[Challenges to endoprosthetic reconstruction after tumor resection around the knee : Management of intra- and postoperative complications]. / Herausforderungen in der Tumorendoprothetik des Kniegelenks : Management von intra- und postoperativen Komplikationen.

BACKGROUND: The good functional outcomes of endoprosthetic knee reconstructions combined with modern oncosurgical concepts have resulted in a decreased rate of primary amputations following tumor resection in the region of the knee, thereby improving the quality of life of affected patients. OBJECTIVE: This study aimed to reappraise complications which are more common than in conventional arthroplasties performed for arthritis or trauma due to the complexity of the surgical procedures, the size of the endoprosthetic reconstructions, and neo-/adjuvant therapies. MATERIAL AND METHODS: Possible intra- and postoperative complications and treatment options are presented. RESULTS: Typical intraoperative complications include malalignment (axis, length, rotation) in implant positioning, unplanned soft tissue defects, impaired implant fixation due to poor bone stock, periprosthetic fractures, vessel/nerve injuries, and lesions/defects of the extensor mechanism. The relevant postoperative complication profile is characterized by local recurrences, periprosthetic infections, thromboembolic events, and mechanical failures (loosening, failure of the constraining mechanism). CONCLUSION: Depending on anatomic conditions and the systemic oncological status of the patient, these complications represent tremendous challenges to reconstructive management. Knowledge of the potential problems enables them to be avoided. This requires profound experience in oncosurgery and tumor endoprosthesis revisions.

Treatment of Geriatric Proximal Humerus Fractures: Indications and Outcome.

Treatment algorithms of proximal humerus fractures are still controversially discussed. The enthusiasm towards operative treatment after the introduction of locking implants, has not been justified by the functional results in the elderly population. The majority of those fractures in the geriatric patients can be successfully treated conservatively. Thorough clinical and radiological examination for fracture analysis, dynamic stability control with the use of an image intensifier, and meticulous reduction, in addition with the appropriate orthesis for its retention and rehabilitation, are the keys for the successful treatment of the proximal humerus fracture in the elderly patient. The present review reports on the main treatment aspects of proximal humerus fractures in the geriatric population and proposes a treatment algorithm.

Acetabular Fractures in an Advanced Age - Current Knowledge and Treatment Options.

The demographic change in industrial countries leads to an increasing population that sustains an acetabular fracture in an advanced age. Some authors predicted elderly individuals to be the most rapidly growing subgroup of patients currently sustaining acetabular fractures. Gold standard of treatment of acetabular fractures remains the open reduction and internal fixation. Relevant factors impeding surgical treatment include the significantly decreased bone stock and the incapability of the patients to partially weight bear following surgery. Therefore, special considerations should be performed when dealing with this patient group as surgical treatment is associated with several risks and often accompanied by poor outcomes. This review aims to summarize the current body of knowledge and to give a recommendation concerning a surgical treatment cascade.

[Operative therapy of fractures of the distal femur. Predictive factors for a complicated course]. / Operative Therapie von distalen Femurfrakturen. Prognostische Faktoren für einen komplikationsbehafteten Verlauf.

BACKGROUND: Fractures of the distal femur are rare injuries that are mainly treated operatively. Complication rates remain high. OBJECTIVES: This study aimed to analyse complications following the operative treatment of these fractures and to identify predictive factors that have the potential to identify patients who are at risk for a complicated course of treatment. MATERIALS AND METHODS: We retrospectively analysed all fractures of the distal femur that were treated operatively at our institution between 2005 and 2015. Besides patient and fracture-specific data, surgical details and the types of complications that occurred were recorded and analysed. RESULTS: Open soft tissue damage, the polytraumatised patient and the timing of surgery (i.e. emergency surgery) are significant risk factors for the development of a nonunion. A risk factor that predicts a postoperative infection is open soft tissue damage. Type C fractures, stabilisation as emergency surgery and an accompanying polytrauma are risk factors for a postoperative pneumonia. CONCLUSIONS: The complication rate is significantly determined by surgical factors. To reduce the rate of nonunion, infection and pneumonia, the optimisation of the patient's general condition before surgery and optimal surgical care is more important than an immediate emergency surgery.

