Introduction: Pain is arguably the most important symptom in the musculoskeletal system. When taking the patient’s history or using patient-questionnaires, pain during activity, at rest and at night are assessed separately, then amalgamated to a composite score. From our experience in regular use of a standardized anamnesis method (interactive anamnesis with Pationnaire), we have gained the impression that pain at rest and night pain might correlate. The aim of this study was to find out if there is a correlation between pain during activity, pain at rest and pain at night.

Patients and Methods: Patients with a variety of disorders of the musculoskeletal system (degenerative pathologies of all major joints, cervical and lumbar spine, multifocal pain syndromes) completed a validated simple patient questionnaire (Pationnaire) during routine consultations. This patient questionnaire allows measurement and documentation of 10 cardinal symptoms and disabilities regarding sleep and normal daily life. All the questionnaires were scanned and filed. The data of more than 1000 observations were statistically analyzed by an external statistical institute for correlations of symptoms using Spearman correlation coefficients.

Results: Included were 938 patients with 1160 observations between October 2006 and June 2008. Average age was 58.9 years, 54% of them were women. Average pain during activity was 59.3, at rest 36.9 and at night 35.6. We found a positive correlation of 0.79 between pain at rest and at night. The correlation coefficient between pain during activity and pain at rest was 0.58, and that between pain during activity and at night was 0.47 (p< 0.05).

Conclusion: Pain at rest and at night, as assessed in a patient questionnaire, are positively correlated. In a questionnaire, these two kinds of pain could be assessed with one single question, i.e. it may be enough to assess and document pain during activity and at rest/night.

Introduction: Implant loosening/pseudartrhosis after THR/TKR with large femoral bone defects is associated with pain and immobilization in a wheelchair. In these cases a total femur replacement (Combined total hip and knee replacement connected with an intramedullary rod) can be a therapeutic procedure as known from tumor surgery. We describe this technique and results with in a case serie of patients.

Study Type: Monocentric prospective case serie

Patients and Methods: All patients who had a total femur replacement were followed regularly after 3, 6 months, 1, 3 and 5 years. The follow up was documented with clinical examination, x-rays and validated questionnaires. Indications were loosening after stem revisions (THR), pseudarthrosis and loosening of femoral component after TKR, pseudarthrosis and instability after THR and fracture.

For every case the implants were planned with a total leg x-ray and manufactured (Link). The implants were removed and the knee and hip joint prepared. The approach was performed with two incisions (knee, hip) to reduce the invasivity. The implantation started with the knee implants connected with the intramedullary rod and was finished with the hip implants. Postoperative weight bearing was following pain.

Results: Included were 5 cases of total femur replacement in 4 patients (three women, age from 54 to 69) with a follow up between 12 to 94 months, average 3.5 years. Three cases with stem loosening after THR and revisions before, one case with loosening and pseudarthrosis after TKR, one with pseudarthrosis and instability after THR with femur fracture. Every patient had 2–4 interventions of the affected joint before.

The pain diminuished significant in all patients in the questionnaires and the pain medication could be reduced substantially. All patients gained mobility already three months after the procedure, every patient could walk with crutches. No patients needed to be reoperated in the follow-up period. Every patient could keep the mobility over the the follow-up time. Two patients reported some pain in the knee. Radiologically the defects of the femur were partially consolidated and we could not see further bone loss.

Conclusion: Total femur replacement can be used also in selected patients with large bone defects after arthroplasty (THR/TKN) and loosening or pseudarthrosis. The patients profit from the reduction of pain and the gain in mobility.

Introduction: Assessment of symptoms regarding quality, strength and localisation is a part of the medical consultation. After that these informations need to be documented in the medical files. This process can be substantially ameliorated with a patient questionnaire, which assessess the symptoms and disabilities in a structured way. We developed a simple graphic questionaire (pationnaire), clearly structured, easy to understand and simple to fill out. The aim of this study was to test the construct validity of the ‚pationnaire’ with personal interviews (the agreement of symptoms and disabilities), and the ability and time to fill it out without help.

Study design: Monocentric analytical study measuring the agreement.

Persons/patients and methods: The persons/patients were randomly selected by the interviewer. They signed an informed consent approved by the local ethical commitee. After a short introduction about the ‚pationnaire’ and its aims, people filled out one directly without help. The time to completion was measured. The person/patient was then personally interviewed about items within the ‚pationnaire’ to assess their correlation with their symptoms and disabilities, and uncover any sources of misunderstanding or misinterpretation.

