[Complication management following resection and reconstruction of the upper limbs and shoulder girdle]. / Komplikationsmanagement nach Tumorresektion und Defektrekonstruktion an der oberen Extremität und am Schultergürtel.

BACKGROUND: Sarcomas of the upper limbs commonly affect the proximal humerus or scapula. Complications after tumor resection and reconstruction are rare but cannot be neglected, particularly after tumor endoprosthetic reconstructions. MATERIALS AND METHODS: The most common complications after resection of sarcomas of the upper limbs and shoulder girdle are described, and current knowledge regarding complication management is presented. Additionally, a selective literature search was performed, incorporating personal experiences. RESULTS: Wound healing disorders and infections after tumor resection without specific reconstruction (clavicle resection, scapulectomy) usually respond well to conservative or surgical treatment. However, periprosthetic infections after reconstruction using a megaendoprosthesis constitute a severe and frequent complication, with an incidence of 5-10%. Two-stage implant replacement still represents the gold standard, although in selected cases, one-stage revision with retention of the prosthetic stem appears warranted. Secondary amputation as a result of periprosthetic infection is rare compared to the situation with infections of the lower limb. Mechanical complications necessitating surgical revision are mostly limited to joint dislocation after inverse total shoulder replacement (TSR). (Sub)luxation in anatomic TSR can be tolerated provided there is no tendency toward perforation of the skin in a asymptomatic patient. Biological reconstructions are most often indicated for reconstruction of intercalary defects of the humerus, and revision is necessitated most frequently by mechanical complications. Despite multiple surgical revisions, stable reconstructions and limb salvage can usually be achieved in the upper limb.

[Current results of tumour endoprosthetics in adolescents and adults]. / Aktuelle Ergebnisse der Tumorendoprothetik bei Jugendlichen und Erwachsenen.

BACKGROUND: The majority of osteoarticular defects after tumor resection in adolescent and adult patients are reconstructed using megaendoprosthetic implants. However, even infant and pre-teen children undergo reconstruction of defects using so-called growing prostheses with an increasing frequency. OBJECTIVES: Presentation of current techniques, outcomes and the most common complications of megaendoprosthetic reconstruction following tumour resection. METHODS: Selective literature review and discussion of current concepts and knowledge in megaendoprosthetic reconstruction against personal experience and treatment strategies. RESULTS: Megaendoprosthetic reconstructions achieve good functional results and long-term limb salvage (ca. 90% of cases) in adolescent and adult patients. Still, periprosthetic infection and mechanical failure of joint components are among the most common complications observed. In infant and pre-teen children treated by reconstruction using a growing prosthesis, mandatory maintenance operations-in the process of elongating the implant-must also be considered when assessing complication risks. CONCLUSIONS: Megaendoprosthetic reconstructions of osteoarticular defects are a standard procedure in adolescent and adult patients. Despite a substantial complication rate, limb salvage is achieved in a majority of patients. When using growing prostheses in younger children, one needs to be aware of additional servicing procedures that occur independently of those arising from complications.

[Isolated limb perfusion for liposarcoma : Histopathological response and subgroup analysis after TNF melphalan-based ILP]. / Isolierte Extremitätenperfusion bei Liposarkomen : Histopathologisches Ansprechen und Subgruppenanalyse nach TNF-Melphalan-ILP.

BACKGROUND: Tumor necrosis factor alpha (TNF) and melphalan-based isolated limb perfusion (TM-ILP) is one of the most effective treatment modalities for unresectable soft tissue sarcoma (STS) of the extremities. Liposarcomas (LS) are a large and heterogeneous subgroup of STS with different biological behavior and prognoses. The aim of this study was to evaluate LS and the different subentities with respect to their responsiveness towards TM-ILP. METHODS: We matched our ILP database with our pathology database to identify patients who received TM-ILP due to STS followed by resection of the residual tumor. We identified 126 patients who matched these inclusion criteria. In this patient group we identified 24 patients with a LS. Histopathological regression was assessed from all resection specimens and was compared between groups: LS vs. non-LS and for myxoid and non-myxoid LS subgroups. RESULTS: There were no significant differences in the overall tumor regression comparing non-LS (median 95%, mean 77%) and LS (median 90%, mean 74%). For the subgroup analysis, a higher grade of regression after TM-ILP was found in myxoid-LS (median 95%, mean 79% ± 31.5) compared to the non-myxoid LS (median 75%, mean 72% ± 24.6). Atypical lipomatous tumors (ALT) were less responsive to TM-ILP treatment (median 40%, mean 40%). CONCLUSION: The histopathological response of LS toward TM-ILP is equally good compared to non-lipomatous STS. Myxoid LS seem to have a tendency towards a better response to TM-ILP compared to non-myxoid LS and ALT showed the lowest response rate in the liposarcoma subgroup. Furthermore, we found that TM-ILP seems to facilitate successful R0 resection. Due to the low number of cases in the subgroups we advocate further research on this topic.

