.
Epitheloid haemangioendothelioma is a rare tumour of vascular origin. It is characterised by the appearance of epitheloid endothelial cells and occurs typically in soft-tissue, skin, and liver. Less frequently it is found in bone. The tumour is more often located in the long bones of the lower extremities, and the pelvis than in the upper extremities, vertebral column, and flat bones. The lesion nearly affects all age groups and there is a male predilection.
Epitheloid haemangioendothelioma of bone is a rare tumour and the diagnosis is quite difficult. Metastatic rate is about 20–30% and mortality about 10–20%. As presented in our cases bone involvement could either be attributed to primary haemangioendotheliomas of bone or to metastases of non-osseous forms. As in our cases it has been reported, that predicting prognosis is difcult, however nuclear atypia, mitotic activity, spindling of cells, and necrosis have been reported as negative prognostic factors.
Although fibrous dysplasia is a benign bone disease, in few cases patient are suffering from severe pain of the skeletal system. The aim of this study was to evaluate the current state regarding pain of patients with fibrous dysplasia treated at our hospital. We searched our digital database since 1990 for patients with fibrous dysplasia. Subsequent we verified the histological diagnosis by reviewing the final pathologic report. Additional we called the identified patients by phone to make an enquiry about their pain course and associated treatment. For rating pain intensity we used a numeric rating scale with a range within zero to ten. We identified 43 patients (21 male, 22 female) with an average age at initial diagnosis of 40 years (range 10 to 72years). The mean follow up was 6 years (range 1 to 23 years). Among these 43 patients we were able to contact 33 by phone. Initial diagnosis was made due to pain in 23 cases, nearly coequal by coincidental examination in 20 cases, for fracture in two cases and for local swelling and bone deformity each time in two cases. Thirty-six patients revealed monostotic and seven patients polyostotic involvement. The following locations were found: three times craniofacial, four times within the spine, eight times at the upper extremity, ten times in the pelvis and 31 times at the lower limb. Two patients were suffering additionally from Mazabraud Syndrome. Actual values at the numeric rating scale regarding pain ranged from 0 to 9 with a mean value of 1. Specific in the polyostotic group we found an average value of 3 and three of seven patients stated a value greater than 5 for persistent pain. Five patients with polyostotic involvement were treated with bisphosphonat for pain control with good response. It is remarkable that patients with polyostotic involvement have marked higher values for pain intensity at the numeric rating scale. So therefore we should have a closer look for potential reasons explaining that fact. In accordance with previous published studies we found that pain decreased by intermittent intravenous application of bisphosphonates.
The ability of hMSCs to differentiate into several mesenchymal cell lineages including the osteoblast lineage plays a key role in skeletogenesis and bone regeneration. Although the importance of physical factors in the development and maintenance of bone tissue has been recognized for many years and we previously demonstrated that mechanical strain constitutes an inherent stimulus for osteogenic differentiation of undifferentiated hMSCs, there is strong evidence to suggest that obesity is an independent factor in the risk of implant failure due to aseptic loosening or fracture after TJR. While mechanical complications and overload have been widely suggested, we hypothesized that the osteogenic mechanoresponse of hMSCs may be profoundly altered in obese patients. hMSCs were isolated from bone marrow of 10 donors (BMI ranging from 18.7 to 37.6 kg/m2). The individual response of unidfferentiated hMSCs to cyclic tensile strain (CTS) was determined in a two-armed study design (strained versus unstrained (CTR)) using a 4-point bending device, where strain was restricted to a maximum of 3,000 μstrain. Phenotypic effects were characterized by analyzing cell numbers, cell viability and ALP activity; mRNA levels of marker genes related to early osteogenic differentiation (RUNX2, ALPL, SPARC, SPP1), protein synthesis (COL1A1), and cell cycle (MKI67) were determined by real-time RT-PCR. Possible contributions to anthropomorphometric variables and individual triglycerides, cholesterin, glucose, leptin, adiponectin, resistin, and estradiol levels were evaluated by linear regression analysis. We found a significant up-regulation of the osteogenic marker genes due to CTS, including RUNX2 (1.9 fold), ALPL (2.4 fold), SPP1 (2.8 fold), and SPARC (4.1 fold), which was accompanied by an increase in cell-based ALP activity from 6.1 ± 1.2 μM/min/106 in CTR to 8.5 ± 1.7 μM/min/106 in CTS (plus 39.6 ± 9.8% SEM, P<