At the end of the interview every person/patient was asked for a statement about their understanding, formulations, difficulties with the ‚pationnaire’, missing questions and general impression.

Results: 78 persons/patients (50 women, 28 men) were included. Their average age was 46.3 years (range 12–93 years). 97% (76) could fill out the ‚pationnaire’ without help, 2 needed help and further explanations. Average time for completion was 9.9 min (range 3–45 mins) – the longest time being taken by those who needed help. Complete agreement between the questionaire and the perceived symptoms/disabilities was found in 94% (n=73), it was partial in 3.8% (n=3), and„no agreement“ occurred in 2.2% (n=2, persons, both of whom needed support). The understanding was rated very good in 98% and difficult in 2% (both elderly persons > 80 years). The formulation ’my symptoms are’ was preferred by everybody compared to ’which symptoms do you have’. In general the overall rating was good or very good for all persons, although older people with co-morbidities needed help.

Aims: Assessment of results in lumbar spine surgery with the SF-36 and NASS (lumbar element) Study design: Prospective monocentric study. Included were all patients with complete data sets. Excluded were patients with incomplete data, who could not read, did not understand german language. Patients and methods: 85 patients were included, 43 women, 42 men. Average age 59 years, SD ±17 years. The patients had surgical treatment (decompression and stabilization) after at least 6 months conservative treatement without amelioration. The questionaires were þlled out the day before operation, after 3, 6 and 12 months. The calculations for the dimensions were the effect size and standardized response mean (delta/SD of delta). Results: ES were large (> 0.8) for all the follow ups (0–3, 0–6, 0–12 months) in the NASS pain and disability dimensions and in the bodily pain and physical function (SF-36) also. ES were small (> 0.2) for all the follow ups (0–3, 0–6, 0–12 months) in the NASS neurology dimension and in the role physical (0–6, 0–12 months) and vitality (0–12 months) (SF-36). SRM showed analogue results. The back pain questions (NASS) depicted greater effects than the leg pain questions. The ES for disturbance was always greater (30%) than that for the frequency. Conclusion: The effect sizes depict large effects regarding back pain, leg pain and disability, small effects regarding neurology. The effects after three/six months are larger than after a year.

The skeleton is the most common site to be affected by metastatic cancer. The place of surgical treatment and of different techniques of reconstruction has not been clearly defined.

We have studied the rate of survival of 94 patients and the results of the surgical treatment of 91 metastases of the limbs and pelvis, and 18 of the spine. Variables included the different primary tumours, the metastatic load at the time of operation, the surgical margin, and the different techniques of reconstruction.

The survival rate was 0.54 at one year and 0.27 at three years. Absence of visceral metastases and of a pathological fracture, a time interval of more than three years between the diagnosis of cancer and that of the first skeletal metastasis, thyroid carcinoma, prostate carcinoma, renal-cell carcinoma, breast cancer, and plasmacytoma were positive variables with regard to survival. The metastatic load of the skeleton and the surgical margin were not of significant influence. In tumours of the limbs and pelvis, the local failure rate was 0% after biological reconstruction (10), 3.6% after cemented or uncemented osteosynthesis (28) and 1.8% after prosthetic replacement (53). The local failure rate after stabilisation of the spine (18) was 16.6%. There was local recurrence in seven patients (6.4%), and in four of these the primary tumour was a renal-cell carcinoma. The local recurrence rate was 0% after extralesional (24) and 8.2% after intralesional resection (85).

Improvements in the oncological management of patients with primary and metastatic disease have resulted in an increased survival rate. In order to avoid additional surgery, it is essential to consider the expected time of survival of the reconstruction and, in bony metastases with a potentially poor response to radiotherapy, the surgical margin.

To study the anatomy of subarticular bone and cartilage, fresh specimens of cartilage on bone from the human shoulder, hip and knee were treated with bleach or papain, or were fixed and decalcified. All were compared using scanning electron microscopy. Papain digestion selectively removed cartilage to the tidemark. The tidemark contour was highly variable; irregularities were indirectly related to degenerative lesions and were most prominent in peripheral non-weight-bearing areas of joints with central fibrillation. Decalcification exposed the interface between the bone and calcified cartilage. Collagen fibrils in articular cartilage did not interdigitate with those of bone. The subchondral bone was appositional, avascular, smooth and very thin in most areas of human joints. Perforations through subchondral bone or calcified cartilage were rare. Bleach maceration destroyed important details.