Cytokine-directed cellular cross-talk imprints synovial pathotypes in rheumatoid arthritis.

INTRODUCTION: Structural reorganisation of the synovium with expansion of fibroblast-like synoviocytes (FLS) and influx of immune cells is a hallmark of rheumatoid arthritis (RA). Activated FLS are increasingly recognised as a critical component driving synovial tissue remodelling by interacting with immune cells resulting in distinct synovial pathotypes of RA. METHODS: Automated high-content fluorescence microscopy of co-cultured cytokine-activated FLS and autologous peripheral CD4+ T cells from patients with RA was established to quantify cell-cell interactions. Phenotypic profiling of cytokine-treated FLS and co-cultured T cells was done by flow cytometry and RNA-Seq, which were integrated with publicly available transcriptomic data from patients with different histological synovial pathotypes. Computational prediction and knock-down experiments were performed in FLS to identify adhesion molecules for cell-cell interaction. RESULTS: Cytokine stimulation, especially with TNF-α, led to enhanced FLS-T cell interaction resulting in cell-cell contact-dependent activation, proliferation and differentiation of T cells. Signatures of cytokine-activated FLS were significantly enriched in RA synovial tissues defined as lymphoid-rich or leucocyte-rich pathotypes, with the most prominent effects for TNF-α. FLS cytokine signatures correlated with the number of infiltrating CD4+ T cells in synovial tissue of patients with RA. Ligand-receptor pair interaction analysis identified ICAM1 on FLS as an important mediator in TNF-mediated FLS-T cell interaction. Both, ICAM1 and its receptors were overexpressed in TNF-treated FLS and co-cultured T cells. Knock-down of ICAM1 in FLS resulted in reduced TNF-mediated FLS-T cell interaction. CONCLUSION: Our study highlights the role of cytokine-activated FLS in orchestrating inflammation-associated synovial pathotypes providing novel insights into disease mechanisms of RA.

Treatment of benign bone lesions with an injectable biphasic bone substitute.

BACKGROUND: Injectable biphasic ceramic bone substitutes (BCBSs) represent a modern alternative to conventional options for bone defect filling, as they further open the possibilities for percutaneous cavity reconstruction. Although recent studies have shown good surgical outcomes after treatment with BCBSs, mid-term follow-up data are still missing. PATIENTS AND METHODS: Between 2013 and 2017, 18 patients were [1] treated with BCBS [2] for benign bone lesions and [3] had a complete set of retrospective information, including surgical protocols, imaging, patient dismission letters and outpatient clinic protocols, [4] with a minimum follow-up time of one year. Eleven patients received percutaneous surgery, while 7 patients had open curettage and BCBS filling. The median follow-up time was 36.5 (range 12-80) months. RESULTS: Local recurrence was reported in four patients. A distinctive bone remodelling pattern was noted on follow-up X-ray and magnetic resonance imaging showing a double-line phenomenon and continuously increasing cortical thickness one year after treatment in nine of thirteen patients. Regarding surgical complications, one patient suffered from a septic complication that required BCBS removal and lavage. One patient experienced superficial surgical site inflammation with redness and swelling, while two other patients had prolonged wound secretion. CONCLUSION: In a limited case series, the studied BCBS demonstrated acceptable surgical outcomes. Initial wound leakage and recurrence seemed to be associated with percutaneous injection. Further studies are needed to compare recurrence and bone graft resorption after open and percutaneous bone cyst surgeries and to further evaluate postoperative surgical site inflammation, which appears self-limiting in most cases.

Proximal femoral reconstruction with modular megaprostheses in non-oncological patients.