TNF-alpha and melphalan-based isolated limb perfusion: no evidence supporting the early destruction of tumour vasculature.

BACKGROUND: Isolated limb perfusion with TNF-alpha and melphalan (TM-ILP) is a highly effective treatment for locally advanced tumours of the extremities. Previous research suggests an almost immediate disintegration of the blood supply of the tumour. The aim of the present study was to verify this hypothesis using non-invasive measurements of microvascular perfusion and tissue oxygenation. METHODS: A total of 11 patients were included in the study. TM-ILP was performed under mildly hyperthermic conditions (39 °C) in the extremities via proximal vascular access. Capillary-venous microvascular blood flow, haemoglobin level (Hb) and oxygen saturation (SO2) were determined using laser Doppler and white-light spectroscopy, respectively, before TM-ILP and at 30 min, 4 h, 1 day, 4 days, 1 week, 2 weeks and 6 weeks after TM-ILP from tumour and healthy muscle tissues. RESULTS: Blood flow and Hb were mostly higher, whereas SO2 was lower, in tumour tissue compared with muscle tissue. In both tumour and muscle tissues, blood flow significantly increased immediately after TM-ILP and remained elevated for at least 2 weeks, followed by a return to the initial values 6 weeks after the procedure. CONCLUSION: No signs were found of early destruction of the tumour vasculature. The observations suggest that an inflammatory reaction is one of the key elements of TM-ILP.

[Sarcoma of the hand and wrist]. / Sarkome an Hand und Handgelenk.

Sarcomas of the hand and wrist are rare malignancies, which should be referred to high-volume comprehensive cancer centres providing multidisciplinary treatment options. The tumour board should propose patient-oriented oncological pathways as well as sophisticated hand and plastic reconstructive procedures. In Addition, isolated limb perfusion with TNF-alpha and melphalan is likely to lead to preoperative tumour shrinkage allowing for R0 resection in sano. Our clinical results in long-term survivors demonstrate reduced amputation rates and salvage of basic hand function when a risk-adapted treatment rationale is applied.

Neoadjuvant treatment improves capsular integrity and the width of the fibrous capsule of high-grade soft-tissue sarcomas.

BACKGROUND: Neoadjuvant treatment is thought to improve resection with margin-negative surgery in locally advanced soft-tissue sarcomas (STS). Treatment-induced alterations of the tumor peripheryhave not yet been microscopically evaluated. OBJECTIVE: This histopathological study compared limb STS with primary resection and those that had undergone neoadjuvant treatment, emphasizing microscopic changes of the fibrous capsule (FC) and reactive zone (RZ) after neoadjuvant treatment. PATIENTS AND METHODS: Patients with primary high-grade limb sarcomas (N = 76) which have not previously been treated were included. Of those, 37 were primarily resected and 39 were treated with one of the following neoadjuvant treatment modalities: 7x chemotherapy (CTX), 3x radiotherapy (RT), 15x isolated limb perfusion (ILP), 8x CTX + RT, and 6x CTX + ILP. Sizes of the FC and RZ were microscopically measured, and FC-integrity was documented. Histopathologic regression was expressed as a percent. RESULTS: Only 35.1% of untreated sarcomas showed an intact FC. We observed significantly higher capsular integrity after treatment (76.9%). Additionally, the average width of the FC (0.21 mm vs. 0.61 mm) and RZ (0.67 mm vs. 1.48 mm) increased significantly. The extent of histopathologic regression showed a correlation with capsular integrity and width. The combination of two treatment modalities (CTX + RT or ILP) showed strongest effects at the tumor periphery. CONCLUSIONS: Neoadjuvant treatment stabilizes the tumor periphery in STS (e.g., the capsule). Concerning local treatment strategies, these novel histopathologic insights might significantly influence the decision as to whether primary resection is advisable in advanced local soft-tissue sarcoma.

Retrospective lifetime estimation of failed and explanted diamond-like carbon coated hip joint balls.

