[Treatment Strategies for Septic Arthritis of the Sternoclavicular Joint]. / Behandlungsstrategie der septischen Arthritiden des Sternoklavikulargelenks.

Septic arthritis of the sternoclavicular joint (SCJ) is a relatively rare disease. Due to serious complications including mediastinitis and generalised sepsis early diagnosis and rapid onset of treatment are mandatory. The disease often affects immunocompromised patients, diabetics, or patients with other infectious diseases. The therapeutic options range from administration of antibiotics to extended surgery including reconstructive procedures. Apart from rare situations where conservative treatment with antibiotics is sufficient, joint resection followed by plastic surgical procedures are required. We present a retrospective analysis with data from two hospitals. From January 2008 to December 2012 23 patients with radiographically confirmed septic arthritis of various aetiology were included. Fourteen (60.8 %) male, nine (39.2 %) female patients with an average age of 60.3 ± 14.2 years (range: 23-88 years) with septic arthritis of the SCJ were treated. Seven (30.4 %) patients suffered from Diabetes mellitus, nine (39.1 %) had underlying diseases with a compromised immune system. In 14 (60.8 %) out of 23 patients a bacterial focus was detected. Only six (26 %) patients suffered from confined septic arthritis of the SCG, in 17 (73,9 %) patients osteomyelitis of the adjacent sternum, and the clavicle was present. In addition, 15 (65.2 %) patients already suffered from mediastinitis at the time of diagnosis, eight (35 %) patients even from septicaemia. In conclusion, septic arthritis requires an active surgical treatment. Limited incision of the joint and debridement alone is only successful at early stages of the disease. The treatment concept has to include the local joint and bone resection as well as complications like mediastinitis. After successful treatment of the infection, the defect of the chest wall requires secondary reconstructive surgery using a pedicled pectoralis muscle flap.

[Use of a pediculed pectoralis major flap for the treatment of septic arthritis of the sternoclavicular joint]. / Der gestielte Pectoralis-major-Lappen zur Behandlung der eitrigen Arthritis des Sternoklavikulargelenks.

OBJECTIVE: Closure of the wound defect with a pedicled pectoralis major muscular flap after successful surgical treatment of septic arthritis of the sternoclavicular joint (SCJ). INDICATIONS: Defect of the thoracic wall after septic arthritis of the SCJ. CONTRAINDICATIONS: Persistent infection of bony or soft tissue structures; persistent septicemia; persistent mediastinitis. SURGICAL TECHNIQUE: After successful treatment of the local infection and radical debridement of the wound, the incision is expanded parallel to the clavicle and to the sternum. The neurovascular pedicled pectoralis flap is mobilized and a resection of the muscular attachment at the humerus is performed. Finally, the flap is rotated at the pedicle and attached to the defect zone. POSTOPERATIVE MANAGEMENT: Anticoagulation with low molecular weight heparin and possibly aspirin (100 mg/day); short-term immobilization of the involved upper extremity. Avoidance of major weight bearing for a period of 6 weeks. RESULTS: Over a period of 4 years, 18 patients suffering from septic arthritis of the SCJ underwent surgical treatment. Of these, 9 patients were treated with pedicled muscular flap. In all patients, uneventful wound healing was observed with no further revision operations being required. The functional and optical results were satisfactory.

[Osteomyelitis in adults. Diagnostic principles and therapeutic strategies]. / Osteomyelitis im Erwachsenenalter. Diagnostische Prinzipien und therapeutische Strategien.

This review focuses on the presentation of the diagnostic and therapeutic principles for treatment of chronic osteomyelitis of long bones in adults. Early detection of the offending bacteria is a crucial step which has to be performed with tissue and fluids from the depth of the wound. Superficial samples and swaps from fistulas should be avoided and are not considered to be representative. Chronic osteomyelitis is characterized by necrotic and nonvascularized bony tissue which represents one of the most relevant sources for recurrence infection. Appropriate therapy includes radical excision of the diseased bone and infected scar tissue, closure of the wound with well-vascularized (muscle) flaps, stabilization, and administration of adequate antibiotics.

