Experience with bioceramic implants in orthopaedic surgery.

In the period from 1974 to March 1980 bioceramic endoprostheses were implanted in 155 patients. 94 patients were suffering from degenerative hip diseases and 61 had been operated for malignant bone tumours. The majority of the total endoprostheses consisted of a ceramic socket and a metal shaft prosthesis with ceramic head attached to it. Bioceramic double-cup prostheses were implanted in 19 patients without using bone cement. Following resection of malignant bone tumours, the proximal humerus and the proximal femur were replaced by special bioceramic endoprostheses. The post-operation period after implantation has reached 70 months in the case of tumour endoprostheses (average 22 months) and up to 49 months in the case of hip joint endoprostheses (average 24 months). The analysis deals exclusively with complications specific to the ceramic material. These complications are: breakage of the ceramic head (8 X), loosening of the ceramic cup (13 X) and pseudarthrosis of the cone connection in tumour endoprostheses (9 X). Abrasion particles were found in all cases which we were able to follow up histologically.

Adjuvant chemotherapy in osteosarcoma - effects of cisplatinum, BCD, and fibroblast interferon in sequential combination with HD-MTX and adriamycin. Preliminary results of the COSS 80 study.

In a cooperative adjuvant chemotherapy study of osteosarcoma (COSS-80), 192 patients were registered from December 1979 to March 1982. Forty-one patients have been excluded from study because of their nonadjuvant situation, therapy-limiting clinical conditions, or inadequate diagnosis. One hundred and fifty-one patients have been randomized to receive either the drug combination bleomycin + cyclophosphamide + dactinomycin (BCD) or cisplatinum (CPL) within a course of sequential multidrug chemotherapy including adriamycin (ADR) and high dose methotrexate (HDMTX). After exclusion of 51 patients with some deviation in history and/or management 100 selected patients were randomized once more to receive in addition or not fibroblast interferon after preoperative chemotherapy and surgical removal of the primary tumor. Patients were stratified for age and sex and for site and extension of tumor as well in both randomizations. Median follow up is now 12 (1-16) months. The expected 2-year disease free survival (DFS) rate of the total doubly randomized group is 78% and of the single randomized group 76%. No difference could be discerned between recombined groups receiving BCD vs CPL or interferon vs no interferon. The effect of preoperative chemotherapy on the tumor was evaluated clinically and by histopathologic grading; 66/85 (78%) patients were judged clinically as responders with pathohistologic verification of this finding in 71% of these cases. No adverse effect arose from delaying definite surgery for preoperative chemotherapy, but initial application of chemotherapy as well as planning, preparing, and performing of the surgical procedure have been facilitated. The majority of patients received some kind of limb-salvage treatment without local recurrences so far. A statistically insignificant but intriguing tendency for a slightly higher incidence of pulmonary metastases after resection as opposed to amputation could be detected. Similar to observations in the previous study COSS-77.

Surgical treatment of distant metastases in differentiated thyroid cancer: indication and results.

A total of 45 patients have received surgical treatment for distant metastases in 41 follicular and four papillary carcinomas. Fifty-four metastatic lesions were removed. In the majority of cases (n = 25, 46%), surgical intervention was indicated on the basis of oncologic data (reduced administration of radioiodine). Sixteen patients (30%) underwent surgery to relieve pain, and 13 other patients (24%) had surgical treatment of pathologic fracture. At the time of surgery, 29 patients (64%) had only one resectable metastasis, while 16 patients (36%) had further nonresectable metastases (six in the bone, 10 in the bones and lungs). In the course of 53 operations, metastases were resected from bone in 46 cases, from the lungs and greater omentum in two cases, and from the skin, suprarenal gland, pleura, and intra-abdominal lymph node in one case each. A total of 25 metastases (17 bone, eight soft tissue) could be removed by resection. In 16 patients, the resulting bone defect was filled with bone cement after resection of the metastases. Osteosynthesis was necessary in another six cases, while seven required the implantation of an endoprosthesis. Thirty-eight patients died between 1 and 136 months after surgical treatment. Twenty-six (58%) died of their primary disease after an average 49.3 months, seven (15%) died with their carcinomas of other causes after an average of 12 months, and five (11%) died intercurrently after an average of 16 months. Seven patients (15%) are still alive after 12 to 264 months (average, 99.3 months); four of them are without recurrence and three have metastases. Five of these patients exhibit normal activity, while the activity of the other two is limited by the progress of the carcinoma or as a result of surgical treatment. The estimated cumulative survival rate (Kaplan-Meier) was 44.8 +/- 11.2% for 5 years and 32.7 +/- 11.0% for 10 years after removal of a solitary metastasis. Analysis of these patients shows that the surgical removal of resectable metastases can be a valuable complement to nuclear medical therapy. The complicated surgical treatment of metastases is justified by the favorable effect it has on prognosis and on the patient's quality of life.