INTRODUCTION: Multiple revision hip arthroplasties and critical trauma might cause severe bone loss that requires proximal femoral replacement (PFR). The aim of this retrospective study was to analyse complication- and revision-free survivals of patients who received modular megaprostheses in an attempt to reconstruct massive non-neoplastic bone defects of the proximal femur. Questions/purposes (1) What were general complication rates and revision-free survivals following PFR? (2) What is the incidence of complication specific survivals? (3) What were risk factors leading to a diminished PFR survival? MATERIALS AND METHODS: Twenty-eight patients with sufficient follow-up after receiving a modular proximal femoral megaprosthesis were identified. The indications for PFR included prosthetic joint infection (PJI), periprosthetic fracture, aseptic loosening, non-union and critical femoral fracture. Complications were grouped according to the ISOLS-classification of segmental endoprosthetic failure by Henderson et al. RESULTS: Overall, the complication-free survival was 64.3% at one year, 43.2% at five years and 38.4% at ten years, with 16 patients (57%) suffering at least one complication. Complications were dislocation in eight patients (29%), PJI in 6 patients (21%), periprosthetic fracture in five patients (18%), and aseptic loosening in six patients (21%). Prosthesis stem cementation showed a lower risk for revision in a cox proportional hazard model (95% CI 0.04-0.93, HR 0.2, p = 0.04). CONCLUSION: PFR with modular megaprostheses represents a viable last resort treatment with high complication rates for patients with severe proximal femoral bone loss due to failed arthroplasty or critical fractures. In revision arthroplasty settings, PFR cementation should be advocated in cases of impaired bone quality.

Distal femoral reconstruction following failed total knee arthroplasty is accompanied with risk for complication and reduced joint function.

BACKGROUND: Substantial bone loss following failed total knee arthroplasty (TKA) represents a major challenge in revision arthroplasty, that can require distal femoral reconstruction (DFR). In this study, we aimed to assess the clinical outcome and the complication frequencies of individuals who underwent DFR with modular megaprostheses. Additionally, we aimed to compare functional outcome measures after DFR in these sophisticated cases to an age-matched control group of total knee prostheses to quantify the potential loss of function. METHODS: A retrospective chart review of 30 consecutive patients after DFR from 1997 to 2017 with a mean age of 74.38 years (± 10.1) was performed. Complications were classified according to the Henderson classification. Knee Society Score (KSS) was calculated and range of motion (ROM) was assessed. RESULTS: Thirteen (43.3%) patients had at least one complication requiring revision surgery. Revision-free survival was 74.8% at one year, 62.5% at three and 40.9% at 10 years post-op. Soft-tissue failure complications were found in three (10.0%) patients, aseptic loosening in four (13.3%) patients, structural failure in one (3.3%) patient and infection in eight (26.6%) patients. Of those with infection, five (16.6%) experienced ongoing prosthetic joint infection and three (10.0%) developed new infection after distal femur reconstruction. Patients with DFR achieved 69.3% of KSS pain score, 23.1% KSS function score and 76.2% of ROM compared to patients with primary TKA. CONCLUSIONS: DFR after failed TKA represents a treatment procedure with high risk for complication in this particular group. Despite the prospect of rapid postoperative mobilization, reduced functionality, range of motion and mobilization have to be considered when choosing this treatment option.

Multiplex PCR Unyvero i60 ITI application improves detection of low-virulent microorganisms in periprosthetic joint infections.

PURPOSE: The aim of this study was to evaluate the pre-operative performance of an automated multiplex PCR (mPCR) system in patients with suspected periprosthetic joint infection (PJI). METHODS: Under sterile conditions, synovial fluid samples from patients with a suspected PJI were collected pre-operatively. One hundred eighty microliter of the aspirate was used for analysis in the mPCR. The remaining joint fluid was sent for microbiological analysis. PJI was diagnosed by using the Musculoskeletal Infection Society (MSIS) criteria. Total percentage agreement and Cohen's kappa coefficient were calculated to measure overall agreement. RESULTS: Overall, 90 patients with a suspected PJI were included. Using MSIS criteria, 38 (42%) patients were classified as septic. Total percent agreement between mPCR and synovial fluid culture was 86% with a Cohen's kappa of 0.68. The mPCR and synovial fluid culture showed sensitivities of 71% and 84%, respectively. Combined evaluation provided an even higher sensitivity of 92%. While Cutibacterium spp. were detected five times by mPCR, it could only be cultured once. A higher detection rate of CoNS by mPCR (n = 7) compared to conventional culture (n = 5) was also demonstrated. In comparison to synovial fluid culture, the mPCR missed Staphylococcus aureus five times. CONCLUSION: With a moderate agreement between synovial fluid mPCR and culture, the mPCR system could be a useful adjunct in diagnosing a PJI pre-operatively. Due to faster availability of results and a higher detection rate of low-virulent microorganisms, it can complement conventional culture.