Treatment of Tibial Non-Unions - State of the Art and Future Implications.

healing disturbances occur in 5-10% of the cases. The anatomical region of the lower limb predisposes the tibia for bone healing disturbances. Reports about the incidence of non-unions of the tibial shaft are inhomogeneous. Different treatment strategies have been published which depend on the type of non-union as well as the history of the patient. These range from conservative approaches to complex procedures including segmental resection and bone transport. This review aimed to summarize the state of the art treatment of tibial non-unions and report about recent basic research results that may improve bone healing. Key words: tibial non-unions, treatment strategies, bone healing.

Quality of life and functional outcome of periprosthetic fractures around the knee following knee arthroplasty.

PURPOSE OF THE STUDY The present study aimed to analyse both, the functional outcome and quality of life after surgical treatment of periprosthetic fractures following TKA. MATERIAL AND METHODS A retrospective review of all periprosthetic fractures following knee arthroplasty which have been surgically treated at our institution between January 2005 and January 2012 was conducted. Beside epidemiologic data, type of surgery and postoperative complications were recorded. The functional outcome was assessed using range of motion, Knee Society Score and VAS to evaluate pain. Quality of life was evaluated using SF-36 and WOMAC. Furthermore patients mobility and comorbidities were analysed. RESULTS 25 (mean age 76 ± 8 years; m:w 5:20) patients were included. The overall complication rate was 24%. Mean KSS knee score was 73 ± 19 and a function score was 41 ± 36. Range of motion revealed 95° ± 24° (active) and 98° ± 16° (passive). The total SF-36 scored a mean of 41 ± 6 and 29 ± 19 in average considering the WOMAC index (pain: 19 ± 20; stiffness: 23 ± 27; daily: 47 ± 29). 20% were able to mobilise without help as opposed to 80% that were in need for assistance. Our analysis revealed no influence of the final outcome as a function of fracture type or type of treatment. Multiple regression analysis could not reveal significant influence of the comorbidities. CONCLUSION Periprosthetic fractures following knee arthroplasty are accompanied by a significant decrease of the knee function and quality of life as well as high complication rates. Since patient's quality of life apparently depends on the functional outcome, future efforts should aim to improve these parameters. Key words: periprosthetic fracture, total knee arthroplasty, quality of life, functional outcome, locking plate.

Skeletal metastatic disease of the femur: results by management with intramedullary nailing.

PURPOSE OF THE STUDY This study aimed to analyse the outcome following intramedullary nailing for metastases of the femur in a large cohort with special regard to mechanical, implant associated complications and patient survival. Furthermore, we aimed to identify factors influencing the overall survival. MATERIAL AND METHODS All patients (n = 74) that underwent intramedullary nailing for metastatic disease of the femur between 2004 and 2008 and were retrospectively reviewed. Data were recorded from the patients' medical record and the outpatients' clinics files. Details about the tumour biology, the surgery performed as well as the postoperative care were documented. Survival data were extracted from patient records or obtained via communication with outpatient oncologists or the community registration office. RESULTS 74 (28 (37.8%) male, 46 (62.2%) female; p = 0.048) patients with a mean age of 64.4 ± 11.7 years were included. Breast (25, 33.8%), lung (18, 24.3%), bone marrow (7, 9.5%) and kidney (6, 8.1%) were the primary tumours in more than 75% of all patients. The mean overall survival was 17.5 (95% CI: 9.6 - 25.5) months. Patients with osseous metastases had a significant longer survival than patients with visceral and/or cerebral metastases (p = 0.025 and p = 0.032). CONCLUSION Intramedullary nailing represents a valuable fixation method for pathologic fractures or impending fractures of the femur in patients with an advanced stage of metastatic disease. It provides adequate stability to outlast the patient s remaining life-span. However, the balance must be found between therapeutic resignation and surgical overtreatment since operative treatment may be accompanied with serious complications. Key words: bone metastases, intramedullary nailing, metastatic disease, cement augmentation, osteolytic defect.