[Clinical observations on the use of high-dose methotrexate treatment in osteogenic sarcoma (author's transl)]. / Erfahrungen mit der Durchführung der hochdosierten Methotrexatbehandlung beim Osteosarkom.

Since January 1976 high-dose methotrexate (HDMTX) therapy has been used in the management of patients with osteogenic sarcoma at the Orthopaedic Department, University of Vienna. 7500 mg MTX/sqm body surface is administrated in a four-hour infusion with citrovorum factor rescue. This therapy is combined with dactinomycin, adriamycin, bleomycin, cyclophosphamide and vincristine in a multi-drug chemotherapeutic program as a prophylactic regimen after surgical treatment of the primary tumour, as well as in the management of metastases. So far, 12 patients have received a total of 46 infusions with HDMTX at montly intervals (6 patients already had widespread metastases). The use of several precautions such as adequate hydration 3 l/sqm body surface fluid), systematic alkalinization of the urine and regular control of the serum MTX level renders HDMTX therapy less hazardous. Five out of the 46 infusions were followed by mild toxic reactions consisting of mouth ulceration, fever and/or bone marrow depression. One out of the 6 patients with metastases and 5 out of the 6 patients receiving HDMTX as a prophylactic measure are without evidence of disease at present. In view of the short observation period, this report is limited to clinical observations only.

A special technique of compound osteosynthesis of the distal humerus. A case report about extramedullary blast crisis in chronic myelogenous leukemia.

In a rare case of chronic myelogenous leukemia, extramedullary myeloblast crisis occurred in the distal humerus after 27 years. The pathological fracture was stabilized with double-plate compound osteosynthesis. The small distal fragment was stabilized without restriction of the range of movement of the elbow joint. The osteosynthesis remained stable until the patient died.

[Long-term results of the treatment of Perthes' disease in the fulminant stage and after development of a coxa magna according to Chiari's pelvic osteotomy]. / Langzeitergebnisse der Behandlung des Morbus Perthes im floriden Stadium und nach Entwicklung einer Coxa magna mit der Beckenosteotomie nach Chiari.

We report about long term follow ups of treatment of Morbus Perthes with Chiari's Pelvic Osteotomy. Average follow up time was 8 years. One of our two main indications for operating was a distinct coxa magna with lack of sufficient roofing or with secondary osteoarthritis caused by this very lack. Cases with advanced destruction or strong lateralisation of the femoral head were the second major indication. Osteotomy as near to the joint as possible and extensive dislocation with maximal medialization of the head are the decisive factors for success for this operation. Two thirds of the cases showed a marked improvement of complaints at follow-up with almost unchanged range of motion. Improvement of the CE-angle and a remarkable increase of the sclerosed parts of the acetabular roof is also noticed in all x-rays at follow up. Nine cases can be judged as excellent, two as good and three as mediocre according to the cup-head-quotient of Heyman and Herndon. A remodelling of the femoral head with a Pelvic Osteotomy is possible even after conclusion of the reconstruction stage.

The results of surgical treatment for Perthes' disease.

We report the clinical and radiological results following intertrochanteric varus osteotomy and Chiari pelvic osteotomy for Perthes' disease in 70 hips with a minimum follow-up of 3 years. The indication depended on lateralization of the epiphysis of the femoral head with or without full containment in the abduction radiograph, thickening of the acetabular floor, coxa magna, and osteoarthritis. Epiphyseal quotient and sphericity showed that head deformity is mostly permanent; the acetabulum-head quotient provided good coverage. Operation in the condensation stage achieved far better results than later operations. From these and other results, the late and mild occurrence of osteoarthritis can be assumed despite deformed femoral head or acetabulum, with full coverage provided.

[Surgical therapy of malignant bone tumors and results of the treatment]. / Operative Therapie maligner Knochentumoren und Behandlungsergebnisse.