Preoperative MRI is helpful but not sufficient to detect associated lesions in patients with chronic ankle instability.

PURPOSE: The aim of this study was to determine the reliability and validity of preoperative magnetic resonance imaging (MRI) scans for the detection of additional pathologies in patients with chronic ankle instability (CAI) compared to arthroscopic findings. METHODS: Preoperative MRI images of 30 patients were evaluated regarding articular and periarticular comorbidities and compared to intraoperative findings. The reliability of MRI was determined by calculating specificity, sensitivity, as well as positive and negative predictive values. The accuracy of the classification of cartilage lesions by Outerbridge and Berndt and Harty rating scales was determined by calculating the area under the receiver operating curve (AUC). RESULTS: In total, 72 additional pathologies were found arthroscopically compared to 73 lesions gathered from MRI images. Sensitivity ranged from 89% for peroneal tendinopathy to 28% for additional ligamentous lesions. Specificity ranged from 100% for anterolateral impingement, loose bodies and peroneal tendinopathy to 38% for additional ligamentous lesions. For cartilage lesions, sensitivity was at 91% and specificity was at 55% for the Outerbridge grading scale. For the Berndt and Harty classification system, sensitivity was at 91% and specificity was at 28%. Correlation of additional pathologies ranged from weak (r s = 0.48; p = 0.02) to moderate results (r s = 0.67; p < 0.001). CONCLUSION: CAI is associated with a high incidence of additional pathologies. In some cases, MRI delivers insufficient results, which may lead to misinterpretation of present comorbidities. MRI is a helpful tool for preoperative evaluation, but arthroscopy remains gold standard in the diagnosis of associated lesions in patients with CAI. LEVEL OF EVIDENCE: III.

Failed Two-Stage Exchange: Factors Leading to Unachievable Endoprosthetic Reconstruction After Multiple Revision Surgeries.

BACKGROUND: Information about the outcome after failed 2-stage exchange is scarce. The aim of this study is to determine possible influencing factors leading to multiple revisions, resulting in a failed endoprosthetic joint reconstruction. METHODS: Medical records of patients (15 hip and 29 knee joints) who had undergone additional revision surgeries due to a failed 2-stage exchange were reviewed concerning infection parameters, number and type of procedure(s), current state of the revised joint, and whether failure of endoprosthetic reconstruction had occurred. RESULTS: Endoprosthetic reconstruction was achieved in 52.3% (n = 23) of the patients. About 36.4% (n = 16) of patients successfully reached the second stage of the initial 2-stage exchange. Half of the patients (n = 22) had to undergo spacer exchange in the initial interstage period. Five or more revision surgeries significantly increased the odds of failure of endoprosthetic reconstruction compared to patients with <5 revision surgeries (odds ratio 4.98, 95% confidence interval 1.34-18.4, P = .016). Patients with initial culture-negative revision surgery showed no significant differences in the odds of failure of endoprosthetic reconstruction (odds ratio 0.69, 95% confidence interval 0.20-2.43, P = .567). CONCLUSION: Patients undergoing re-revision surgery due to a failed 2-stage exchange are very likely to ultimately experience a failed endoprosthetic reconstruction. The identification of the underlying pathogen does not influence the likelihood of a better outcome in terms of a successful endoprosthetic reconstruction.

The influence of antibiotic-loaded cement spacers on the risk of reinfection after septic two-stage hip revision surgery.

PURPOSE: The aim of this study was the evaluation of possible outcome differences of patients undergoing two-stage hip exchange with antibiotic-loaded spacers, compared to patients without an interim spacer implantation. METHODS: We evaluated 46 patients undergoing two-stage hip revision surgery. Twenty-five patients received an interim ALS. Additional to a Kaplan-Meier survival analysis, a competing risk analysis was performed to estimate the cumulative incidence function for re-revisions due to infection accounting for death as a competing event. RESULTS: Nine patients (seven non-ALS vs. two ALS) had to undergo re-revision surgery due to reinfection of the hip joint. The non-ALS group showed a risk of re-revision of 19% (95% CI 5-38%) at 12 and 24 months and 30% (95% CI 12-51%) at 36 months. The group with ALS implantation displayed a 0% risk of re-revision surgery in the first 36 months. The Gray test revealed a significant difference in the cumulative incidence between both observed groups (p = 0.026). CONCLUSION: Our findings suggest that ALS implantation significantly reduces the risk of reinfection after two-stage hip revision surgery.