0.05). Cell density was significantly lower following CTS (minus 20.0 ± 4.7%, P<
0.05), which was also found for cell viability (XTT minus 17.8 ± 5.6%, P<
0.05). As a consequence, the phenotypic CTS response (ALP activity w/o normalization) ranged widely between donors (−30.8% to +60.1%) and was highly significant inverse correlated to donor’s BMI (r= −0.91, P<
0.0001). Additionally, leptin and estradiol levels determined within bone marrow plasma were significantly correlated with the phenotypic mechanoresponse (r=−0.71, P=0.028, and r=0.67; P=0.039; respectively). The findings demonstrate that the osteogenic mechanosensitivity of hMSCs is highly affected by physiological factors related to donor’s BMI. Such an upstream imprinting process within bone marrow may be an important area of further research, since obesity-linked problems constitute increasing concerns in orthopaedic surgery within the western world.
The induction of differentiation is a highly programmed lineage-specific process and several studies have provided great insight into the microenvironment affecting differentiation of multipotential hMSCs. In this regard, the importance of physical factors has been recognized for many years, but only little is known about its effects on undifferentiated hMSCs. The study aimed to determine the early osteogenic differentiation response to physiologically-based mechanical tensile strain with possible contributions to donor-specific physiological conditions. MSCs of ten donors were expanded under standard culture conditions, and the individual response to cyclic tensile strain (CTS) was determined in a two-armed study design (strained versus unstrained (CTR)). CTS was applied with a maximum of 3,000 μstrain. Genotypic characteristics (RUNX2, ALPL, SPARC, SPP1; COL1A1, MKI67, etc) as well as phenotypic effects (cell numbers, cell viability and ALP activity) were compared between CTR and CTS, and possible relations to donor-specific physiological characteristics including anthropomorphometric and biochemical variables were determined. We found a significant up-regulation of the osteogenic marker genes due to CTS, which was accompanied by an increase in cell-based ALP activity (plus 39.6 ± 9.8% SEM, P<
0.05). Cell density as well as XTT were significantly lower following CTS (minus 20.0 ± 4.7% and minus 17.8 ± 5.6%, respectively, P<
0.05). As a consequence, the ALP activity w/o normalization ranged widely from minus 30.8% to plus 60.1% between individual donors and was a function of donor’s BMI (r=−0.91, P<
0.0001), weight (r=−0.73, P=0.016), and age (r=−0.65, P=0.041). The findings demonstrate that
the application of CTS provides an inherent osteogenic differentiation stimulus for undifferentiated hMSCs in vitro, and the functional response of hMSCs to CTS was found to be highly related to donor’s BMI/fat mass, thus suggesting an upstream imprinting process of the hMSCs within bone marrow
Whereas thermography has already been used as an assessment of disease activity in some kinds of inflammatory arthritis, it is a new method for objektive pain evaluation in patients with joint prosthesis. To our knowledge, no study has tested the correlation between increase of temperature and anterior knee pain with total knee prosthesis yet. Thirteen patients were included in this study who suffered from anterior knee pain of the retinaculum patellae with total knee prosthesis. The patients were asked to walk 3 km before entering a room which was cooled down to 20 degrees Celsius. A black 1 cm times 4.5 cm square stripe was attached on the diameter of the patella and the patients rested for 20 minutes to cool down before thermographic fotos were taken from 90 degrees, 45 degrees, frontal medial and lateral. The evaluation of temperature difference of each side was performed by marking a 1cm times 2cm square field rectangular around the black stripe and comparing it with a reference point of the same size 3 cm distal of the field. The patients were compared with thirteen others, not suffering from anterior knee pain. Statistical analysis was performed using a t- test and a p value <
0.05 was considered to be significant. The temperature differences between the rectangular field and the reference point increased significantly on the medial (p= 0.00037) or lateral (p= 0.000002) pain side of the knee. The thirteen knees with knee pain had significantly higher temperature differences between medial and lateral temperature differences, than the knees without knee pain. We demonstrate a significant correlation between anterior knee pain and an increase of superficial skin temperature around the retinaculum patellae. To our knowledge, this is the first report of an objective assessment of pain of the retinaculum patellae with total knee prosthesis.