[Complications after osteosynthetic treatment of acetabular fractures]. / Komplikationen nach osteosynthetischer Versorgung von Azetabulumfrakturen.

The early work of Judet and Letournel in the 1970s and 1980s led to a paradigm shift in the treatment of acetabular fractures. The previously purely conservative treatment was replaced more and more by open surgical approaches. The complex, three-dimensional bony anatomy and the periacetabular soft tissue with a close topographic relationship to intrapelvic and extrapelvic neurovascular and visceral structures implicate an increased rate as well as a high risk for intraoperative and postoperative complications. Simultaneously, anatomical reconstruction with a gap step-off less than 1-2 mm is required. Fractures of the acetabulum are comparatively rare and only few trauma centers have the capability and the infrastructure to treat acetabular fractures. Therefore, the aim of this review was to illustrate the possible intraoperative and postoperative complications of osteosynthetic treatment of acetabular fractures as well as to identify possible strategies for treatment and prevention.

[Management of complications following resection and defect reconstruction of tumors near the hip joint]. / Komplikationsmanagement nach Resektion und Defektrekonstruktion hüftgelenknaher Tumoren.

BACKGROUND: Tumorous destruction of the periacetabular region and the proximal femur are a consequence of either primary malignant bone tumor manifestation or metastatic disease, which is observed much more frequently and occurs typically in these skeletal segments. Pathological fractures of the proximal femur and periacetabular regions of the pelvis have a high incidence and ultimately lead to severe pain and immobilization. TREATMENT METHODS: Advanced resection techniques and different types of defect reconstruction, allowing for oncologically sufficient resection of extensive tumors have contributed to a marked increase in the limb salvage rate. However, these procedures are associated with an increasing rate of several, sometimes severe intraoperative and postoperative complications. COMPLICATIONS: Compared to elective total hip arthroplasty, the rate of postoperative deep infections, dislocations, the incidence of pathological and periprosthetic fractures and the prevalence of deep vein thrombosis are increased with high rates of postoperative mortality and local tumor recurrence, being the most serious complications. Pelvic involvement and subsequent periacetabular resection have the highest complication rate when compared to proximal femur resection with endoprosthetic treatment. CONCLUSION: In order to minimize the risk of these intraoperative and postoperative complications wide resection and advanced reconstruction as well as complicated palliative stabilization due to malignant bone tumor growth around the hip joint should be performed in musculoskeletal tumor centers with profound expertise in osteosynthetic and endoprosthetic reconstruction of the pelvis and the proximal femur. Only in specialized centers an effective, multidisciplinary emergency management of these complications and, more importantly, reliable prevention of complications can be ensured.

[Benign cystic bone lesions]. / Benigne zystische Knochenläsionen.

BACKGROUND: Bone cysts are benign tumor-like lesions which often present as a fluid-containing cavity in the bone. They can occur in the skeletal bone as solitary or sometimes multiple bone lesions. OBJECTIVES: This review discusses the diagnostics, radiological appearance and therapeutic strategies of the most important benign cystic bone lesions, such as simple bone cysts, aneurysmal bone cysts, intraosseous ganglia, epidermoid cysts and subchondral cysts. The differential diagnoses with respect to cystoid formations and tumors with cystic components are discussed. METHOD: A selective literature search was performed taking own experiences into consideration. RESULTS: These tumor-like lesions can have the radiological appearance of bone tumors but show no autonomic, stimulus-independent growth and can resolve spontaneously. In the majority of cases open biopsy is necessary to confirm the diagnosis. In some cases no surgical intervention is necessary (e.g. do not touch and leave me alone lesions), whereas in other cases the focus of treatment is on the prevention and therapy of pathological fractures as well as prevention of recurrence. CONCLUSION: Cystic bone formations are among the most commonly occurring non-traumatic bone lesions. To eliminate differential diagnostic unclarity, histological investigation of biopsy material is essential. In terms of surgical intervention there exists a trend towards multimodal therapy mostly based on a meticulous curretage.

Lower limb salvage: indication and decision making for replantation, revascularisation and amputation.

