Local Staging of Soft-Tissue Sarcoma: Emphasis on Assessment of Neurovascular Encasement-Value of MR Imaging in 174 Confirmed Cases.

PURPOSE: To evaluate utility of magnetic resonance (MR) imaging in local staging of soft-tissue sarcoma, with an emphasis on assessment of neurovascular encasement. MATERIALS AND METHODS: Institutional review board approval was obtained; informed consent requirement was waived. Preoperative MR images in 174 patients with soft-tissue sarcoma were analyzed by two readers. Tumor staging according to the American Joint Committee on Cancer/Union International Contre le Cancer and Enneking staging systems and analysis of osseous and articular invasion were performed. To assess neurovascular encasement, contact between tumor and arteries, between tumor and veins, and between tumor and nerves was classified (no contact, contact ≤90°, 91°-180°, 181°-270°, >271°). Interobserver agreement was determined; imaging findings were correlated with intraoperative findings and/or histopathologic findings (Pearson correlation coefficient [r] and Cohen κ coefficient). RESULTS: Intraoperative evaluation and/or histopathologic evaluation confirmed osseous, articular, and neurovascular invasion in 8.6%, 2.9%, and 25.3% of patients. Interobserver agreement was excellent for tumor staging (American Joint Committee on Cancer/Union International Contre le Cancer staging, κ = 0.811; Enneking staging, κ = 0.943) and osseous invasion (κ = 1.000). It was substantial for articular invasion (κ = 0.794). Sensitivity and specificity for osseous invasion were 100% and 98.7%, respectively (both readers). For articular invasion, sensitivity was 80% (both readers); specificities were 100% and 98.8% for readers 1 and 2, respectively. Interobserver agreement in quantifying contact between tumor and vessels and between tumor and nerves was excellent for arteries, veins, and nerves (κ = 0.845, 0.892, 0.893, respectively). Receiver operating characteristic analysis revealed optimal threshold of greater than 180° for prediction of arterial and venous encasement (both readers). For neural encasement, optimal threshold was greater than 180° (reader 1) and greater than 270° (reader 2). Sensitivities in diagnosing encasement for arteries, veins, and nerves were 84.6%, 84.6%, and 77.8% (reader 1) and 84.6%, 84.6%, and 72.2% (reader 2). Specificities for encasement of arteries, veins, and nerves, respectively, were 97.5%, 97.5%, and 93.2% (reader 1) and 93.8%, 94.7%, 97.3% (reader 2). CONCLUSION: MR imaging allows reliable and accurate local staging of soft-tissue sarcoma. Encasement of arteries, veins, and nerves should be diagnosed, if the contact between tumor and vascular or neural circumference exceeds 180°.

Customised osteotomy guides and endoprosthetic reconstruction for periacetabular tumours.

PURPOSE: We sought to analyse clinical and oncological outcomes of patients after guided resection of periacetabular tumours and endoprosthetic reconstruction of the remaining defect. METHODS: From 1988 to 2008, we treated 56 consecutive patients (mean age 52.5 years, 41.1 % women). Patients were followed up either until death or February 2011 (mean follow up 5.5 years, range 0.1-22.5, standard deviation ± 5.3). Kaplan-Meier analysis was used to estimate survival rates. RESULTS: Disease-specific survival was 59.9 % at five years and 49.7 % at ten and 20 years, respectively. Wide resection margins were achieved in 38 patients, whereas 11 patients underwent marginal and seven intralesional resection. Survival was significantly better in patients with wide or marginal resection than in patients with intralesional resection (p = 0.022). Survival for patients with secondary tumours was significantly worse than for patients with primary tumours (p = 0.003). In 29 patients (51.8 %), at least one reoperation was necessary, resulting in a revision-free survival of 50.5 % at five years, 41.1 % at ten years and 30.6 % at 20 years. Implant survival was 77.0 % at five years, 68.6 % at ten years and 51.8 % at 20 years. A total of 35 patients (62.5 %) experienced one or more complications after surgery. Ten of 56 patients (17.9 %) experienced local recurrence after a mean of 8.9 months. The mean postoperative Musculoskeletal Tumor Society (MSTS) score was 18.1 (60.1 %). CONCLUSION: The surgical approach assessed in this study simplifies the process of tumour resection and prosthesis implantation and leads to acceptable clinical and oncological outcomes.