Aseptic loosening is the most frequent cause of implant failure in total hip arthroplasty (THA). Additionally, failure rate was still found by some authors to be increased in patients with osteonecrosis of the femoral head (ON-FH). It is well evidenced that low initial fixation and early migration precedes and predicts long-term failure rate of both, the acetabular and femoral component in THA. This independent, double-blind, randomized, controlled study was primarily designed to evaluate whether a single infusion of 4 mg of zoledronic acid is sufficient to prevent implant migration determined by the EBRA-digital method. Fifty patients were consecutively enrolled between July 2002 and March 2005 to receive either 4 mg zoledronic acid (ZOL) or saline solution (CTR) one day after THA (Zweymüller system, cementless). Plain radiographs were performed postoperatively and all parameters were evaluated at each follow-up meeting interval at 7 weeks, 6 months, 1 year, and yearly thereafter during a median follow-up period of 2.8 years (2 years minimum). In CTR, subsidence increased up to −1.2 mm ± 0.6 SD at 2 years in CTR (P<
0.001). Less, but a near curve-linear shaped migration pattern was found for the ace-tabular component, with an averaged medialization of 0.6 mm ± 1.0 SD and a cranialization of 0.6 mm ± 0.8 SD at 2 years (P<
0.05, Friedman ANOVA) at 2 years. In ZOL, a significant reduction in bone turnover markers was accompanied by a complete prevention of cup migration in both, the transverse and vertical direction (P<
0.05, ANOVA), while there was only a trend to a decreased subsidence in stems. The study provides useful data which are promising and support the suggestions that bisphosphonates may offer significant opportunities to reduce and prevent implant migration of THA, thus increasing long-term durability of THA especially in selected high-risk patients.
In several countries fine needle aspiration (FNA) biopsy of soft tissue tumours is regarded as a standard procedure. However, various problems using FNA compared to core needle biopsy have been reported. Less cell amount, blood and other non tumour tissue aspirated and cells torn out of their environment lead to problems in histological diagnose. The aim of this study was to measure the number of cells harvested by two new needle systems (THYROSAMPLER®) in comparison with the conventional fine needle system (C-FNA). The innovation of the new system is aeration after aspiration by a valve, so that undesired aspiration of blood, debris, and cells from outside the tumour during withdrawal of the needle is minimized. In a blinded setting, 45 punctures from fresh pig thyroid glands were made and analysed – 15 for each needle (C-FNA, single-needle with air valve T-ONE and multi needle system with air valve T-THREE). The aspirated cell material was evacuated into 10ml cell-culture liquid and calculated according to the manufacturer’s recommendations for the CASY cell counter (CASY® technology, Reutlingen). With each system, 15 punctures each were aspirated and the cells counted. With the T-ONE System the amount of vital cells was 688%, the amount of total cells 521% higher then using the C-FNA system. With the T-THREE System the amount of vital cells was 901%, the amount of total cells 798% higher then using the C-FNA system. The mean difference between C-FNA and T-ONE was significant regarding total number of cells (p=0.030) as well as number of vital cells (p=0.032). The needle systems with the air-valve led to a significantly higher cell amount in needle aspiration biopsy. According to the requirement of cytological diagnosis of soft tissue sarcomas more cell volume could be harvested, which is a well-defined benefit.
