Development of a simplified urban water balance model (WABILA).

During the last decade, water sensitive urban design (WSUD) has become more and more accepted. However, there is not any simple tool or option available to evaluate the influence of these measures on the local water balance. To counteract the impact of new settlements, planners focus on mitigating increases in runoff through installation of infiltration systems. This leads to an increasing non-natural groundwater recharge and decreased evapotranspiration. Simple software tools which evaluate or simulate the effect of WSUD on the local water balance are still needed. The authors developed a tool named WABILA (Wasserbilanz) that could support planners for optimal WSUD. WABILA is an easy-to-use planning tool that is based on simplified regression functions for established measures and land covers. Results show that WSUD has to be site-specific, based on climate conditions and the natural water balance.

[New surgical treatment options for bone tumors]. / Neue Operationsverfahren bei Knochentumoren.

Primary bone neoplasms can be classified into benign, locally/aggressive and rarely metastasizing and malignant tumors. Patients with benign tumors usually undergo surgical treatment in cases of local symptoms, mainly consisting of pain or functional deficits due to compression of important anatomical structures, such as nerves or blood vessels. Locally/aggressive and rarely metastasizing tumors exhibit an infiltrative growth pattern, so that surgical treatment is necessary to prevent further destruction of bone leading to local instability. Finally, the surgical treatment of malignant tumors is, with few exceptions, considered to be a prerequisite for long-term survival, either alone or in combination with systemic chemotherapy. Whereas the main objective of surgery in the treatment of benign tumors is relief of local symptoms with a minimum amount of damage to healthy tissue and minimizing the risk of local recurrence while ensuring bone stability in locally aggressive and rarely metastasizing tumors, the primary goal in the operative treatment of bone sarcomas is the resection of the tumor with clear surgical margins followed by defect reconstruction and the preservation of function. This review examines the current developments in the surgical treatment of primary bone neoplasms with respect to the management of the tumors and novel reconstructive options.

[Benign cartilage tumors. What should I do with incidental findings?]. / Benigne Knorpeltumoren. Was mache ich mit dem Zufallsbefund?

BACKGROUND: The majority of benign bone tumors are cartilage tumors. Most common are enchondroma and osteochondroma. Often they represent incidental findings in radiological diagnostics. Thus, the incidence of cartilage tumors is unknown, as most of them are never diagnosed due to the absence of any symptoms. OBJECTIVES: This article describes the diagnostic and therapeutic approach of benign cartilage tumors, focusing on incidental findings. METHODS: The current knowledge and our own experience in the diagnostics and treatment of benign condroid tumors are presented. RESULTS: As enchondroma represent most often the classic incidental finding without any symptoms or clinical findings, osteochondroma are often diagnosed in young patients by clinical examination showing a painless swelling that can increase in size according to skeletal growth. Most of these asymptomatic enchondroma and osteochondroma are so called "leave me alone lesions" and do not need any treatment, while other benign tumors (e.g., atypical cartilage tumors, chondroblastoma, chondromyxoidfibroma or osteochondroma with a cartilage cap of over 2 cm) need surgical treatment. These active or local aggressive tumors must be differentiated from the "leave me alone lesions". Additionally, patients with syndromes like Ollier disease (enchondromatosis), Maffucci syndrome or hereditary multiple exostosis must be examined and checked carefully as malignant degradation is possible. CONCLUSION: As most cartilage tumors are benign and remain benign, inappropriate diagnostics or operative treatment just to provide security is obsolete. Plain X-ray is often enough for follow-up and other modalities only become necessary when symptoms occur.

[Management of complications in megaprostheses]. / Komplikationsmanagement bei Megaprothesen.

BACKGROUND: Megaprostheses are frequently used after segmental resection of bone sarcomas, bone metastases, and in large osseous defects in revision arthroplasty. OBJECTIVES: The incidence of the most common complications associated the use of megaprostheses are reported. The management of complications including therapeutic recommendations are described. MATERIALS AND METHODS: The current knowledge and our own experience of complication management with the use of megaprostheses are presented. RESULTS: Prospective, randomized studies or meta-analyses on this topic are lacking. An analysis of the literature shows that beside the occurrence of a local recurrence, periprosthetic infection remains the most serious complication. Two-stage revision remains the gold standard, but a single-stage exchange of the prosthesis without removing the stems might be possible in selected cases. Infection is associated with a higher risk of secondary amputation. In contrast, mechanical failures (e.g., wear of the bushings in knee replacements and aseptic loosening of the stems) can be treated more easily. Dislocation of a proximal femur replacement can mostly be prevented by using bi- or tripolar cups. CONCLUSIONS: Complications with the use of megaprostheses can be successfully treated by revision surgery in most cases.