What Sport Activity Levels Are Achieved in Patients After Resection and Endoprosthetic Reconstruction for a Proximal Femur Bone Sarcoma?

BACKGROUND: Limited information is available about sports activities of survivors after resection and reconstruction of primary malignant bone tumors with megaprostheses. Because patients often ask what activities are possible after treatment, objective knowledge about sports activities is needed to help assess the risks of sports participation and to help guide patients' expectations. QUESTIONS/PURPOSES: The aims of this study were to evaluate (1) what proportion of patients with proximal-femoral megaprostheses placed as part of tumor reconstructions can perform sports; (2) what activity levels they achieved; and (3) whether sports activity levels are associated with an increased likelihood of revision. METHODS: This retrospective study considered all 27 living patients in our institutional tumor registry with enduring proximal-femoral reconstructions performed more than 5 years ago who were between the ages of 11 and 49 years at the time of the reconstruction; seven were lost to followup and one was excluded because of paraplegia as a result of a car accident and another because of senile dementia; another two were excluded from statistics because of growing prostheses and skeletal immaturity at the time of followup, leaving 16 (11 male, five female) for analysis. Their mean age was 26 ± 12 years (range, 11-49 years) at surgery, and the mean followup was 18 ± 7 years (range, 5-27 years). Types of sports, frequency per week, duration of each sports session as well as the UCLA and modified Weighted Activity Score were assessed retrospectively by an independent assessor a median of 18 years (range, 5.3-27 years) after surgery. RESULTS: Patients recalled that preoperatively 14 were practicing sports 5 (± 4) hours/week. At followup, 11 of the patients were practicing one or more sports activities 2 (± 3) hours/week on a regular basis. The preoperative UCLA and modified Weighted Activity Score levels of 9 and 6 fell to levels of 6 (p = 0.005) and 3 (p = 0.025), respectively, at followup. With the numbers of patients available for study, we could not determine that prosthetic failures were associated with sport activity levels. CONCLUSIONS: Patients who survive primary malignant bone tumors in the proximal femur reconstructed by megaprostheses are able to perform some sports activities. The estimates of activity levels made in this study probably are best-case estimates, given that some patients were lost to followup; patients unaccounted for might not be doing as well as those represented here. Also, the degree to which sports participation influences implant durability remains, for the most part, unanswered; studies with more patients and longer followup will be needed to determine to what degree prosthesis survivorship relates to sporting activity levels. Most patients perform low-impact sports and at a lower level than they had preoperatively. Because this is a preliminary study of a select group of patients, further information is necessary to weight the benefits of higher sports activity levels against potential risks. If this can be confirmed in a larger number of patients, the information may guide surgeons in their discussion with patients preoperatively and give them some objective assessment of what to expect regarding sports activities. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Surgical treatment of shoulder infections: a comparison between arthroscopy and arthrotomy.

BACKGROUND: Management of bacterial shoulder infections includes antibiotic therapy and surgical joint decompression. Arthroscopy and open arthrotomy are recommended treatment options. Whether 1 of the 2 surgical options is superior remains unclear. The present study aimed (1) to compare the reinfection rates after arthroscopy and open arthrotomy and (2) to identify risk factors of reinfection after surgical intervention. MATERIALS AND METHODS: The data of 59 consecutive patients were available for final analysis. All patients received arthroscopy or open arthrotomy at our institution between 2001 and 2015. The reinfection rates between the 2 distinct interventions were compared. We also evaluated the influence of potential confounders, such as age, sex, comorbidities, microbiological findings, duration of symptoms, osteoarthritis, Gächter score, and preoperative inflammatory parameters, on the recurrence of infections and compared the functional outcome between the 2 surgery groups. RESULTS: From 59 included patients, 38 (64.4%) underwent open arthrotomy, and 21 (35.6%) were treated arthroscopically. Reinfection was documented in 18 patients (30.5%). The reinfection rate was significantly higher in arthroscopically treated patients (11 [52.4%]) than in patients who underwent open arthrotomy (7 [18.4%]; P = .007). An infection with Staphylococcus aureus negatively influenced the treatment success (P = .034). CONCLUSION: According to our data, open arthrotomy is the more effective treatment method in septic arthritis of the shoulder, with lower reinfection rates and a comparable functional outcome. Furthermore, we could identify Staphylococcus aureus as an independent risk factor for the recurrence of infections.