The surgical management of bone metastases should relieve pain and improve function. Of the operative cases (170 in the last 10 years), 30% underwent resectional therapy with successful implantation of an endoprosthesis. Surgical management of primary malignant bone tumors should result in cure. Since 1976, in 44 of 54 cases of osteosarcoma a tumor resection was performed and in 40 cases the operation was adequate. A rotation plasty operation was performed in 15 of the 44, a tumor endoprosthesis was implanted in 22, and other methods were used in seven.

[Results of inpatient postoperative rehabilitation after hip replacement]. / Ergebnisse der stationären postoperativen Rehabilitation nach Hüftgelenkersatz.

The study was performed as a pilot study evaluating the benefit of a 4-week inpatient postoperative rehabilitation programme. We examined 177 patients admitted after total hip replacement. We found statistically significant improvements of joint mobility, muscle power, gait, walking distance and a significant reduction of various pain parameters. The decline in usage of crutches, improvements in the activities of daily living and the positive patients' assessments were of striking evidence. A short time inpatient postoperative rehabilitation programme achieved significant success through an acceptable expenditure of treatment and resulted in substantially increased mobility and autonomy of the patients.

[Interferon/Controlled study in 3-year survival of patients with osteosarcoma (author's transl)]. / Verträglichkeitsprüfung von humanem Lymphoblasten-Interferon. Kontrollierte Studie bei 8 Osteosarkom-Patienten mit 3-Jahres-Uberleben.

In eight patients with osteosarcoma we conducted a controlled tolerance study with human lymphoblast interferon. Interferon was applied for 12 months and the control period after stopping interferon has lasted 12-42 months up to now. 4 out of 8 patients who received interferon did not show any adverse reaction concerning clinical and laboratory tests during the course of a 1-year application and during the follow-up period, resp. Only reversible thrombopenias and an increase in the alpha 2-globulins fraction were observed in the interferon and in the control group, resp. All of the 8 patients have up to now survived tumor-free.

[Experiences with ventral stabilization in vertebral metastases in the area of the thoracic and lumbar spine]. / Erfahrungen mit der ventralen Stabilisierung bei Wirbelkörpermetastasen im Brust- und Lendenwirbelsäulenbereich.

43 cases of tumor resection followed by ventral stabilisation are reported in 42 patients with metastases in the spine. Indications for surgery were beginning or incomplete transversal lesion of the spinal cord, bedrest for at least 3 weeks, unsusceible pain caused by instability, or unsuccessful conservative and radiotherapeutic treatment. 46.5% of the cases can be rated as good considering the time of survival and life quality, 18.5% can be judged as a partial success. 7 patients hat to be reoperated in the same level, most of them because of local recurrence. Complications occurred in 40% of the cases. These operations should be performed by a "term of specialists". Postoperative treatment with isotope-, hormone- or radiotherapy is decisive to obtain good results.

[The Cooperative Ewing Sarcoma Study CESS 81 of the German Pediatric Oncology Society--analysis after 4 years]. / Die kooperative Ewing-Sarkom-Studie CESS 81 der GPO--Analyse nach 4 Jahren.

In 1981 the cooperative Ewing's sarcoma study CESS 81 was initiated with initial 18-weeks-chemotherapy consisting of vincristine, actinomycin D, cyclophosphamide and adriamycin (VACA) followed by local therapy consisting of either radical surgery with complete resection of the involved bone or incomplete resection followed by radiation with 36 gy or radiotherapy only. Patients with radiation only for local therapy and extremity tumor sites are randomised for 46 gy vs 60 gy tumor dose. Following local therapy chemotherapy is continued for an additional 18 weeks. The actuarial results of 83 consecutive patients entered from 51 participating institutions from January 1, 1981, until November 15, 1984 are presented. 68/83 patients were off therapy and under observation for longer than one year following diagnosis. The longest follow-up was 41 months. On November 15, 1984, 39/68 (57%) patients were disease free. According to the site of the primary tumor patients with distal extremity lesions had a more favourable prognosis as compared to proximal extremity and central lesions. According to local therapy patients with radical surgery had a better prognosis as compared to those with resection followed by radiation and those with radiation only for local control. Analysis according to tumor volume revealed the strong interaction between tumor site, local therapy and tumor volume. According to life-table-analysis the disease free survival for patients with a tumor volume less than 100 ml was 75% after 41 months compared to 10% for patients with a tumor volume greater than or equal to 100 ml. The consequences of this analysis for a stratified treatment regimen for patients with primary Ewing's sarcoma of bone are discussed.