[Septic arthritis of the sternoclavicular joint: radical resection and treatment with a pectoralis flap]. / Septische Arthritis des Sternoklavikulargelenks: radikale Resektion und Weichteildeckung mittels Pektoralislappen.

After infection of a vascular prosthesis with generalised sepsis, a 59-year-old male patient suffered from an increasing swelling of his right sternoclavicular joint. We performed an incision and debridement of the SC joint and harvested material for microbiological diagnosis. However, we were not able to overcome the inflammation until we performed a radical resection including the medial aspect of the clavicle and parts of the manubrium followed by coverage with a pectoralis flap. The further course was uneventful with a good functional result. Reviewing data from the literature there are no unequivocal guidelines available for this rare disease. However, in most cases a radical debridement and a consecutive flap coverage are required.

[A false aneurysm as a rare complication of knee arthroscopy]. / Aneurysma spurium als seltene Komplikation einer Kniegelenksarthroskopie.

We present the rare case of a false aneurysm of the genus lat which occurred after knee arthroscopy. Apart from a pulse-synchronic swelling in close proximity to the former anterolateral portal there were no complaints and no pain. The diagnostic and therapeutic strategies - in this case performed with coiling of the involved vessel - are presented and discussed.

[Kyphoplasty and vertebroplasty. Indications, techniques, complications and results]. / Kyphoplastie und Vertebroplastie. Indikationen, Techniken, Komplikationen und Ergebnisse.

The indications, technical principals, and results after vertebroplasty and kyphoplasty are presented in detail. We focus on the complications of both procedures. The benefit of vertebroplasty has been fundamentally questioned by two papers which have recently been published in the New England Journal of Medicine. Our paper discusses the present knowledge and policy about indication. The contradictory results from different studies are presented. In general, there is a lack of randomized clinical trials. Therefore, a final judgement of these two techniques is not possible. New procedures like stent-kyphoplasty or lordoplasty are briefly described. However, at present an assessment of these new techniques is impossible. A similar situation is give for the application of resorbable bone cements.

[Electromagnetic fields, electric current and bone healing - what is the evidence?]. / Elektromagnetische Felder, elektrischer Strom und Knochenheilung: was ist gesichert?

For more than 30 years the potential effects of electrical stimulation on bone healing have been investigated. Up to now this therapy is controversial and not established as a standardised treatment option. This systematic review and metaanalysis focuses on the potential effects of electromagnetic fields and high-frequency electric fields on bony healing. In a systematic literature search randomised clinical trials were identified and analysed. Those studies with the primary endpoint "rate of bony healing" were combined in a metaanalysis which was performed with the "random effects" model. We found a total of 14 randomised clinical trials. These studies included a total of 915 patients. The majority of these studies used pulsed electromagnetic fields (PEMF). Out of the 14 studies nine were suitable for the metaanalysis which revealed a cumulative odds ratio of 3.5 and a 95 % confidence interval of 1.94-6.3. When performing a subgroup analysis a statistically significant result could not be confirmed by the studies with a higher methodological quality. In view of the heterogeneous physical parameters with different frequencies, time course, flux densities and in view of the methodological deficits, a general conclusion seems difficult. Recommendations or standards of therapy are so far not available.

[Fractures of the acetabulum. Diagnostic and therapeutic strategies]. / Azetabulumfraktur : Diagnostik und Versorgungsstrategien.

Fractures of the acetabulum are a challenge in terms of orientation and the surgical skills of the orthopedic trauma surgeon. Due to the surrounding soft tissues and because of the indirect reduction control, operative treatment of acetabular fractures can be very demanding. This review includes the anatomical and clinical features, the radiological diagnostic approach, the classification systems, and, in particular, the surgical approaches and treatment principles. The work houses for surgical approaches are the ilioinguinal and the posterior (Kocher-Langenbeck) approach. In view of the high complication rate, the extended approaches are of less relevance. The therapeutic relevance of recent developments including navigation is discussed.

[Corrective growth after vertebral body fracture in the adolescence]. / Korrigierendes Wachstum nach Wirbelköperfrakturen im Jugendalter.