Silver is a long known local antimicrobial agent. The use of silver coated prostheses is a valuable option in some cases. Yet there are patients for whom the permanent implantation of large amounts of silver does not seem to be the perfect solution.
From 04/2004 to 01/2006 seventeen patients of slightly less impaired disposition were treated by a comparable two-stage procedure using silver-augmented cemented spacer prostheses or cement fills. Patients are closely observed regarding toxic side effects. Concentration of silver in blood and puncture samples are measured using an argon plasma mass spectrometer.
In the second group one patient of seventeen actually shows a persisting infection, but cannot be matched properly as he primarily suffered from a long-term infected knee arthrodesis. Silver concentrations ranged from a maximum of 1010 to 243 μg/kg (ppb) to a minimum of 84 to 304 μg/kg (ppb) with silver coating, and a maximum of 380 to 22,9 μg/kg (ppb) to a minimum of 76 to 5,02 μg/kg (ppb) with silver spacers. There are large individual differences in both groups. We found no signs of argyrosis or recently developed neurological deficits.
We conducted a prospective clinical study to determine the influence of personality traits on the subjective outcome of operative hallux valgus correction. The surgical technique used in all patients was the chevron osteotomy. Preoperatively, personality traits were evaluated by means of the Freiburg Personality Inventory (FPI-R). 42 patients (38 female, 4 male) could be enrolled in the analysis. The mean age of the patients at the time of operation was 48.3 years (20 to 70). Three months postoperatively 37 patients were satisfied, and 5 patients were not satisfied with the operative procedure. The comparison of the two groups (satisfied and dissatisfied patients) revealed statistically significant differences in the personality traits aggressiveness (p=0.003), extraversion (p=0.001) and health worries (p=0.04). The postoperative hallux valgus angles were 12.2° ± 7.8 and 13.4° ± 8.3 (p=0.74), and the first-second intermetatarsal angles were 7.4° ± 2.5 and 7.6° ± 4 (p=0.89) in the two groups. The results of the current study suggest that the patient’s subjective result after the operative hallux valgus correction is influenced by some individual personality profiles.
A prospective single-cohort study was designed to include 20 patients with enchondromas but was stopped because of poor early results. Four patients with an enchondroma, three in the proximal humerus and one in the distal femur, were treated by curettage and filling of the defect with Norian SRS cement. Clinical and radiological follow-up including CT and MRI was carried out for 18 months. All three patients with lesions in the proximal humerus had severe pain and limited movement of the shoulder. The radiological and CT appearances of the cement were unchanged at follow-up. There were characteristic appearances of synovitis and periosteitis on MRI in two patients. Since the cement induces a soft-tissue reaction the bony cavity should be sealed with the curetted and burred bone after curettage and introduction of Norian cement, especially in sites where a tourniquet cannot be applied.
We have investigated in a prospective, randomised placebo-controlled study the effect of high-dose aprotinin on blood loss in patients admitted for major surgery (revision arthroplasty of the hip or knee, or for resection of a soft-tissue sarcoma). The mean intraoperative blood loss was reduced from 1957 ml in the control group to 736 ml in the aprotinin group (p = 0.002). The mean requirement for intraoperative homologous blood transfusion in the aprotinin group was 1.4 units (95% CI 0.2 to 2.7) and 3.1 units (95% CI 1.7 to 4.6) in the control group (p = 0.033). The mean length of hospital stay was reduced from 27.8 days in the control group to 17.6 days in the aprotinin group which was not statistically significant. The intraoperative use of aprotinin in major orthopaedic operations significantly reduced blood loss and the required amount of packed cells. It may result in a decrease in the length of hospital stay and costs.