Measurement considerations on examiner-dependent factors in the ultrasound assessment of developmental dysplasia of the hip.

PURPOSE: The standardized sonographic hip screening according to Graf has increased reliability and comparability of measurements in the screening of developmental dysplasia of the hip (DDH). However, examiner dependent factors have been discussed to influence sonographic measurements. The objectives of this study were to examine the tolerance of the transducer positioning and to analyse the impact of transducer inclinations on Graf's hip grading system. MATERIALS AND METHODS: Twenty-four hips in consecutive newborns were screened sonographically in combination with an optoelectronic motion capture system to trace transducer positions in space. Subsequently five defined inclinations of the transducer relative to Graf's neutral transducer position were analysed, giving a total of 144 sonographic images. RESULTS: We found a permissible transducer inclination in the axial plane of 8.8° to anterior and 8.1° to posterior. In the frontal plane we found a permissible inclination of 15.4° to caudal and 7.2° to cranial. The impact on the α-angle was significant for posterior-cranial (p < 0.001), cranial (p = 0.009), and caudal (p < 0.001) inclined transducer positions. The effect on the results according to Graf's grading system was significant for the caudal inclination of the transducer position (p < 0.001). CONCLUSION: Our findings show that the standardized plane defined by Graf's criteria allows notable inclinations of the transducer positions. Transducer inclinations show an impact on measurement results, which are clinically relevant. Those effects cannot be ruled out using Graf's ultrasound criteria alone. The examiner should pay attention to avoid transducer inclinations in the frontal plane and a combination of posterior and cranial inclination.

Treatment of septic arthritis of the knee: a comparison between arthroscopy and arthrotomy.

PURPOSE: The aim of this study was to compare the efficacy of arthroscopy and arthrotomy in patients with septic monarthritis of the knee. METHODS: Seventy consecutive patients who underwent surgery because of a bacterial monarthritis were evaluated. Patients were either treated with arthroscopy or with arthrotomy. Our primary outcome was the early recurrence of infection (>3 months after surgery), which made a second surgical procedure necessary. Furthermore, the influence of potential confounders on treatment outcome was analysed. RESULTS: Of the 70 patients, 41 were treated arthroscopically and 29 with arthrotomy. Eight patients (11.4 %) had to undergo a second surgical procedure because of early re-infection. The rate was significantly higher in patients treated with arthrotomy (n = 6; 20.7 %) compared with those treated by arthroscopy (n = 2) (p = 0.041). Range of motion was significantly better in patients who underwent arthroscopy (p < 0.001). Male sex had negative influence on the treatment success (p = 0.03). CONCLUSIONS: Patients with bacterial monarthritis of the knee who were treated with arthroscopy had a significantly lower re-infection rate and a better functional outcome than those treated with arthrotomy. As arthroscopy is the less invasive method, it should be considered the routine treatment, according to our data. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Is the state of health of rheumatoid arthritis patients receiving adequate treatment, predictable? - Results of a survey.

BACKGROUND: A survey was conducted to evaluate whether a steady improvement in the quality of life of Rheumatoid Arthritis (RA) patients as frequently reported in clinical studies, does actually occur. The focus of this study laid on the personal perception of RA patients. How do patients who have been treated along accepted guidelines see the state of their health and their joint pain at different points in time? METHODS: RA patients were asked to complete a questionnaire and return it to an opinion research centre. The questionnaire, which was developed by the authors, was divided into the areas: demography, symptom description and medical care, as well as the illness in a personal context. Three telephone interviews followed in monthly intervals when the patients' feelings about their illness, their every-day coping mechanisms and their social lives were rated. Intra-subject correlation and the level of agreement among patients when assessed at three different points within a two month period, was determined. RESULTS: 127 patients replied to the questionnaire. RA exerts a significant impact on a patient's daily life. Average ratings of current state of health and joint pain (answered on a 5-part scale extending from 1 (very good) to 5 (very bad)) range between 2.6 and 2.9 all three times. However, intra-subject correlation between the different assessment times, is in general quite modest. Concerning the question: "How is your join pain today?" only 14 of 127 participants express identical ratings all three times , while in one third of the participants, a difference of two digits on the 5-part scale, at least twice had to be noticed. Intra-class correlation coefficients between answers at different points are often much smaller than 0.5. Results were similar in all subgroups analysed (men vs. women; patients receiving biologics vs. those not receiving biologics; disease duration ≤3 years vs. 4 to 10 years vs. ≥11 years). CONCLUSION: On an individual level personal assessments of health, well-being and joint pain are nevertheless unsteady even within the timeframe of two months. This is why, even now, RA patients still cannot plan their lives as non-affected people can.