We present the case of a 13-year-old female patient who sustained an incomplete burst fracture of the 1st lumbar vertebral body and an impression fracture of the 3rd vertebral body. Using a dorsal instrumentation the kyphosis of the thoracolumbar junction was treated. The radiographical follow-up indicated a correction of the involved vertebral bodies. However, complete restoration of the height of the vertebral bodies was not achieved. In view of this long-term follow-up the potential for correction of the adolescent thoracolumbar junction spine is discussed.

[Tissue engineering of bone tissue. Principles and clinical applications]. / Tissue Engineering von Knochengewebe: Prinzipien und klinische Anwendungsmöglichkeiten.

Complex fractures are still a major clinical challenge. The treatment options of large bony defects either with autografts or allografts are limited in terms of material availability and tissue in-growth. Tissue engineering might offer a solution to this problem. In an interdisciplinary approach artificial bony tissue can be generated which mimics normal bone in terms of function and morphology. So far tissue engineering of bone is mainly confined to laboratory investigations whereas clinical applications are still in the beginning. This manuscript presents the most important scaffolds as well as growth factors and cell systems. Furthermore, it focuses on clinical studies for the treatment of large bony defects using tissue engineered cell-matrix constructs.

[Unstable pertrochanteric femur fractures. Failure rate, lag screw sliding and outcome with extra- and intramedullary devices (PCCP, DHS and PFN)]. / Die instabile pertrochantäre Femurfraktur. Komplikationen, Fraktursinterung und Funktion nach extra- und intramedullärer Versorgung (PCCP, DHS und PFN).

AIM OF THE STUDY: The dynamic hip screw (DHS) often shows a high incidence of therapeutic failure and an impared outcome in the treatment of the unstable pertrochanteric femur fracture (31A2). Therefore often an intramedullary device is recommended. In a retrospective clinical study we examined whether the percutaneous compression plate (PCCP, Gotfried) provides advantages following unstable fractures in comparison to DHS and PFN. METHODS: From January 2002 to April 2007 135 patients with unstable pertrochanteric femur fractures underwent internal fixation with the PCCP (n = 46, age 78.3, ASA 2.8), DHS (n = 36, age 75.9, ASA 3.0) or PFN (n = 53, age 77.2, ASA 2.8). Radiological and clinical re-examination of the patients (33 PCCP, 24 DHS, 34 PFN) was performed 17 months later. RESULTS AND DISCUSSION: The PCCP was implanted in less time than the DHS and PFN (59 vs. 80 vs. 79 min, p = 0.004). Radiographic screening time was low (PCCP 143 vs. DHS 146 vs. PFN 280 s, p = 0.001). Re-operations for wound infections and haematomas occurred in 2 % after PCCP, 14 % after DHS and 4 % after PFN (p = 0.058). There was a low re-operation rate for fracture fixation complications in PCCP (9 %), in contrast to DHS (25 %) and PFN (13 %, p = 0.109). Cut-out was seen more in DHS (19 %, PCCP 2 %, PFN 4 %, p = 0.005). Lag screw sliding was high with DHS (PCCP 4 mm vs. DHS 9 mm vs. PFN 6 mm, p = 0.032). There was no correlation between lag screw sliding and outcome. PCCP, DHS and PFN had the same functional results in Merle d'Aubigné and Harris hip scores. CONCLUSIONS: Using the minimally invasive PCCP technique in unstable pertrochanteric femur fractures provides a promising therapy option especially with regard to surgical time, radiographic screening time and failure rate. Lag screw sliding was low. There was no advantage of the intramedullary device PFN.

Expression of ion channels of the TRP family in articular chondrocytes from osteoarthritic patients: changes between native and in vitro propagated chondrocytes.

