[Histopathological classification principles of rheumatic joint diseases : Contribution of pathology to the diagnosis]. / Histopathologische Klassifikationsprinzipien rheumatischer Gelenkerkrankungen : Beitrag der Pathologie zur Diagnose.

Even though the diagnostics of rheumatic joint diseases are mostly based on clinical, immunoserological and imaging criteria, histopathology can also make a significant contribution. This is particularly true for clinically unclear monoarticular and periarticular diseases. The contribution of histopathology to the diagnosis of rheumatic diseases is manifold since the histopathological differential diagnosis includes the complete spectrum of synovial diseases. This heterogeneous pathogenetic spectrum is described in the joint pathology algorithm, which includes inflammatory and non-inflammatory diseases. To the latter group belong certain benign tumors such as the diffuse variant of the tenosynovial giant cell tumor, lipoma, hemangioma, vascular malformations and synovial chondromatosis. Additionally, the rare group of storage diseases should be kept in mind. Inflammatory diseases can be discriminated into crystal-induced arthropathies mainly such as gout and pseudogout, into granulomatous diseases such as tuberculosis and foreign-body inoculations, and finally into the large group of non-granulomatous, non-infectious synovitis. This large group is by far the most common, and it often causes difficulties in assigning the histopathological findings to a concrete rheumatologic diagnosis. In this context the synovitis score should be applied as a diagnostic device in these cases, leading to the diagnosis of a low-grade synovitis (which is associated with degenerative arthropathies) or of a high-grade synovitis (associated with rheumatic diseases). Identification of crystals and crystal-like deposits should be carried out with the application of the joint particle algorithm which addresses the identification of endogenous and non-endogenous particle deposits in the synovial tissues. Additionally, the synovitis-score may be used for evaluation of arthritis-progresssion and for the evaluation of inflammation-regression as a consequence of therapy with biologicals.

[Abdominal wall injury - risk of seat belt use]. / Bauchwandzerreißung - Risiko Sicherheitsgurt?

Abdominal seat belt marks can be an indication of abdominal wall rupture. The focused assessment with sonography for trauma (FAST) and computed tomography (CT) scanning are the diagnostic tools of choice in hemodynamically stable patients. The typical mechanism of trauma frequently leads to additional intra-abdominal injuries, spinal injuries and in some cases aortic rupture. Abdominal wall injuries of grade IV according to Dennis should be surgically treated. The increasing numbers of obese vehicle occupants and the resulting special risk of injury warrant optimization of technical restraint systems.

Union of the ulnar styloid fracture as a function of fracture morphology on conventional radiographs.

OBJECTIVE: In a retrospective radiological study, the authors aimed to detect the influence of fracture morphology on the union rate of ulnar styloid fractures associated with distal radial fractures. MATERIALS AND METHODS: Eighty-two out of 101 ulnar styloid fractures were included in the final statistical analysis. Initially, they were grouped into six different morphological types based on a novel classification system. They were also classified as per the established Fernández and Frykman classification systems. Furthermore, the initial ulnar styloid displacement was measured in conventional anteroposterior radiographs. Union of the ulnar styloid fracture was evaluated after at least 6 months of follow-up. RESULTS: The current investigators demonstrated that the various ulnar styloid fracture patterns have no significant predictive value for ulnar styloid union. In contrast, it could be attested, that an initial fragment dislocation of greater than 2.4 mm in the conventional AP radiographs has a significantly lower chance of successful union (p = 0.022). CONCLUSION: Initial displacement of the ulnar styloid should be measured in each distal radial fracture with a concomitant ulnar styloid fracture. This could be useful to inform the decision regarding surgical fixation of the ulnar styloid fragment in patients with an unstable distal radioulnar joint (DRUJ) or persistent symptoms at the ulnar aspect of the wrist.

[Adult onset septic coxitis : etiology, diagnostics, indication for and technique of open revision of the hip]. / Die septische Koxitis des Erwachsenen : Ätiologie, Diagnostik, Operationsindikation und Operationstechnik der offenen Hüftgelenkrevision.