Primary malignant tumours should be resected with wide margins. This may be difficult to apply to lesions of the spine. We undertook total vertebrectomy on seven patients, four males and three females with a mean age at operation of 26.5 years (6.3 to 45.8). The mean follow-up was 52.3 months. Histological examination revealed a Ewing’s sarcoma in two patients and osteosarcoma, leiomyosarcoma, spindle-cell sarcoma, chondrosarcoma and malignant schwannoma in one each. In five patients, histological examination showed that a wide resection had been achieved. At follow-up there was no infection and a permanent neurological deficit was only seen in those patients in whom the surgical procedure had required resection of nerve roots. Despite the high demands placed on the surgeon and anaesthetist and the length of postoperative care we consider total vertebrectomy to be an appropriate procedure for the operative treatment of primary malignant lesions of the spine.
In 251 patients over a period of 15 years an uncemented Kotz modular femoral and tibial reconstruction mega prosthesis was implanted after resection of a malignant tumour of the lower limb. Twenty-one patients (8.4%) underwent revision for aseptic loosening, again using an uncemented prosthesis, and five of these required a further revision procedure. The median follow-up time from the first revision was 60 months (11 to 168) and after a second revision, 33 months (2 to 50). The probability of a patient avoiding aseptic loosening for ten years was 96% for a proximal femoral, 76% for a distal femoral and 85% for a proximal tibial implant. At the time of follow-up all radiographs were assessed according to the International Symposium of Limb Salvage criteria. The first radiological signs of aseptic loosening were always seen at the most proximal or distal part of the anchorage stem at a mean of 12 months (4 to 23) after the first implantation. Using the Musculoskeletal Tumor Society score for evaluation, the clinical results showed a mean of 88% of normal function.
We treated 106 patients with a peripheral osteoid osteoma by conventional surgical methods; 81 had curettage and 25 The rate of local recurrence after curettage was 12% and after We compared our findings with those reported in the literature after minimally invasive treatment and concluded that curettage can be regarded as the treatment of choice in patients in whom minimally invasive methods do not offer any advantage, for example, for subperiosteal tumours which are readily accessible, or when the diagnosis is unclear and further histological analysis is required.
We performed a retrospective analysis of the clinical and radiological outcomes of total hip replacement using an uncemented femoral component proximally coated with hydroxyapatite. Of 136 patients, 118 who had undergone 124 primary total hip replacements were available for study. Their mean age was 66.5 years (19 to 90) and the mean follow-up was 5.6 years (4.25 to 7.25). At the final follow-up the mean Harris hip score was 92 (47.7 to 100). Periprosthetic femoral fractures, which occurred in seven patients (5.6%), were treated by osteosynthesis in six and conservatively in one. We had to revise five femoral components, one because of aseptic loosening, one because of septic loosening and three because of periprosthetic fracture. At the final follow-up there were definite signs of aseptic loosening in two patients. Radiologically, proximal femoral bone loss in Gruen zones I and VI was evident in 96.8% of hips, while bone hypertrophy in zones III and V was seen in 64.7%. In 24 hips (20.2%) the mean subsidence of the stem was 3.7 mm which occurred within the first 12 postoperative weeks. This indicated poor initial stability, which might have been aggravated by early weight-bearing. The high rate of failure in our study suggests that proximal femoral bone loss affects the long-term survival of the replacement.
We have reviewed the results of one-stage revision surgery in 18 patients for infection of megaprostheses implanted after the resection of malignant bone and soft-tissue tumours. At a mean follow-up of 52.0 ± 35.0 months (18 to 135) infection was eliminated in 14 of the 18 patients. The infection-free patients showed no abnormal tests for inflammation and had a mean Enneking score of 20.6 ± 5.0 points (maximum 30 points). We suggest that one-stage revision without exchange of the anchorage parts is justified in patients with megaprostheses infected by antibiotic-sensitive micro-organisms.