Defining reproducible criteria for lower extremity salvage following severe high-energy trauma continues to be one of the most challenging and controversially discussed fields in orthopaedic surgery. At present, however, the difficult performance, limited availability and number of valid reconstructive options for complex injury types, i. e. simultaneous osteoligamentous trauma with neurovascular lesions and severe soft tissue defects ("composite/compound multilayer defects") represent the decisive prognostic injury components triggering and determining the fate of the limb. Consequently, due to the complex injury pattern of the extremity and the overall situation of multiple injured patient the treatment and decision making has to be made in a priority-adapted algorithm. In this treatment algorithm interdisciplinary cooperation with vascular and plastic surgeons is of tremendous importance. Although the number of severely injured patients remains stable in the last decade, changes in the treatment algorithms result from increased survival rates of multiple injured patients and improved modern reconstructive options leading to continuously increasing rates of salvaged limbs. This paper aimed to systematically review the current literature for lower extremity injuries in order to unravel the different surgical treatment options and provide guidelines for decision making with corresponding treatment algorithms for limb salvage. Furthermore, the experiences in the management of mangled extremities in our centre are presented and illustrated/underscored with different cases.

Surgical management and outcome of skeletal metastatic disease of the humerus.

PURPOSE OF THE STUDY Evaluation of outcome after surgical treatment of humerus metastases with a focus on tumour and patient derived factors, timing and strategy of intervention, surgical outcome and complications. MATERIAL AND METHODS Sixty-fie patients with a mean age of 64.3 years (range 25-89) with 66 metastases of the humerus were surgically treated in a 7-year time-period and retrospectively reviewed. RESULTS Renal cell carcinoma and breast cancer were the most abundant types of primary tumour. The mean time from diagnosis of primary tumour to fist metastasis was 14.5 months (range 0-173). The mean time from diagnosis of metastasis to surgery was 21.4 months (range 0-173). 38/28 intramedullary nails/locking plates were used for 58/8 manifest/impending pathological fractures. Mean cumulative survival was 16.3 months and implant failure rate was 6.1% with a mean time from initial surgery to revision of 22.2-20.6 months. CONCLUSIONS Our data indicate that treatment with intramedullary fiation or cement augmented plate osteosynthesis is successful for the vast majority of patients, but thorough clinical evaluation and precise decision making adapted to the patient's estimated life expectancy must be applied to avoid overtreatment or risk of implant failure. Key words: bone metastases, skeletal metastatic disease, humerus metastasis, pathologic fracture, impending fracture.

[Solitary spinal metastases. Is aggressive surgical management justified?]. / Solitäre Metastasen der Wirbelsäule. Indikationen für eine aggressive chirurgische Therapie?

Advances in oncological and surgical therapies have led to a significant increase in life expectancy of cancer patients and also prolonged survival of patients with isolated or multiple metastases. Among the skeletal manifestations the spine is the most often affected site. Using novel imaging techniques with higher resolution and use of metabolic signatures, the screening of cancer patients has improved considerably. Consequently, the diagnosis of metastases is becoming increasingly more sensitive. Therefore, but also due to more effective polychemotherapy protocols, singular or solitary metastases are more frequently observed either in the early stages or as a result of a controlled malignant tumor entity (stable disease). The questions whether a solitary metastasis really exists (illusion or reality?) and its radical oncological and surgical treatment as a circumscribed singular tumor manifestation, is really relevant for the overall prognosis, remains controversial. However, it seems evident that a biologically favorable underlying tumor biology, radical treatment of the primary tumor and a long metastasis-free interval are valid predictors of a good oncological outcome. In the presence of a solitary metastasis under these circumstances (typical example: solitary metastasis of renal cell carcinoma many years after radical tumor nephrectomy) a radical surgical procedure (en bloc spondylectomy) can significantly improve the long-term prognosis of this patient group in combination with adjuvant chemotherapy and/or radiotherapy. However, a thorough evaluation of the overall survival prognosis, a detailed and complete staging followed by a treatment consensus in the interdisciplinary tumor board has to precede any therapeutical decisions.

[Manifestation of osteosarcoma of chronic osteomyelitis: 2 case reports]. / Osteosarkommanifestation bei chronischer Osteomyelitis: 2 Fallberichte.