Acute osteomyelitis of the humerus mimicking malignancy: Streptococcus pneumoniae as exceptional pathogen in an immunocompetent adult.

BACKGROUND: Chronic osteomyelitis due to direct bone trauma or vascular insufficiency is a frequent problem in orthopaedic surgery. In contrast, acute haematogenous osteomyelitis represents a rare entity that almost exclusively affects prepubescent children or immunodeficient adults. CASE PRESENTATION: In this article, we report the case of acute pneumococcal osteomyelitis of the humerus in an immunocompetent and otherwise healthy 44-year-old male patient presenting with minor inflammation signs and misleading clinical features. CONCLUSIONS: The diagnosis had to be confirmed by open biopsy which allowed the initiation of a targeted therapy. A case of pneumococcal osteomyelitis of a long bone, lacking predisposing factors or trauma, is unique in adults and has not been reported previously.

Primary extrahepatic alveolar echinococcosis of the lumbar spine and the psoas muscle.

Alveolar echinococcosis (AE) of human being caused by Echinococcus multilocularis is a rare but important zoonosis especially in tempered zones of middle Europe and Northern America with endemic character in many countries. Due to the long incubation period, various clinical manifestations, critical prognosis, and outcome AE presents a serious and severe disease. The primary focus of infection is usually the liver. Although secondary affection of visceral organs is possible extrahepatic AE is highly uncommon. Moreover, the involvement of bone and muscle presents with an even lower incidence. In the literature numerous cases on hepatic AE have been reported. However, extrahepatic AE involving bones and/or muscles was described very rarely. We report a case of an 80-year-old man with primary extrahepatic alveolar Echinococcosis of the lumbar spine and the psoas muscle. The etiology, diagnosis, differential diagnoses, treatment options and outcome of this rare disease are discussed in context with the current literature.

A new modification of combining vacuum therapy and brachytherapy in large subfascial soft -tissue sarcomas of the extremities.

PURPOSE: To present a modification of a technique combining the advantages of brachytherapy for local radiation treatment and vacuum therapy for wound conditioning after resection of subfascial soft-tissue sarcomas (STS) of the extremities. PATIENTS AND METHODS: Between January and May 2008, four patients with large (> 10 cm) subfascial STS of the thigh underwent marginal tumor excision followed by early postoperative HDR (high-dose-rate) brachytherapy (iridium-192) and vacuum therapy as part of their interdisciplinary treatment. The sponge of the vacuum system was used to stabilize brachytherapy applicators in parallel positions and to allow for a maximal wound contraction in the early postoperative phase, thus preventing seroma and deterioration of local dose distribution as optimized in computed tomography-(CT-)based three-dimensional conformal treatment planning. In three patients this was followed by external-beam radiotherapy. Acute wound complications and late effects according to LENT-SOMA after 4-8 months of follow-up were recorded. RESULTS: The combination of vacuum and brachytherapy was applicable in all patients. CT scans from the 1st postoperative day showed the shrinkage of the sponge located in the tumor bed with the brachytherapy applicators in the intended position and easily visible. 15-18 Gy in fractions of 3 Gy bid prescribed to 5 mm tissue depth were applied over the next days with removal of the sponge and applicators on days 5-8. No early or late toxicity exceeding grade 2 was observed. The mean Enneking Score for functional outcome was 63% (perfect function = 100%). CONCLUSION: The combination of vacuum and brachytherapy is applicable and safe in the treatment of large subfascial STS.

Sclerosing epithelioid fibrosarcoma of the bone: a case report of high resistance to chemotherapy and a survey of the literature.

Sclerosing epithelioid fibrosarcoma (SEF) is a rare soft tissue sarcoma mostly occurring in extraosseous sites. SEF represents a clinically challenging entity especially because no standardized treatment regimens are available. Intraosseous localization is an additional challenge with respect to the therapeutical approach. We report on a 16-year-old patient with SEF of the right proximal tibia. The patient underwent standardized neoadjuvant chemotherapy analogous to the EURAMOS-1 protocol for the treatment of osteosarcoma followed by tumor resection and endoprosthetic reconstruction. Histopathological analysis of the resected tumor showed >90% vital tumor cells suggesting no response to chemotherapy. Therefore, therapy was reassigned to the CWS 2002 High-Risk protocol for the treatment of soft tissue sarcoma. To date (22 months after diagnosis), there is no evidence of relapse or metastasis. Our data suggest that SEF may be resistant to a chemotherapy regimen containing Cisplatin, Doxorubicin, and Methotrexate, which should be considered in planning treatment for patients with SEF.