From 1986 to 1991 we fitted 20 children with endoprostheses after resection of malignant bone tumours of the leg; six have reached skeletal maturity and are the subject of this study. Reconstruction of defects in growing limbs in which the eventual shortening can be predicted requires the use of extendable prostheses. The mean age at operation was 11 years (9.2 to 13.7) and the average follow-up period was 6.3 years (4.3 to 7.6). The diagnosis was osteosarcoma in five patients and Ewing's sarcoma in one. All tumours were Enneking stage-IIB. When seen for follow-up all patients were free from disease. The extendable implants used included the Pafford-Lewis prosthesis and the Kotz Modular Femur Tibia Reconstruction system with a compatible, newly-designed growth module. Telescope-like elongation of the prostheses was performed by insertion of a screwdriver through a small skin incision. Active epiphyseal growth in the adjacent growth plate was preserved by using prosthetic stems with a smooth surface. The mean length gained was 13.15 cm (4.5 to 19.5) requiring 53 planned procedures. Seven revision operations were necessary for complications. Functional evaluation showed excellent and good results in all cases. Stress-shielding at the site of anchorage of the prosthesis was more pronounced than in adults. Implantation of extendable endoprostheses in children provides a reasonable alternative to rotationplasty, but limb salvage requires more operations.
We describe a method of partial limb salvage for the treatment of large primary malignant tumours of the arm. The tumour-bearing area is resected as a cylindrical segment and the distal arm is then replanted with the necessary shortening. The method is suitable for stage-IIB tumours with or without neurovascular involvement which, because of their extent, could otherwise be adequately treated only by amputation. From 1987 to 1992 we used this method in 12 patients with primary malignant bone or soft-tissue sarcomas. Wide resection margins were achieved in all, but six patients died from their disease at a mean of 21.5 months (6 to 48), none with any local recurrence. Five patients have no evidence of disease at a mean follow-up period of 52.2 months (22 to 78), and one was lost to follow-up at 48 months postoperatively when there was no evidence of disease. The results of the functional evaluation of ten patients with a follow-up of over ten months were excellent in one, good in six and fair in three, by the criteria of Enneking (1987). Recovery after nerve reconstruction was satisfactory in all cases with sensation S3 or higher and motor function M2+ or higher. Detailed evaluation of hand function on the Millesi score rated only 22% (9.6% to 33.7%) as compared with the contralateral side, but the patients were satisfied and refused further operations for the improvement of function. These oncological and functional results allow us to recommend resection-replantation as a valuable alternative to amputation for the treatment of primary malignant tumours of the arm.
We reviewed 236 of the 388 Chiari pelvic osteotomies performed between 1953 and 1967 at the Orthopaedic University Clinic of Vienna for the treatment of congenital dislocation and subluxation of the hip. Over 90% of the operations were performed by Chiari himself. Twenty-one hips had needed reoperation after an average of 15.4 years; the other 215 hips had been followed up for 20 to 34 years (mean 24.8). The overall clinical results were excellent or good in 51.4%, fair in 29.8% and poor in 18.3%. The results were worse with increasing age at operation. The Trendelenburg sign improved only in patients aged seven or less at operation, and range of movement decreased in all cases. Subjectively poor results were seen in patients with pre-operative signs of osteoarthritis. Radiological loss of correction during follow-up was seen only in cases with incomplete primary correction. The addition of an intertrochanteric varus osteotomy in 36 cases did not achieve either better centering or better development of the acetabular roof. Degenerative changes increased significantly during the long-term follow-up, but their progress seemed to have been slowed down by the osteotomy in the younger age groups. Indications and contra-indications for the operation are discussed.
Of 142 Chiari pelvic osteotomies for osteoarthritis in dysplastic hips, most performed by Chiari himself, we were able to review 82 and obtain information about 18 by questionnaire. All patients were over 30 years of age at operation; follow-up averaged 15.5 years. Twenty hips had undergone secondary total hip replacement. The outcome was good in 75%, fair in 9% and poor in 16%. High osteotomies all gave good results, and the result also depended on adequate medialisation. Statistics were worse for patients over 44 years of age at the time of operation. For osteoarthritis secondary to hip dysplasia, the Chiari pelvic osteotomy is an alternative procedure to early hip replacement. In contrast to intertrochanteric osteotomy, it has the advantage of facilitating the implantation of an acetabular prosthesis should arthroplasty become necessary at a later stage.