Percutaneous CT-guided radio-frequency ablation of osteoid osteoma of the foot and ankle.

INTRODUCTION: Percutaneous radiofrequency ablation (RFA) has been considered, in recent years, the standard treatment for osteoid osteoma (OO) of the appendicular skeleton. The variable clinical presentations in the foot and ankle pose problems in diagnosis, localization and thus treatment. The aim of this study was to assess the efficacy of RFA for patients with osteoid osteoma of the foot and ankle. MATERIALS AND METHODS: A total of 29 patients (22 males, 7 females; mean age 16.7 years; range 8-44 years) with OO of the foot and ankle (distal tibia, n = 17; distal fibula, n = 6; talus, n = 3; calcaneus, n = 3) were enrolled in the study. A CT-guided RFA was performed, using a cool-tip electrode without the cooling system, heating the lesion up to 90 °C for 4-5 min. Clinical success, assessed at a minimum follow-up of 1 year, was defined as complete or partial pain relief after RFA. Pain and clinical outcomes were scored pre-operatively and at the follow-up with a visual analogue scale (VAS) and with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Complications and local recurrences were also recorded. RESULTS: Clinical success was achieved in 26 patients (89.6 %). After RFA, mean VAS and AOFAS score significantly improved from 8 ± 1 to 2 ± 1 (p < 0.05) and from 60.7 ± 12.7 to 89.6 ± 7.1 (p < 0.05), respectively. Two patients experienced partial relief of pain and underwent a second successful ablation. Local recurrences were found in three patients, always associated with pain. These underwent conventional excision through open surgery. No early or late complications were detected after RFA. CONCLUSION: CT-guided RFA of foot and ankle osteoid osteoma is a safe and effective procedure, showing similar results for the rest of the appendicular skeleton.

[Monarthritis of the ankle due to osteoid osteoma of the talus. Difficulties in diagnosis and treatment]. / Monarthritis des oberen Sprunggelenks bei Osteoidosteom des Talus. Schwierigkeiten bei Diagnose und Therapie.

The case of a 22-year-old man with an osteoid osteoma of the right talus neck is reported. After 2 years of pain and swelling we confirmed the diagnosis by CT and MRI scan. Afterwards we performed CT-guided thermocoagulation; 12 months afterwards the patient shows no symptoms anymore.

Modelling of biofilters for ammonium reduction in combined sewer overflow.

Biofiltration has proved to be a useful system to treat combined sewer overflow (CSO). The study presented uses numerical simulation to detect the critical operating conditions of the filter. The multi-component reactive transport module CW2D was used for the simulation study. Single-event simulations of lab-scale-column experiments with varying boundary conditions regarding the throttle outflow rate were carried out. For the calibration of the CW2D model measurement results of four experiments in two lab-scale columns were used. The model was validated by simulating four events of two further columns filled with the same filter material. These columns were operating with higher throttle outflow rates than the columns used for calibration. For ammonium (NH(4)-N) a good fit between measured and simulated data could be achieved. However, the comparison of simulated and measured effluent concentrations of nitrate (NO(3)-N) showed that there is a need for further investigations mainly due to the uncertainties in the degradation process during dry periods between the loadings.

Selective arterial Embolisation of Aneurysmal Bone Cysts of the Sacrum: a promising Alternative to Surgery.

PURPOSE: The sacrum is a rare but unfavourable location for Aneurysmal Bone Cysts (ABCs), surgical procedures aiming to achieve local tumour control can be mutilating. Aim of this study was to evaluate whether selective arterial embolisation (AE) of ABC of the sacrum is an effective treatment and might be an alternative to surgical treatment options. MATERIALS AND METHODS: Between 2007 and 2011 six patients (mean age 13.7 years, range 8 - 18 years) with an ABC of the sacrum were treated by AE. Follow-up was performed by MRI-scans as well as clinical examination (mean 36.5 months, range 14 - 56 months). RESULTS: No treatment related complications have been observed. AE resulted in devascularisation of ABC and led to local tumour control in all patients. A partial consolidation was noticed in three patients. Pain relief was achieved in five of six patients, neurological deficits dissolved. In two patients more than one embolization was necessary. In one of these patients due to exacerbation of pain a surgical decompression was performed. CONCLUSION: AE of sacral ABCs can serve as an effective and safe treatment option. Thus it might be an alternative to potentially harmful surgical procedures. In case of ongoing tumour growth or pain recurrence AE can be repeated. In case of treatment failure surgical interventions are still possible. KEY POINTS: • transarterial embolisation enables local tumour control in sacral ABCs. • transarterial embolisation of sacral ABCs is a safe procedure. • in case of tumour progression repetitive embolisations are possible and effective.