Closed wedge osteotomy in 66 patients for the treatment of moderate to severe hallux valgus.

BACKGROUND: The intention of this study was to analyze the long-term results of the proximal closing wedge osteotomy for the correction of hallux valgus deformity, modified by adding a mini L-plate for osteosynthesis. METHODS: The outcome of a proximal first metatarsal closing wedge osteotomy was retrospectively evaluated after a mean follow-up of 52 months. A total of 66 female patients (86 feet) participated in this study. The AOFAS-score was used to evaluate the postoperative results. Pre- and postoperative weight-bearing radiographs were used to evaluate the osseous development. RESULTS: 95.5% of the patients were satisfied, 3 patients (4.5%) were not satisfied with the overall result of the operation. Transfer metatarsalgia was registered in 7 of 50 cases. The mean improvement of the HV-angle was 22.1 degrees (36.4 degrees to 14.3 degrees ) and the intermetatarsal angle was reduced from a mean of 17.6 degrees to a mean of 6.5 degrees . The mean first metatarsal shortening was 3.2mm. The mean AOFAS-score was 78 points. CONCLUSION: The results confirm, that the closing wedge osteotomy is indicated for moderate to severe hallux valgus. The shortening of the first ray is comparable with other well-established operative procedures. The risk of transfer metatarsalgia can only be lightly reduced by this procedure.

The effect of antibacterial acting extracorporeal shockwaves on bacterial cell integrity.

BACKGROUND: Antibacterial effects of extracorporeal shockwaves (ESWs) have been demonstrated in vitro against bacteria under static and dynamic growth conditions. This study assessed the effects of ESWs on the cell wall integrity of bacteria. MATERIAL/METHODS: Standardized suspensions of Staphylococcus aureus were exposed to various shockwave impulses (2000-12,000) of different energy flux densities (EFD, 0.38-0.96 mJ/mm(2)). Bacterial suspensions of equal concentration that had been permeabilized (to >99%) with isopropanol were used as positive controls. The bacteria of all groups were stained with Sytox Green nucleic acid stain. The fluorescence of the shockwave-treated, permeabilized, and untreated suspensions was measured and compared for bacterial survival, quantified by colony-forming units after plating. RESULTS: Although ESWs showed a significant energy-dependent antibacterial effect that reduced CFUs in the treated suspensions by between 56% and 99%, only maximum energies (4000 impulses at 0.96 mJ/mm(2) and 12,000 impulses at 0.59 mJ/mm(2)) were followed by a significant increase in fluorescence compared with the untreated control (p<0.05). However, the fluorescence of these treated groups was still far less than that of the alcohol-permeabilized positive control groups (p<0.05). Lower energies and impulse rates did not show increased intracellular uptake of the fluorescent dye (p>0.05). CONCLUSIONS: This is the first study to assess bacterial cell wall permeability after ESW treatment. It was found that the permeabilization of bacterial cells after ESW treatment was far less than expected due to the corresponding antibacterial effect. Other mechanisms, such as intracellular effects, might be involved in bacterial killing after ESWs and still must be elucidated.

Energy-dependent stimulatory and inhibitory effects of extracorporeal shock waves on bacteria and on gentamicin activity.