The treatment and outcome of two patients suffering from osteosarcoma of the lower extremity evolving many years after manifestation of chronic osteomyelitis are reported. After neoadjuvant polychemotherapy in one patient en bloc resection, interposition of a cement spacer and stabilization was performed in both cases. After eradication of infections final segmental reconstruction was accomplished by knee arthrodesis using rotation plasty of the split femoral condyle, free local fibula transposition and gastrocnemius muscle transfer. A custom-made diaphyseal replacement (3D-rapid prototyping titanium mesh) was used for defect reconstruction. After 1 year postoperative follow-up and restaging both patients showed no evidence of recurrent disease and had no local or systemic signs of infection.

Effect of a novel nonviral gene delivery of BMP-2 on bone healing.

BACKGROUND: Gene therapeutic drug delivery approaches have been introduced to improve the efficiency of growth factors at the site of interest. This study investigated the efficacy and safety of a new nonviral copolymer-protected gene vector (COPROG) for the stimulation of bone healing. METHODS: In vitro, rat osteoblasts were transfected with COPROG + luciferase plasmid or COPROG + hBMP-2 plasmid. In vivo, rat tibial fractures were intramedullary stabilized with uncoated versus COPROG+hBMP-2-plasmid-coated titanium K-wires. The tibiae were prepared for biomechanical and histological analyses at days 28 and 42 and for transfection/safety study at days 2, 4, 7, 28, and 42. RESULTS: In vitro results showed luciferase expression until day 21, and hBMP-2-protein was measured from day 2 - day 10. In vivo, the local application of hBMP-2-plasmid showed a significantly higher maximum load after 42 days compared to that in the control. The histomorphometric analysis revealed a significantly less mineralized periosteal callus area in the BMP-2 group compared to the control at day 28. The rt-PCR showed no systemic biodistribution of luciferase RNA. CONCLUSION: A positive effect on fracture healing by nonviral BMP-2 plasmid application from COPROG-coated implants could be shown in this study; however, the effect of the vector may be improved with higher plasmid concentrations. Transfection showed no biodistribution to distant organs and was considered to be safe.

Periprosthetic fractures around the knee: update on therapeutic algorithms for internal fixation and revision arthroplasty.

Effective treatment of periprosthetic fractures following TKA continues to represent a surgical challenge. The incidence and frequency of these complicated type of fractures is expected to increase as the number of TKA as well as the activity level of these patients steadily rises. A careful and correct analysis of the fracture pattern, its classification, the quality of the existing bone stock and the fixation / loosening of the underlying prosthetic system has to precede decision making for successful conservative or surgical treatment. Therefore, improved diagnostic radiographic imaging of fracture patterns and reliable assessment of prosthesis loosening progressive development of new implant methods and refinement of soft tissue preserving surgical techniques will hold the key for regaining the functional level prior to the fracture.

[Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies]. / Extremitätenfrakturen mit schwerem offenem Weichteilschaden. Initiales Management und rekonstruktive Versorgungsstrategien.

The successful management of open extremity injuries continues to represent a surgical challenge requiring a structured and multidisciplinary treatment concept. The treatment strategy depends on specific parameters, including the overall injury severity, life threatening trauma components, the degree oft soft tissue injury, the ischemia time, the contamination of the wound as well as the age and accompanying diseases of the patient. The treatment of fractures with a high-grade open soft tissue injury is guided by the severity of soft tissue damage including neurovascular damages, type of the fracture, overall state of the patient and is based on a clearly defined reconstructive algorithm sequentially employing initial wound treatment (debridement), stabilisation of the fracture and soft tissue coverage. The initial wound management includes radical and serial debridements and vessel reconstruction, followed by the gradual reconstruction of bone, tendons and nerves and a subsequent plastic soft tissue coverage.The sequential and priority-orientated implementation of these treatment steps is decisive for the long term outcome, which ideally results in an regular healing of bone and soft tissue without the presence of infection and good regain of extremity function.

Aprotinin application has no negative effect on osseous implant integration: a biomechanical and histomorphometric investigation in a rat model.