[Interdisciplinary diagnostic and treatment of bone sarcomas of the extremities and trunk]. / Die interdisziplinäre Diagnostik und Therapie von Knochensarkomen der Extremitäten und des Rumpfes.

Contrary to the relatively common benign bone tumours and tumour-like lesions, bone sarcomas are rare malignancies with an incidence of 0.8 new cases per 100 000 persons per year. The most common primary malignant bone tumour is osteosarcoma, followed by chondrosarcoma and Ewing sarcoma. Osteosarcomas and Ewing sarcomas occur predominantly in children, adolescents and young adults, while chondrosarcomas primarily affect older patients. Most of the tumours are located in the extremities and the pelvis and in about 90% of the cases the surgical treatment can be performed by means of a limb-sparing wide resection. An endoprosthetic or biological reconstruction of the resulting defect, depending on several patient- und tumour-related factors, is usually necessary. Apart from the surgical treatment, patients with osteosarcoma and Ewing sarcoma require a pre- and postoperative chemotherapy, while Ewing sarcoma patients often undergo radiation therapy as well. Regular follow-up examinations are required after the completion of treatment for the early detection and management of local and/or systemic recurrences as well as treatment-related complications. An extensive experience in the clinical and imaging features as well as the interdisciplinary treatment of these tumours is necessary for optimal patient care. Without it mistakes are often made, which can have grave consequences on the patients' prognosis and functional outcome. The centralised treatment of these patients in specialised sarcoma centres is therefore recommended.

Pelvic reconstruction with compound osteosynthesis following hemipelvectomy: A clinical study.

To date, all surgical techniques used for reconstruction of the pelvic ring following supra-acetabular tumour resection produce high complication rates. We evaluated the clinical, oncological and functional outcomes of a cohort of 35 patients (15 men and 20 women), including 21 Ewing's sarcomas, six chondrosarcomas, three sarcomas not otherwise specified, one osteosarcoma, two osseous malignant fibrous histiocytomas, one synovial cell sarcoma and one metastasis. The mean age of the patients was 31 years (8 to 79) and the latest follow-up was carried out at a mean of 46 months (1.9 to 139.5) post-operatively. We undertook a functional reconstruction of the pelvic ring using polyaxial screws and titanium rods. In 31 patients (89%) the construct was encased in antibiotic-impregnated polymethylmethacrylate. Preservation of the extremities was possible for all patients. The survival rate at three years was 93.9% (95% confidence interval (CI) 77.9 to 98.4), at five years it was 82.4% (95% CI 57.6 to 93.4). For the 21 patients with Ewing's sarcoma it was 95.2% (95% CI 70.7 to 99.3) and 81.5% (95% CI 52.0 to 93.8), respectively. Wound healing problems were observed in eight patients, deep infection in five and clinically asymptomatic breakage of the screws in six. The five-year implant survival was 93.3% (95% CI 57.8 to 95.7). Patients were mobilised at a mean of 3.5 weeks (1 to 7) post-operatively. A post-operative neurological defect occurred in 12 patients. The mean Musculoskeletal Tumor Society score at last available follow-up was 21.2 (10 to 27). This reconstruction technique is characterised by simple and oncologically appropriate applicability, achieving high primary stability that allows early mobilisation, good functional results and relatively low complication rates.

Endoprosthetic replacement after extra-articular resection of bone and soft-tissue tumours around the knee.

We evaluated the clinical results and complications after extra-articular resection of the distal femur and/or proximal tibia and reconstruction with a tumour endoprosthesis (MUTARS) in 59 patients (mean age 33 years (11 to 74)) with malignant bone or soft-tissue tumours. According to a Kaplan-Meier analysis, limb survival was 76% (95% confidence interval (CI) 64.1 to 88.5) after a mean follow-up of 4.7 years (one month to 17 years). Peri-prosthetic infection was the most common indication for subsequent amputation (eight patients). Survival of the prosthesis without revision was 48% (95% CI 34.8 to 62.0) at two years and 25% (95% CI 11.1 to 39.9) at five years post-operatively. Failure of the prosthesis was due to deep infection in 22 patients (37%), aseptic loosening in ten patients (17%), and peri-prosthetic fracture in six patients (10%). Wear of the bearings made a minor revision necessary in 12 patients (20%). The mean Musculoskeletal Tumor Society score was 23 (10 to 29). An extensor lag > 10° was noted in ten patients (17%). These results suggest that limb salvage after extra-articular resection with a tumour prosthesis can achieve good functional results in most patients, although the rates of complications and subsequent amputation are higher than in patients treated with intra-articular resection.

