Thrombus or tumor? A case report of a rare sarcoma entity: intimal sarcoma of the pulmonary arteries.

BACKGROUND: Tumor embolism is a very rare primary manifestation of cancers and the diagnosis is challenging, especially if located in the pulmonary arteries, where it can mimic nonmalignant pulmonary embolism. Intimal sarcoma is one of the least commonly reported primary tumors of vessels with only a few cases reported worldwide. A typical location of this malignancy is the pulmonary artery. Herein, we present a case report of an intimal sarcoma with primary manifestation in the pulmonary arteries. A 53-year-old male initially presented with dyspnea. On imaging, a pulmonary artery embolism was detected and was followed by thrombectomy of the right ventricular outflow tract, main pulmonary artery trunk, and right pulmonary artery after ineffective lysis therapy. Complementary imaging of the chest and abdomen including a PET-CT scan demonstrated no evidence of a primary tumor. Subsequent pathology assessment suggested an intimal sarcoma further confirmed by DNA methylation based molecular analysis. We initiated adjuvant chemotherapy with doxorubicin. Four months after the completion of adjuvant therapy a follow-up scan revealed a local recurrence without distant metastases. DISCUSSION: Primary pulmonary artery intimal sarcoma (PAS) is an exceedingly rare entity and pathological diagnosis remains challenging. Therefore, the detection of entity-specific molecular alterations is a supporting argument in the diagnostic spectrum. Complete surgical resection is the prognostically most important treatment for intimal cardiac sarcomas. Despite adjuvant chemotherapy, the prognosis of cardiac sarcomas remains very poor. This case of a PAS highlights the difficulty in establishing a diagnosis and the aggressive natural course of the disease. CONCLUSION: In case of atypical presentation of a pulmonary embolism, a tumor originating from the great vessels should be considered. Molecular pathology techniques support in establishing a reliable diagnosis.

Digital adaptation of teaching disaster and deployment medicine under COVID-19 conditions: a comparative evaluation over 5 years.

BACKGROUND: The COVID-19 pandemic has not only brought many aspects of disaster medicine into everyday awareness but also led to a massive change in medical teaching due to the necessity of contact restrictions. This study aimed to evaluate student acceptance of a curricular elective module on disaster and deployment medicine over a 5-year period and to present content adjustments due to COVID-19 restrictions. METHODS: Since 2016, 8 semesters of the curricular elective module took place in face-to-face teaching (pre-COVID-19 group). From the summer semester of 2020 to the summer semester of 2021, 3 semesters took place as online and hybrid courses (mid-COVID-19 group). Student attitudes and knowledge gains were measured using pretests, posttests, and final evaluations. These data were statistically compared across years, and new forms of teaching under COVID-19 conditions were examined in more detail. RESULTS: A total of 189 students participated in the module from the summer semester of 2016 through the summer semester of 2021 (pre-COVID-19: n = 138; mid-COVID-19: n = 51). There was a high level of satisfaction with the module across all semesters, with no significant differences between the groups. There was also no significant difference between the two cohorts in terms of knowledge gain, which was always significant (p < 0.05). COVID-19 adaptations included online seminars using Microsoft Teams or Zoom, the interactive live-streaming of practical training components, and digital simulation games. CONCLUSION: The high level of satisfaction and knowledge gained during the module did not change even under a digital redesign of the content offered. The curricular elective module was consistently evaluated positively by the students, and the adaptation to online teaching was well accepted. Experiences with digital forms of teaching should also be used after the COVID-19 pandemic to create digitally supported blended learning concepts in the field of deployment and disaster medicine and thus further promote the expansion of teaching in this important medical field.

Impact of a specialised palliative care intervention in patients with advanced soft tissue sarcoma - a single-centre retrospective analysis.

BACKGROUND: Soft tissue sarcomas (STS) account for less than 1% of all malignancies. Approximately 50% of the patients develop metastases with limited survival in the course of their disease. For those patients, palliative treatment aiming at symptom relief and improvement of quality of life is most important. However, data on symptom burden and palliative intervention are limited in STS patients. AIM: Our study evaluates the effectiveness of a palliative care intervention on symptom relief and quality of life in STS patients. DESIGN/SETTING: We retrospectively analysed 53 inpatient visits of 34 patients with advanced STS, admitted to our palliative care unit between 2012 and 2018. Symptom burden was measured with a standardised base assessment questionnaire at admission and discharge. RESULTS: Median disease duration before admission was 24 months, 85% of patients had metastases. The predominant indication for admission was pain, weakness and fatigue. Palliative care intervention led to a significant reduction of pain: median NRS for acute pain was reduced from 3 to 1 (p < 0.001), pain within the last 24 h from 5 to 2 (p < 0.001) and of the median MIDOS symptom score: 18 to 13 (p < 0.001). Also, the median stress level, according to the distress thermometer, was reduced significantly: 7.5 to 5 (p = 0.027). CONCLUSIONS: Our data underline that specialised palliative care intervention leads to significant symptom relief in patients with advanced STS. Further efforts should aim for an early integration of palliative care in these patients focusing primarily on the identification of subjects at high risk for severe symptomatic disease.

[Ulceroglandular tularemia after contact with a wild boar : Risk of infection for medical personnel by aerosol inhalation during lymph node resection]. / Ulzeroglanduläre Tularämie nach Kontakt mit Wildschwein : Infektionsrisiko für medizinisches Personal durch Inhalation von Aerosolen bei Lymphknotenresektion.