Primary malignant tumours of the scapula--a review of 29 cases.

PURPOSE: Primary malignant bone tumours of the scapula are very rare. Apart from limited small series and some case reports, international literature on flat bone sarcoma is exiguous and not much is known about the oncological outcome. METHODS: A retrospective analysis of 29 patients diagnosed with a primary malignant tumour of the scapula was performed. The mean age was 40 years. The average time of follow-up was 60 months. Diagnoses included chondrosarcoma in 11 patients, Ewing's sarcoma/PNET in six, osteosarcoma in three, and others in nine. RESULTS: Five patients (19%) had no surgery. Wide resection was performed in 18 patients (74%) and marginal and intralesional resection in three patients (13%) each. Fifteen patients underwent resection without bony reconstruction, seven patients underwent a Tikhoff-Linberg procedure, and two patients received a custom-made scapula prosthesis. Six patients were diagnosed with metastasis after a mean time of nine months after surgery, while three patients suffered local recurrence at an average of six months after surgery. Disease-specific survival was 70% at one year and 47% at five years. The mean MSTS score was 69% and was highest for patients with scapular prosthesis. CONCLUSION: The overall prognosis of primary malignant bone tumours of the scapula remains to be inferior compared to extremity sarcoma. Endoprosthetic reconstruction, however, shows promising functional results even in cases of total scapulectomy.

Incidence and management of hip dislocation in tumour patients with a modular prosthesis of the proximal femur.

PURPOSE: Little data is available about the incidence and especially the management of hip dislocation following the implantation of modular tumor prostheses of the proximal femur. In this retrospective single-centre study we assessed the incidence of hip dislocation following implantation of a proximal femoral modular prosthesis as well as the success of the subsequent surgical or non-surgical treatment in tumor patients. METHODS: Between 1982 and 2008, 166 tumor patients received a modular prosthesis of the proximal femur at our institution. The average age at the time of surgery was 50 ± 20 years (range, six to 84 years). An additional pelvic reconstruction was done in 14 patients. An artificial band for soft tissue reconstruction of the hip was used in 19 patients. The average time of follow-up was 46 ± 64 months (range, one to 277 months). RESULTS: The overall dislocation rate after proximal femoral replacement was 13% after a mean time of seven ± eight months (range, 0.3-33 months) after surgery. Between 1982 and 1986 the dislocation rate was 33% and declined to 9% in subsequent years (1987-2008). Patients who had received an additional pelvic reconstruction had a three fold higher dislocation rate (p <0.05). Patients with closed reduction had a 58% (eight of 12) re-dislocation rate compared to 11% (one of nine) for open reduction (p = 0.0357). CONCLUSIONS: Dislocation of a modular prosthesis of the proximal femur is a common complication, especially in cases with additional pelvic resection with extensive bone and soft-tissue defects. Open surgical management may be more effective in preventing re-dislocation than closed reduction and bracing alone.

Recurrence-Free Survival after Synovectomy and Subsequent Radiosynoviorthesis in Patients with Synovitis of the Knee-A Retrospective Data Analysis.