[Endoprosthetic reconstruction of the proximal humerus in malignoma]. / Proximaler Humerusersatz bei malignen Schultergelenktumoren.

OBJECTIVE: The aim of the operation is local tumor control in malignant primary and secondary bone tumors of the proximal humerus. Limb salvage and preservation of function with the ability to lift the hand to the mouth. Stable suspension of the arm in the shoulder joint or the artificial joint. INDICATIONS: Primary malignant bone tumors of the proximal humerus or the scapula with joint infiltration but without involvement of the vessel/nerve bundle. Metastases of solid tumors with osteolytic defects in palliative or curative intention or after failure of primary osteosynthesis. CONTRAINDICATIONS: Tumor infiltration of the vessel/nerve bundle. Massive tumor infiltration of the soft tissues without the possibility of sufficient soft tissue coverage of the implant. SURGICAL TECHNIQUE: Transdeltoid approach with splitting of the deltoid muscle. Preparation and removal of the tumor-bearing humerus with exposure of the vessel/nerve bundle. Ensure an oncologically sufficient soft tissue and bone margin in all directions of the resection. Cementless or cemented stem implantation. Reconstruction of the joint capsule and fixation of the prosthesis using a synthetic tube. Soft tissue coverage of the prosthesis with anatomical positioning of the muscle to regain function. POSTOPERATIVE TREATMENT: Immobilization of the arm/shoulder joint for 4-6 weeks in a Gilchrist bandage. Passive mobilization of the elbow joint after 3-4 weeks. Active mobilization of the shoulder and elbow joint at the earliest after 4-6 weeks.

The treatment of locally recurrent chondrosarcoma: Is extensive further surgery justified?

The aim of this study was to define the treatment criteria for patients with recurrent chondrosarcoma. We reviewed the data of 77 patients to examine the influence of factors such as the intention of treatment (curative/palliative), extent of surgery, resection margins, status of disease at the time of local recurrence and the grade of the tumour. A total of 70 patients underwent surgery for recurrent chondrosarcoma. In seven patients surgery was not a viable option. Metastatic disease occurred in 41 patients, appearing synchronously with the local recurrence in 56% of cases. For patients without metastasis at the time of local recurrence, the overall survival at a mean follow-up after recurrence of 67 months (0 to 289) was 74% (5 of 27) compared with 19% (13 of 50) for patients with metastasis at or before the development of the recurrence. Neither the type/extent of surgery, site of tumour, nor the resection margins for the recurrent tumour significantly influenced the overall survival. With limited survival for patients with metastatic disease at the time of local recurrence (0% for patients with grade III and de-differentiated chondrosarcoma), palliative treatment, including local radiation therapy and debulking procedures, should be discussed with the patients to avoid long hospitalisation and functional deficits. For patients without metastasis at the time of local recurrence, the overall survival of 74% justifies an aggressive approach including wide resection margins and extensive reconstruction.

[Attachment tube for soft tissue reconstruction after implantation of a mega-endoprosthesis]. / Der Anbindungsschlauch zur Weichteilrekonstruktion nach Megaprothesenimplantation.

OBJECTIVE: To restore function and an active range of motion, and stabilize the joint after joint resection. INDICATIONS: Restoration of a joint capsule following reconstruction of a defect using a proximal humerus and femur prosthesis. Reattachment of tendons and muscles. CONTRAINDICATIONS: Acute or chronic infection. Status after cured infection. SURGICAL TECHNIQUE: The attachment tube (Implantcast, Buxtehude, Germany) is attached to the joint capsule (proximal humerus and femur replacement) or directly to the prosthesis (for proximal tibial replacements) using nonresorbable Ethibond® sutures (Johnson & Johnson Medical, Norderstedt, Germany). Bone anchors are used, if the joint capsule has been completely resected. The body of the prosthesis, which has previously been attached to the shaft, is then pulled distally through the tube, and a (bipolar) head or humerus cap is placed on top of it. In the proximal humerus and femur replacement, proximal slitting of the tube may be helpful to reposition the prosthesis under vision. Following repositioning, fixation of the tube is completed ventrally and the slits previously made in the tube are sutured. Fixation of the tube to the prosthesis is carried out either with Ethibond® sutures placed around the tube, or--for a proximal humerus and tibia replacement--it is possible to attach suture material to the prosthesis through eyelets. POSTOPERATIVE MANAGEMENT: Further treatment basically depends on the location of the mega-endoprosthesis used. RESULTS: Macroscopically and microscopically, fibroblasts migrate into the tube's mesh, so that attachment of the soft tissue takes place. As of yet, no cases of luxation have occurred when the tube is used in combination with a bipolar head, and with fixed-implant cups the risk of luxation can be reduced using tripolar cup systems. In patients with a proximal tibial replacement, active straightening of the knee joint can be restored in most cases, although some limitation on active extension is still possible depending on the extent of the tumor resection.