Intraoperative blood loss requiring allogenic blood transfusion (ABT) is a common problem in major orthopedic surgery. Since transfusion related side effects up to fatal consequences due to blood type incompatibility cannot be excluded completely, it is desirable to reduce the amount of blood loss and transfusions to a minimum. Encouraging results in the application of aprotinin, a natural protease-inhibitor with antifibrinolytic, bleeding-reducing properties, in thoracic-, heart- and abdominal surgery led to the use of aprotinin also in orthopedic surgery. One important safety issue in the use of aprotinin in orthopedic surgery is a possible negative effect on the osseous integration of an implant due to the multiple interactions of aprotinin with several enzymatic systems. In this study, we therefore investigated the influence of aprotinin on the osseous ingrowth of a titanium-implant in a rat model. Forty female Sprague-Dawley rats underwent unilateral retrograde nailing of the femur. Animals were divided in two groups, one receiving i.v. aprotinin intraoperatively, the other group receiving the same amount as saline solution. After 56 days animals were killed and from each group half of the femora were prepared for biomechanical testing, the other half for histological examination. The push-out experiment revealed no significant difference between the aprotinin-group and the control-group, both showing comparable shear stresses. In addition, the histomorphometrical analysis showed comparable implant integration between both groups. The results demonstrate that perioperative aprotinin application has no negative effect on osseous implant integration in a rat model.

Clinical experiences in the use of a gentamicin-coated titanium nail in tibia fractures.

Despite the improvement of surgical techniques surgical site infections (SSIs) still remain clinically challenging in high risk patients undergoing osteosynthesis for tibia fractures. The use of an antibiotic coated implant might reduce the adhesion of bacteria on the implant surface and could therefore reduce the rate of implant-related infection or osteomyelitis. A gentamicin-coated tibia nail was evaluated in a prospective study. Four centers enrolled 100 patients (99 treated) with fresh open or closed tibia fractures, or for non-union revision surgery and followed them for 18 months. Data collected included infection events, radiographs, SF-12, EQ-5D, Iowa Ankle score, and the WOMAC questionnaire. Sixty-eight of the 99 treated patients suffered from a fresh fracture, while in 31 patients, the intramedullary nail was implanted for revision purposes, including non-unions due to infection. Fifteen (22%) of the fresh fractures were GA Type III. The follow-up rate was 87% and 82% at 12 months and 18 months, respectively. Deep surgical site infections occurred in 3 fresh fractures and two in revision surgeries. We did not observe any local or systemic toxic effects related to gentamicin during this study. The use of the antibiotic coated nail is an option in patients with a high infection risk, like open factures or infected non unions, in the prevention of the onset of an implant-related infection or osteomyelitis.

Cardiac disease and advanced age increase the mortality risk following surgery for periprosthetic femoral fractures.

AIMS: Periprosthetic fracture is a significant complication of total hip and knee arthroplasty. This study aimed to describe the survival of patients sustaining periprosthetic femoral fractures and compare this with that of the general population, as well as to identify the factors that influence survival. PATIENTS AND METHODS: A total of 151 patients (women: men 116:35, mean age 74.6 years, standard deviation 11.5) that sustained a periprosthetic fracture between January 2005 and October 2012 were retrospectively analysed. Epidemiological data, comorbidities, type of surgical management, type of implant, and mortality data were studied. RESULTS: The mean survival time was 77 months (95% confidence interval 71 to 84; numbers at risk: 73) and was lower than that of the general population. The risk analyses showed that previous cardiac disease, particularly ischaemic heart disease, cardiac arrhythmias, and heart failure, age over 75 years and American Society of Anesthesiologists (ASA) scores above 3 were associated with a significantly higher mortality. CONCLUSIONS: Periprosthetic fractures carry a high risk of post-operative mortality. Our data demonstrate that advanced age (> 75 years) and previous cardiac disease are associated with a significantly higher risk of mortality. The ASA score is an appropriate instrument for risk stratification. Pre-operative cardiac status should be optimised before surgery. Cite this article: Bone Joint J 2017;99-B:921-6.