This article presents a case of ulceroglandular tularemia with local lymph node manifestation in a hobby hunter. An adequate diagnosis and early treatment of tularemia is of crucial importance not only for the patient, as when a surgical intervention is necessary there are also substantial risks for medical personnel. In the diagnosis of tularemia, which is rare but with an increasing incidence in Germany, the anamnesis provides the most important clues. A surgical intervention should only be performed after adequate treatment and duration of treatment.

[Digital OR]. / Digitaler OP.

BACKGROUND: Numerous processes are involved in the orthopedic and trauma surgery operating room (OR). Technical progress, particularly in the area of digitalization, is increasingly changing routine surgical procedures. OBJECTIVE: This article highlights the possibilities and also limitations regarding this matter. MATERIAL AND METHODS: Based on the current literature this article provides insights into innovations in the areas of digitalization of surgical devices, hybrid OR, machine-2-machine networking, management systems for perioperative efficiency improvement, 3D printing technology and robotics. RESULTS: The technical possibilities for the use of digital applications in the surgical environment are rapidly increasing. Close cooperation with industrial partners is important in this context. Technologies from the automotive, gaming and mobile phone industries are being adopted. CONCLUSION: Digital technology in the OR can improve treatment quality, patient and staff safety and cost efficiency; however, the networking of devices, implementation of innovations in existing structures and the sometimes high acquisition costs are still limiting factors.

Mid-Term Survival of Total Knee Arthroplasty in Patients with Posttraumatic Osteoarthritis.

PURPOSE OF THE STUDY There is limited evidence on survival and complication rates in patients after total knee arthroplasty for posttraumatic osteoarthritis. The failure mechanisms leading to revision remain an issue of constant debate. The purpose of this study was to analyze the mid-term survival of primary total knee arthroplasties as well as to evaluate complications and failure mechanisms in patients with posttraumatic knee osteoarthritis. MATERIAL AND METHODS This retrospective study included 79 patients with an average age of 59 years at the time of primary total knee arthroplasty. A functional and radiographic assessment was obtained during outpatient clinical follow-up at 3 and 12 months postoperatively and yearly intervals after that. Survival rates were calculated using Kaplan-Meier analyses. The mean postoperative follow-up was 69 months. RESULTS At 69 month the revision-free survival rate was 88.6%. In nine cases (11.4%) a revision procedure was performed. The leading cause of revision was a periprosthetic infection (n = 6, 66.6%). An age of fewer than 55 years at the time of total knee arthroplasty had a significant influence on implant survival (p = 0.018) with superior survival in favor of the older patient population. At most recent follow-up, a mean Knee Society Score of 82 points and an average Function Score of 77 points were observed. CONCLUSIONS Periprosthetic joint infection is the primary failure mechanism leading to a revision in patients with total knee arthroplasty for posttraumatic osteoarthritis. Apart from the increased infection rate, total knee arthroplasties in patients with posttraumatic osteoarthritis revealed results that were comparable to patients with primary osteoarthritis. Key words:posttraumatic knee osteoarthritis, total knee replacement, survival, complications, revision, outcome.

[Steel or titanium for osteosynthesis : A mechanobiological perspective]. / Stahl oder Titan bei der Osteosynthese : Eine mechanobiologische Perspektive.

BACKGROUND: An implant used for stabilizing a fracture creates a mechanical construct, which directly determines the biology of bone healing. The stabilization of fractures places high mechanical demands on implants and therefore steel and titanium are currently almost exclusively used as the materials of choice. OBJECTIVES: The possible range of attainable mechanobiological stimulation for mechanotherapy as a function of plate stiffness depending on the selection of the plate material and the physical and mechanical properties of the material options are discussed. MATERIAL AND METHODS: An overview of the material properties of steel and titanium is given. For dynamically fixed long bone fractures as examples, various finite element models of plate osteosynthesis (steel/titanium) are created and the plate working length (PWL, screw configuration close to fracture) is varied. The interfragmentary movement (IFM) as a measure of mechanobiological stimulation is evaluated. RESULTS: Stimulation in the form of IFM varies across the fracture and also as a function of the osteosynthesis material and the configuration. The influence of the material appears to be notably smaller than the influence of PWL but both lose their influence largely over a bridged fracture situation (contact). With a flexible titanium plate and large PSS, a greater mechanobiological stimulation is produced. CONCLUSION: An essential prerequisite for the secondary fracture healing is an appropriate mechanobiological environment, which can be controlled by the osteosynthesis material and the configuration and is also affected by the type of fracture and load.

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.

[Thrombosis of the subclavian vein after conservative treatment of a clavicular fracture: A rare complication]. / Thrombose der V. subclavia bei konservativ therapierter Klavikulaschaftfraktur: Eine seltene Komplikation.

We report the case of a 16-year-old male patient who presented with a clavicular fracture that was conservatively treated with a redressment bandage. After a few days the patient developed deep vein thrombosis of the subclavian, axillary and brachial veins, which was successfully treated with nadroparin. Conservative treatment of clavicular fractures is a common procedure in modern traumatology. Continuous, close monitoring and knowledge of rare but severe complications are necessary to avoid further complications.

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.