Septic arthritis of the hip can be caused via a hematogenous route, by penetration of periarticular infections, open hip trauma, injections or operations. Ultrasound, hip puncture and elevation of inflammatory parameters lead to the diagnosis. Differentiation of septic arthritis from gout and chondrocalcinosis may be difficult. Nevertheless, early revision of the hip has to be performed to avoid joint destruction. Open revision is the therapy of choice in the majority of cases.

[Is routine implant removal after trauma surgery sensible?]. / Ist eine routinemäßige Implantatentfernung nach unfallchirurgischen Eingriffen sinnvoll?

We present a literature review about implant removal after operative extremity and spine fracture treatment. The indication for implant removal procedures has become less frequent in recent years, but is still more common in Europe than for example in North America. The time required to perform a implant removal can easily exceed the planned amount. Implant removal can result in significant complications like soft tissue damage, fractures, infections, and other problems. Not only because of these problems, the decision on whether or not to remove the implant should be made with great care. Therefore good communication with the patient and thorough information about risks and benefits are essential.

Arthroplasty of the trapeziometacarpal joint with or without bioabsorbable polylactide scaffold (RegJoint™) interposition.

The RegJoint™, a bioabsorbable polylactide scaffold, was introduced in 2011 for scaphometacarpal interposition following trapeziectomy for osteoarthritis. As previous clinical trials provided controversial results, we aimed to prove the non-inferiority of RegJoint™ interposition. In this retrospective study, first metacarpal suspension arthroplasty alone (SA) was compared to suspension with RegJoint™ interposition (RJ). Thirty-four patients with 37 treated thumbs (SA: 14; RJ: 23) were assessed clinically and radiologically at a mean follow-up of 5.3 ± 2.6 years (SA: 7.96; RJ: 3.73). Patient-reported outcomes were measured on three questionnaires (DASH, PRWE and PEM) and a visual analogue pain scale; there were no significant differences between the 2 groups. Clinical assessment comprised range of motion, opposition, pain, first-ray length, hand span, prominence, instability, force and sensitivity to touch. The RJ group showed significantly better palmar abduction (p = 0.026); the other outcome parameters were comparable in the 2 groups. Follow-up radiographs showed osteolysis in 2 SA hands and 3 RJ hands (p = 0.551). First-ray length had decreased by a mean 4.7 ± 2.7 mm at follow-up (SA: -3.8; RJ: -5.2; p = 0.056). No signs of adverse tissue reactions were observed. We conclude that RegJoint™ spacers do not produce more complications than suspension alone but provide no added benefit.

The dorsal tangent line - A new approach in the radiological analysis of metacarpal fractures.

Traditionally, the angle between the intersecting central axes (lateral projection intersecting central axes - LCA) of the proximal and distal fragments of metacarpal fractures is measured on radiographs. We recommend using the angle between the intersecting dorsal tangent lines instead (lateral projection intersecting dorsal tangent lines - LDT). We analyzed radiographs of 25 fractures of the fifth metacarpal bone shaft in three planes. Intraclass correlation coefficients (ICC) were used to estimate inter-rater and intra-rater reliability. Mean palmar tilt was 35.6° ± 12.5° according to LCA and 27.6° ± 12.0° according to LDT. There were no differences during repeated measurements. Intra-rater reliability was high: ICC (95% CI) for LDT was 0.82 (0.74-0.88) and for LCA it was 0.71 (0.51-0.83). Mean values of palmar tilt using LCA exceeded those using LDT by 8.0° ± 7.7° (p < 0.001). Only LDT measurements provided comparable results between all raters. In conclusion, we demonstrated the feasibility and reliability of intersecting dorsal tangent lines for measuring palmar tilt in fifth metacarpal fractures as an alternative to the commonly used angle between the intersecting central axes.

Modified rerouting procedure for failed peroneal tendon dislocation surgery.