BACKGROUND: Local infection is considered a contraindication for extracorporeal shock wave (ESW) application, although the antibacterial effects of ESW have been clearly demonstrated in vitro. This study aimed to assess the effects of ESW on bacteria under growth-promoting conditions and to evaluate interactions with the activity of gentamicin. MATERIAL/METHODS: Standardized suspensions of Staphylococcus aureus were exposed to 4000 shock wave impulses of various energy flux densities (EFD) both at 37 degrees C in growth medium and at 20 degrees C in saline. Bacterial viability of treatment groups and controls were quantified. Furthermore, the MICs of gentamicin against ESW-treated and untreated suspensions of S. aureus were compared. Finally, suspensions of S. aureus containing graded concentrations of gentamicin were exposed to ESW and bacterial growth was assessed. RESULTS: Antibacterial effects of ESW (0.59-0.96 mJ/mm2) were confirmed with bacteria suspended in normal saline (20 degrees C, p<0.05). However, bacteria suspended in growth medium at 37 degrees C demonstrated significantly increased proliferation (p=0.009) after treatment with shock waves of lower EFD (0.59 mJ/mm2). At higher EFD a significant reduction of bacteria was observed (p=0.009). The MIC of gentamicin against S. aureus was not altered by ESW application. Furthermore, the combination of gentamicin and ESW did not alter gentamicin activity (p>0.05). Nevertheless, a growth-promoting effect of ESW at 0.59 mJ/mm(2) was demonstrated despite simultaneous administration of gentamicin. CONCLUSIONS: This is the first study reporting energy-dependent stimulation of bacterial growth by ESW. Also important is that ESW did not alter the activity of gentamicin.

High risk of cognitive and functional decline after postoperative delirium. A three-year prospective study.

BACKGROUND/AIMS: The aim of the study was to investigate the association of postoperative delirium with the outcomes of cognitive impairment, functional disability and death. METHODS: Hip surgery patients aged 60 years or over (n = 200) underwent preoperative and daily postoperative assessment of their cognitive status during hospital stay. Outcome variables were determined at an average of 8 and 38 months after discharge from hospital. RESULTS: Fourty-one patients developed postoperative delirium. Delirium was a strong independent predictor of cognitive impairment and the occurrence of severe dependency in activities of daily living. The associations were more marked for the long- than for the short-term outcome. Thirty-eight months after discharge from hospital, 53.8% of the surviving patients with postoperative delirium suffered from cognitive impairment, as compared to only 4.4% of the nondelirious participants. Logistic regression analysis adjusted for age, sex, medical comorbidity and preoperative cognitive performance revealed highly significant associations between delirium and cognitive impairment (OR = 41.2; 95% CI = 4.3-396.2), subjective memory decline (OR = 6.2; 95% CI = 1.5-25.8) and incident need for long-term care (OR = 5.6; 95% CI = 1.6-19.7). CONCLUSION: The present study confirms a poor prognosis after delirium in elderly patients. The findings suggest that delirium does not simply persist for a certain time but also predicts a future cognitive decline with an increased risk of dementia.

[Extracorporeal high hydrostatic pressure as a new technology for the disinfection of infected bone specimens]]. / Extrakorporale hydrostatische Hochdruckbehandlung als neues Verfahren zur Desinfektion infizierter Knochenpräparate.

BACKGROUND: Allogeneic bone transplantation is at risk of infection, and established disinfection methods typically compromise bone quality. High hydrostatic pressure (HHP) is well established for disinfection in food technology, and also it does protect biomechanical and biological properties of bone. This study is the first investigation of HHP regarding disinfection of bone biopsies. MATERIALS AND METHODS: Bone biopsies of 34 patients with chronic infections were subjected to HHP and assessed for persisting bacterial growth. In series 1, bone biopsies were proceeded directly to HHP (10 min; maximal pressure Pmax 600 MPa). In series 2, HHP was applied after 5-day incubation in growth media (10 min or 2x30 min; Pmax 600 MPa). Furthermore, HHP-induced changes of bacterial morphology on artificially infected bone samples were evaluated by scanning electron microscopy (SEM). RESULTS: For series 1, 71% of the bone samples were sterilised by HHP (n=17), compared to 38% of the untreated control samples, which were obtained during the same surgery (n=8). For series 2, after prior incubation, HHP disinfected 7% of the bone specimens (n=55), all control samples showed bacterial growth (n=33). Destruction of cell wall integrity of Gram-negative strains was observed by SEM. CONCLUSION: The effectiveness of HHP for bone disinfection should be improved by optimising treatment parameters. Infections with barosensitive Gram-negative bacteria or yeast might represent possible clinical indications.

[Total hip endoprosthesis]. / Tipps für die TEP. Das sollte Ihr Patient vor der Hüft-OP wissen.