Intramedullary and total femur replacement in revision arthroplasty as a last limb-saving option: is there any benefit from the less invasive intramedullary replacement?

There has been a substantial increase in the number of hip and knee prostheses implanted in recent years, with a consequent increase in the number of revisions required. Total femur replacement (TFR) following destruction of the entire femur, usually after several previous revision operations, is a rare procedure but is the only way of avoiding amputation. Intramedullary femur replacement (IFR) with preservation of the femoral diaphysis is a modification of TFR. Between 1999 and 2010, 27 patients with non-oncological conditions underwent surgery in our department with either IFR (n = 15) or TFR (n = 12) and were included in this study retrospectively. The aim of the study was to assess the indications, complications and outcomes of IFR and TFR in revision cases. The mean follow-up period was 31.3 months (6 to 90). Complications developed in 37% of cases, 33% in the IFR group and 4% in the TFR group. Despite a trend towards a slightly better functional outcome compared with TFR, the indication for intramedullary femur replacement should be established on a very strict basis in view of the procedure's much higher complication rate.

Intensive inpatient treatment of young adult chronic patients.

Young adults with chronic mental disorders have become a major concern among mental health professionals during the past decade. Many of these patients require frequent hospitalizations, are noncompliant with treatment, experience behavioral crises that threaten themselves or others, abuse drugs and alcohol, and alienate their families and support systems. The authors describe an intensive inpatient program for young adult chronic patients who have repeatedly failed to respond to community-based and standard state hospital care and appear to need extended institutional care. The program, which integrates psychiatric and rehabilitation strategies, has succeeded in increasing the amount of time these patients remain in the community. Although the goal for such patients remains a community-based treatment program, the value of an extended period of active inpatient treatment for some patients may be overlooked in current planning for them.

Proinflammatory cytokines trigger MUC gene expression and mucin release in the intestinal cancer cell line LS180.

OBJECTIVES AND DESIGN: Proinflammatory cytokines and a defective mucus layer are involved in the pathogenesis of colitis. Therefore, we determined cytokine effects on MUC gene expression and mucin secretion. MATERIALS AND METHODS: LS180 cells were characterized by light and electron microscopy and subsequently exposed to interleukin 1 (IL-1, 1 ng/ml), interleukin 6 (IL-6, 10 ng/ml), or tumor necrosis factor-alpha (TNFalpha, 10 ng/ml). MUC gene (MUC2, MUC5AC, MUC5B, MUC6) mRNA expression was assessed by RT-PCR, the encoded proteins were identified by immunocytochemistry and Western blotting, and the released mucins were isolated and chromatographically characterized. RESULTS: Thirty to 40% of the cells contained intracellular mucin granules. Incubation with IL-1 transiently stimulated the mRNA expression of MUC2 and MUC5AC, whereas IL-6 induced an early response of MUC2, MUC5B and MUC6. TNFalpha upregulated the expression of MUC2 and MUC5B for 3 hours, and had no effect on the expression of MUC 5AC and MUC6. Immunocytochemistry and Western blotting confirmed TNFalpha effects on MUC2 and MUC5AC on the protein levels. All cytokines stimulated the release of less glycosylated mucins and considerably modulated their carbohydrate composition. CONCLUSION: Our data demonstrate differential cytokine effects on mucin synthesis, secretion and composition. These alterations may contribute to the defective mucus layer in colitis.

The prevalence of psychiatric disorders among cancer patients.

Two hundred fifteen randomly accessed cancer patients who were new admissions to three collaborating cancer centers were examined for the presence of formal psychiatric disorder. Each patient was assessed in a common protocol via a psychiatric interview and standardized psychological tests. The American Psychiatric Association's DSM-III diagnostic system was used in making the diagnoses. Results indicated that 47% of the patients received a DSM-III diagnosis, with 44% being diagnosed as manifesting a clinical syndrome and 3% with personality disorders. Approximately 68% of the psychiatric diagnoses consisted of adjustment disorders, with 13% representing major affective disorders (depression). The remaining diagnoses were split among organic mental disorders (8%), personality disorders (7%), and anxiety disorders (4%). Approximately 85% of those patients with a positive psychiatric condition were experiencing a disorder with depression or anxiety as the central symptom. The large majority of conditions were judged to represent highly treatable disorders.