BACKGROUND: Persistent knee synovitis leads to joint discomfort, incapacitating inflammation, and functional limitations. The conventional approach has involved surgical procedures to eliminate the actively inflamed synovial membrane. This study aims to investigate the recurrence-free survival and functional outcome after synovectomy and subsequent radiosynoviorthesis (RSO) in patients with knee synovitis. METHODS: Thirty-seven knees diagnosed with pigmented villonodular synovitis (PVNS), rheumatoid arthritis (RA), and peripheral spondyloarthritis underwent synovectomy and subsequent RSO between May 2005 and October 2016. The mean age was 34.9 ± 15.1 years, and the mean follow-up period was 84 ± 36.4 months. Clinical outcomes were assessed using the Oxford Knee Score and the presence of swelling and pain at the last follow-up. Recurrence-free survival denotes the duration from synovectomy to surgical re-synovectomy. RESULTS: In general, twelve knees underwent re-synovectomy after a mean follow-up of 34.8 ± 24.9 months. The recurrence-free survival was 83.8% at two years, 71.3% at five years, and 61.7% at ten years. The subgroup analysis revealed recurrence-free survival at two years in 63.6% of patients with PVNS, 86.7% of those with RA, and 100% of individuals with peripheral spondyloarthritis. CONCLUSIONS: This study demonstrates that combined therapy for synovitis is an effective approach, significantly improving clinical outcomes.

[Treatment of haemophilia in Austria]. / Hämophilie-Behandlung in Österreich.

This guideline is intended to provide practical guidance for the diagnosis and treatment of haemophilia in Austria. Few randomized controlled interventional trials are available addressing the treatment of haemophilia, therefore recommendations are usually based on low level of evidence and represent expert consensus.This guideline is based on the WFH guideline, published in 2020, and adapted according to the national circumstances and experience.It includes recommendations and suggestions for diagnosis and follow-up visits and pharmacological therapies for treatment and prophylaxis. Further topics comprise special aspects in children and adults with severe haemophilia, outcome measurement, and management of trauma, special bleedings and interventions, including dental procedures, inhibitors, management of haemophilia carriers, and psychosocial aspects.

Successful treatment of a painful os peroneum using conservative measures, infiltration therapy, and shock waves.

Lateroplantar foot pain may be caused by various entities, whereby painful os peroneum syndrome should be included in the differential diagnosis. Physical examination and multimodal imaging enable a definitive diagnosis. We report on a 59-year-old man with severe, load-dependent pain, corresponding to an os peroneum syndrome, triggered by a pes planovalgus with consecutively induced focal inflammation and tendovaginitis of the tendon of the peroneus longus muscle. Multifactorial conservative measures including infiltration and shockwave therapy finally led to a restoration of the original condition.

Open surgical treatment of unicameral bone cysts : A retrospective data analysis.

BACKGROUND: A variety of treatment options for unicameral bone cysts (UBC) exist. The controversy of open management of UBC is discussed. The aim of this study was to analyze a single institution's experience in the open surgical treatment of UBC. PATIENTS AND METHODS: By retrospective analysis of the Vienna Bone and Soft Tissue Tumor Registry, 119 patients with open surgery and histologically verified UBC with a mean follow up of 4.8 years (range 1-30 years) were included. Lesion treatment failure was defined as surgically addressed UBC undergoing revision surgery due to persistence or recurrence. RESULTS: Local revision-free survival for lesion treatment failure was 93% after 1 year, 80% after 2 years, 60% after 5 years and 57% after 10 years. Of the patients 34 (29%) had at least 1 revision surgery due to lesion treatment failure. We found that patients with lesion treatment failure were younger (p = 0.03), had UBC with less minimal distance to the growth plate (p = 0.02) and more septation chambers in radiologic imaging (p = 0.02). Patients with open revision surgery were less likely to require a second revision due to lesion treatment failure than patients with percutaneous revision surgery (p = 0.03). CONCLUSION: Open surgery for UBC can only be recommended as reserve treatment in younger children with actively growing lesions. Open UBC surgery carries a relatively high risk of almost 30% of lesion treatment failure and therefore the indications should be limited to extensive osteolysis with high risk of pathological fractures, lesions with displaced pathological fractures, and lesions with an ambiguous radiological presentation that require tissue collection.

[Adult Acquired Flatfoot Deformity: Diagnosis and Surgical Treatment]. / Erworbener Plattfuß: Diagnose und chirurgische Behandlung.

The adult acquired flatfoot is a deformity with slow progression, which may leads to pain and restrictions of activities of daily living if untreated. Various treatment strategies, depending on the clinical and radiological presentation, exist. Therefore, an individual therapy approach is necessary for optimal treatment. This article covers etiopathologic aspects, conservative and operative treatments as well as postoperative mobilization and rehabilitation.