Diamond-like carbon (DLC) coatings are known to have extremely low wear in many technical applications. The application of DLC as a coating has aimed at lowering wear and to preventing wear particle-induced osteolysis in artificial hip joints. In a medical study femoral heads coated with diamond-like amorphous carbon, a subgroup of DLC, articulating against polyethylene cups were implanted between 1993 and 1995. Within 8.5 years about half of the hip joints had to be revised due to aseptic loosening. The explanted femoral heads showed many spots of local coating delamination. Several of these explanted coated TiAlV femoral heads have been analyzed to investigate the reason for this failure. Raman analysis and X-ray photoelectron spectroscopy (XPS) depth profiling showed that the coating consists of diamond-like amorphous carbon, several Si-doped layers and an adhesion-promoting Si interlayer. Focused ion beam (FIB) transverse cuts revealed that the delamination of the coatings is caused by in vivo corrosion of the Si interlayer. Using a delamination test set-up dissolution of the silicon adhesion-promoting interlayer at a speed of more than 100 µm year(-1) was measured in vitro in solutions containing proteins. Although proteins are not directly involved in the corrosion reactions, they can block existing small cracks and crevices under the coating, hindering the exchange of liquid. This results in a build-up of crevice corrosion conditions in the crack, causing a slow dissolution of the Si interlayer.

Sample taking during orthopedic surgery: sensitivity and specificity using the BACTEC blood culture system.

The use of blood culture systems for sterile body fluids other than blood has proven to be superior to routine culture methods. This study was conducted in order to assess the performance of the BACTEC blood culture system compared to swab/tissue sample collection for the detection of infection from intraoperative samples taken during surgical procedures. Sensitivity was determined by taking samples (BACTEC and swab/tissue samples) from patients with clinically evident infection (Infection group). Specificity was tested by taking the same sample sets from patients who had aseptic operations with no history of infection (Control group). The sensitivity was found to be much higher for the BACTEC group (50 isolates from 56 samples, sensitivity: 89%) compared to the swab/tissue samples (29 isolates out of 56 samples, sensitivity: 52%). The specificity was lower in the BACTEC group (32 isolates out of 44 samples, specificity: 27%) compared to the swab/tissue samples (1 isolate out of 44 samples, specificity: 98%). We conclude that BACTEC is useful for intraoperative sample collection in cases of low-grade infection. However, it is less specific and there is always the possibility for contamination. Therefore, it is advisable to use this technique in combination with regular tissue samples.

Effectiveness of regional chemotherapy with TNF-alpha/melphalan in advanced soft tissue sarcoma of the extremities.

Hyperthermic isolated limb perfusion with tumour necrosis factor alpha (TNF-alpha) and melphalan was repeatedly reported to achieve extraordinarily high clinical remission rates in advanced and non-resectable soft tissue sarcoma of the limbs, thus avoiding imminent mutilation or amputation for most of those patients. With the limb being isolated throughout the extracorporal perfusion, high doses of recombinant TNF-alpha as well as melphalan can be applied. Basically, TNF-alpha directly affects the vasculature of the tumour and induces a severe inflammation with consecutive deterioration of the tumour capillaries. Furthermore, TNF-alpha increases the tumour-selective uptake of melphalan into the tumour cells thus leading to synergy of antivascular targeted treatment and antineoplastic effects of highest dose chemotherapy supplemented by hyperthermia. Meanwhile, a lot of sarcoma centres in Europe adopted this technique and established referral programmes for patients with non-resectable soft tissue sarcomas of the limbs. Despite these programmes many patients still do not get offered hyperthermic ILP with TNF-alpha and melphalan as a treatment option and modality. This article summarizes multimodality in treatment of soft tissue sarcoma of the limbs and reviews the current status of melphalan-based ILP with TNF-alpha (TM-ILP) and its results, to enable comparison and critical consideration of other treatment options.

[Fractures close to the epiphysis in children. Part I: upper extremities]. / Epiphysennahe Frakturen bei Kindern : Teil I: Obere Extremität.

Fractures in children require special knowledge and skills due to the differences in biological and biomechanical properties of growing skeletons. Children suffer from fractures of the upper extremities much more than fractures of the lower extremities. While fractures of the diaphysis have a high regenerative and proliferation potential, impairment of the growth plate with consecutive disturbance of growth can be found more often in fractures close to the epiphysis. Most epiphysis fractures in children can be identified by a set of 2-plane X-ray images but precise knowledge about the skeletal maturation is required. In order to correctly decide about treatment regimes (conservative versus operative treatment) the limitations and limits of the ability of bone to correct misalignment must be anticipated. Clinical examination following fracture healing is mandatory to recognize differences in length, misalignment and deficits in function, which should receive further treatment.