The family physician can provide his patient with useful information to help him decide in favor of or against a total hip replacement procedure. This also applies to the choice of the most suitable endoprosthetic system, such pre-operative measures as discontinuation or change of medication, and the assessment of possible perioperative or postoperative complications.

Growth promoting in vitro effect of synthetic cyclic RGD-peptides on human osteoblast-like cells attached to cancellous bone.

In tissue engineering, the application of biofunctional compounds on biomaterials such as integrin binding RGD-peptides has gained growing interest. Anchorage-dependent cells like osteoblasts bind to these peptides thus ameliorating the integration of a synthetic implant. In case sterilized bone grafts are used as substitutes for reconstruction of bone defects, the ingrowth of the implanted bone is often disturbed because of severe pretreatment such as irradiation or autoclaving, impairing the biological and mechanical properties of the bone. We report for the first time on the in vitro coating of the surface of freshly resected, cleaned bone discs with synthetic, cyclic RGD-peptides. For this approach, two different RGD-peptides were used, one containing two phosphonate anchors, the other peptide four of these binding moieties to allow efficient association of these reactive RGD-peptides to the inorganic bone matrix. Human osteoblast-like cells were cultured on RGD-coated bone discs and the adherence and growth of the cells were analyzed. Coating of bone discs with RGD-peptides did not improve the adhesion rate of osteoblast-like cells to the discs but significantly (up to 40%) accelerated growth of these cells within 8 days after attachment. This effect points to pretreatment of bone implants, especially at the critical interface area between the implanted bone and the non-resected residual bone structure, before re-implantation in order to stimulate and enhance osteointegration of a bone implant.

Effect of extracorporeal high hydrostatic pressure on cellular outgrowth from tumor-afflicted bone.

At present, in orthopedic surgery, the reconstruction of bone defects following resection of malignant tumors is effected by several methods. The irradiation and autoclaving of bone segments are the 2 methods of choice to extracorporeally devitalize the resected tumor-bearing bone segments. An alternative, gentle method of devitalizing bone-associated cells by exposing normal and tumor cells to extracorporeal high hydrostatic pressure (HHP) has been introduced. The aim of this study was to examine the ex vivo effect of HHP on the cell growth of normal and tumor-afflicted freshly-resected small human bone segments. For this, tumor-afflicted human bone segments of 5 x 5 x 5 mm in size, obtained during surgery from 14 patients suffering from chondrosarcoma or osteosarcoma, in comparison to bone segments obtained from 36 patients with normal bone, disease were exposed to HHP levels of 0, 150 and 300 MPa for 10 min at 37 degrees C. Following HHP-treatment, the specimens were placed into cell culture and observed for cell outgrowth up to 50 days. In control samples (0 MPa), rapid outgrowth of cells was observed. HHP-treatment of 150 MPa however, resulted in reduced outgrowth of cells from these bone specimens; at 300 MPa, no outgrowth of cells was detected. Light microscopy and standard histological examination showed morphological changes between control samples (0 MPa) and 150 MPa. Our results suggest that the treatment of tumor-afflicted bone and the associated cartilage by HHP leads to the devitalization of bone cells concomitant with complete impairment of cellular outgrowth, a precondition for re-implantation of the HHP-treated bone.

MRT-measurements of muscle volumes of the lower extremities of youths with spastic hemiplegia caused by cerebral palsy.

After long term of studies from our gait lab, the typical muscular dysbalances by all of our patients with cerebral palsy where pointed out. Now we wanted to examine using the MRT, weather the dysbalances of the hemiparetic musculoskeletal system also show up in discrepancies of the muscle volumes. The MRT slices of the lower extremities were segmented. From this cross sections the muscles volumes were derived. These where analyzed particularly with regard to asymmetries between spastic and healthy side. Hemiparetic patients showed reduced volumes of all muscles on the paretic leg in comparison to the healthy side. The muscles of the thigh of the paretic leg were reduced to 84% in the mean over all muscles and in comparison to the healthy leg. The volume of the muscles of the shank was reduced to 72%, significantly more than the muscles of the thigh. Concerning flexor and extensor muscles located at thigh and shank of the paretic leg there was found significantly the same relative deficit of the muscle volume. Examining the muscle volumes of subjects with different neurogene foot deformities, significant differences of the volume reduction of single muscles appeared within the lower leg.