UNLABELLED: Recurrent dislocation of the peroneal tendons following operative treatment is relatively uncommon, but can be difficult to treat. We asked whether subligamental transposition of the peroneus brevis tendon, fibular grooving, and reattachment of the superior peroneal retinaculum for failed peroneal tendon dislocation surgery would achieve a stable fixation of the peroneal tendons and whether there would be restrictions of ROM or instability of the hindfoot. We reviewed six female patients (mean age, 24.5 years) with general laxity of joints preoperatively and at 6 weeks and 3, 6, and 12 months postoperatively. Within 1 year postoperatively no recurrence was found. In two ankles the extension was restricted 5 degrees to 10 degrees . In another pronation and supination was restricted 5 degrees each. Stability of the ankle increased in four patients and stayed unchanged in two. AOFAS score increased from a mean value of 36 +/- 20.6 preoperatively to 90 +/- 7 postoperatively at 1 year. We conclude transposition of the peroneus brevis tendon is a reasonable treatment for failed peroneal tendon dislocation surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study (prospective case series). See Guidelines for Authors for a complete description of levels of evidence.

Long-term outcome after joint reconstruction or medial resection arthroplasty for anterior SCJ instability.

INTRODUCTION: In the present study, the long-term results of 11 patients with anterior sternoclavicular joint (SCJ) instability are reported. All included patients had an anterior SCJ instability and due to delayed diagnosis, operative treatment was not done immediately. METHOD: The patients had a mean age of 29.2 years (range 16-63 years). One patient sustained concomitant injuries. Six patients had resection arthroplasty. Five patients had reconstruction of the SCJ with transosseous tension band PDS fixation or ligament reconstruction with additional wire cerclage. The results of treatment were evaluated after a mean follow-up period of 9.9 years (range 1-27 years) using the ASES, DASH and power-, age and gender adjusted Constant-Murley Score. RESULTS: In general, the mean values of the different scores (ASES 79.8; DASH 11.8; Constant-Murley 81%) demonstrated good outcome. The outcome evaluation of the patients who had SCJ reconstruction did not differ significantly from the patients who had medial resection arthroplasty. The rate of postoperative pain or instability was low using visual analog scale and did not differ significantly between the groups. The outcome results of the reconstruction group were equal to the results of the resection group when SCJ-reconstruction was performed soon after SCJ injury. One patient in the resection group (6 patients) demonstrated poor results due to continued instability of the remaining clavicle. CONCLUSION: We concluded that patient selection and a specific clinical indication for operative treatment are crucial. Resection of the medial clavicle results in good functional outcome when the costoclavicular ligament is preserved or reconstructed.

[Conservative functional treatment of Achilles tendon ruptures]. / Konservativ-funktionelle Behandlung der Achillessehnenruptur.

The conservative functional treatment of Achilles tendon ruptures has developed further over the last 20 years and is basically possible for 60-80% of patients. The treatment leads to success if the indications obtained by dynamic sonography are correctly interpreted (adaptation of the tendon ends up to 20 degrees plantar flexion), if the patient presents sufficient compliance and the physiotherapy is increasingly intensified depending on tendon healing. Modern ortheses allow an increased equinus position and therefore improved protection of the healing tendon. If these factors are present a relatively low re-rupture rate of only 7% can be achieved. The decisive advantage of conservative functional therapy is the avoidance of specific operative risks, such as infection and injury to the sural nerve. After removal of the orthesis the tendon should continue to be modeled using shoe insoles and raised heels.

Autoantibodies against P29ING4 are associated with complex regional pain syndrome.

INTRODUCTION: Complex regional pain syndrome (CRPS) is a complication following trauma or surgery and may be difficult to diagnose since biomarkers are lacking. Using protein array technology, we found antibodies binding to p29ING4, which we further characterized using ELISA. METHODS: Thirty-six sera of early-stage type 1 CRPS, 66 sera of rheumatoid arthritis (RA), 53 sera of axial spondyloarthritis (axSpA), 29 sera of psoriatic arthritis (PsA), 22 sera of patients after radial fractures (trauma control), and 100 sera of blood donors (BD) were analyzed for anti-p29ING4. We established ELISAs with 7 different antigens and using different secondary antibodies binding to IgG, IgG1, IgG2, IgG3, IgG4, IgA, and IgM, and 2 different tests to detect immune complexes (IC) of p29ING4 and IgG or IgG1. RESULTS: The highest likelihood ratios versus CRPS and trauma control were observed considering the A1-23 (sensitivity 19%, specificity 100%, LR > 19) using IgG as a secondary antibody, the A120-165 (sensitivity 17%, specificity 100%, LR = 17) using IgG as a secondary antibody and the A120-165 (sensitivity 31%, specificity 95%, LR = 6.2) using IgA as a secondary antibody. IC of p29ING4 and IgG were present in 11/36 (31%) CRPS sera, 17/64 (27%) RA sera, 13/53 (25%) SpA sera, 5/29 (17%) PsA sera, 1/22 (5%) trauma control sera, and 4/100 (4%) sera of BD. IC of p29ING4 and IgG1 were present in 14/36 (39%) CRPS sera, 19/64 (30%) RA sera, 13/53 (25%) SpA, 1/29 (3%) PsA, 2/22 (9%) trauma control, and 4/100 (4%) of the BD sera. CONCLUSION: Due to the lack of other biomarkers of type 1 CRPS, P29ING4 autoantibodies could be helpful in its diagnostic work-up.

[Recurrence of solitary enchondroma at the hand after operative treatment]. / Rezidive operativ versorgter solitärer Enchondrome des Handskeletts.

PURPOSE: Solitary enchondroma is the most common bone tumour at the hand. Nevertheless there are only a few studies referring to a recurrence of this lesion after operative treatment. PATIENTS AND METHOD: 21 patients (17 women/4 men) were examined retrospectively 2 to 18 (mean: 9) years after operative treatment. Clinical and radiological examinations were performed. 3 to 4 years later 9 of these patients were re-examined. 1 patient was first seen at the time of the second examination. Recurrence was the endpoint of the study. RESULTS: At the first examination 11 patients had normal cancellous bone structure 4 to 18 (mean: 8) years after operative treatment. 7 patients had remaining bone defects and their follow-up was 2 to 15 (mean: 8) years. Recurrence was found in 3 patients 11 to 17 years postoperatively. Through the re-examination of 9 patients 2 further recurrences were found 4 to 6 or, respectively, 11 to 14 years postoperatively arising from remaining defects. Another remaining defect became normal cancellous bone structure 2 to 5 years postoperatively. Over all 6 recurrences were found in 22 patients. All patients were free of clinical symptoms. CONCLUSION: Recurrence may occur even more than 10 years postoperatively. Therefore we recommend periodical radiological re-examination for recurrence before weakness of bone can lead to a pathological fracture. Re-examination intervals of 2 to 5 years would probably be adequate.

[Suspension arthroplasty of the thumb carpometacarpal joint in different views--a questionnaire]. / Die Suspensionsarthroplastik am Daumensattelgelenk--Gute Ergebnisse im Spannungsfeld unterschiedlicher Wertschätzungen.

PURPOSE: Obviously there are different judgements of the results of suspension arthroplasties of the thumb carpometacarpal joint. Consequently, the three main groups involved in therapy were asked about this topic. PATIENTS AND METHODS: 51 patients who had had a suspension arthroplasty on the thumb carpometacarpal joint in the period 1998 - 2006 were questioned. 12 of these patients were operated on both hands (63 operations). A questionnaire sent to 250 family doctors was compared with the results from the 51 patients. Furthermore there was an interview by telephone which included 25 practising specialists (orthopaedicians and surgeons). RESULTS: The results contrasted widely. Concerning the operation, 50 from 51 patients had a high subjective satisfaction. The family doctors had a different view. Nearly 80 % disregarded the success of the operation or they could not judge the chances. Only 50 % of all family doctors arranged for an X-ray or a consultation at a specialist when the patient had continuing problems. The results of the 25 specialists were also not uniform. 50 % of them, especially the hand surgeons, believe in the success of the primary osteoarthritis operation. The high barrier to operations for rhizarthrosis is based on a lack of information.