The maintenance of a differentiated chondrocyte phenotype is influenced by several factors of which signal transduction of extracellular stimuli through the cell membrane is of major interest. One important group of membrane-bound proteins which are involved in transmembrane signal transduction are ion channels. Human articular chondrocytes were obtained from osteoarthritic femoral condyles. Cells were released from the surrounding matrix and cultivated under standard conditions. We investigated gene expression of 12 members of the TRP ion channel family of freshly prepared (passage 0; P0) and in vitro propagated human articular chondrocytes (passage 2; P2) using conventional and real-time PCR (RT-PCR). In addition, the protein appearance of four TRP channels was demonstrated by immunofluorescence and western blotting. Chondrocyte differentiation was monitored by quantification of collagen type-II, type-I, and aggrecan gene expression. By conventional PCR, 8 channels could be detected, of which some displayed a heterogeneous PCR pattern. RT-PCR quantification revealed that TRPC1 was expressed on the same level in P0 and P2 chondrocytes while gene expression of TRPC3 and TRPC6 was elevated in passage 2 cells. TRPM5, TRPM7, and TRPV1 displayed an enhanced gene expression in freshly isolated chondrocytes. Immunofluorescence signal intensity of all four investigated TRP proteins was consistent with the corresponding gene expression data. In the present study, a correlation between the appearance of some members of the TRP ion channel family and the state of de-differentiation of osteoarthritic articular chondrocytes was shown. A possible direct involvement in the process of chondrocyte de-differentiation has to be investigated in further studies.

[Surgical outcome in pertrochanteric femur fracture: the impact of osteoporosis. Comparison between DHS and percutaneous compression plate]. / Operationsergebnisse nach pertrochantärer Femurfraktur: Welchen Einfluss hat die Osteoporose? Vergleich zwischen DHS und perkutaner Kompressionsplatte.

AIM: The dynamic hip screw (DHS) often shows an impared outcome and a high incidence of therapeutic failure in patients with osteoporotic pertrochanteric femur fractures. This is caused predominantly by a fracture collapse and appears often in unstable fractures (31A2, 31A3). In a prospectively documented clinical study, we examined whether or not the percutaneous compression plate (PCCP, Gotfried) offers advantages following osteoporotic fractures. METHOD: From August 2003 to December 2005, 103 patients underwent internal fixation with the DHS (n = 40, age 76.1, ASA 2.9) or with the PCCP (n = 63, age 76.9, ASA 2.8). Proximal femurs were classified with the Singh grading system, which uses six grades of trabecular patterns to describe the degree of osteoporosis. Reexamination of the patients (27 DHS, 43 PCCP) was performed on average 18 months later. RESULTS: The PCCP was implanted into very osteoporotic femurs (Singh 2) in less time than the DHS (47 vs. 79 min). These patients treated with PCCP showed no difference in blood loss, but tended to have better outcomes (Merle d'Aubigné, Harris hip score) than those treated with DHS. Life quality, subjectively measured with the visual analogue score, was significantly better in the PCCP group with high-grade osteoporosis (Singh 2). The outcome after implantation of the PCCP was not correlated to the Singh index in stable or in unstable fractures. Mechanical complications occurred especially in unstable fractures (re-operation rate: DHS 4/18 [22 %], PCCP 3/29 [10 %], p = 0.266), without correlation to the Singh index. Excluding the avoidable complication of loosening of the screw-barrel portion, the re-operation rate for the PCCP was 3 % (cut-out: 1/29, p = 0.042) in unstable fractures. CONCLUSION: Use of the minimally invasive PCCP technique in osteoporotic pertrochanteric femur fractures provides an alternative to the dynamic hip screw, especially with regard to surgical time and outcome. Advantages occurred also in the re-operation rate following fracture fixation complications. The cut-out rate was significantly lower than in the DHS group in unstable fractures.

[Bilateral fracture of the femoral neck following transient osteoporosis in pregnancy]. / Beidseitige Schenkelhalsfraktur bei transienter Osteoporose während der Schwangerschaft.

During pregnancy changes of the bone metabolism can occur. Femoral neck fractures are known as a very rare consequence of transient osteoporosis in pregnancy. In a case report we present the clinical, radiological and histological features of a bilateral fracture of the femoral neck. A 29-year-old woman presented with pain in the right hip, which occurred in the 34 (th) week of pregnancy. The symptoms were initially interpreted as a sacroiliac joint affection and consequently a conservative treatment was initiated. Five days after a Caesarean section a dislocated fracture of the femoral neck was diagnosed on the left side. On the contralateral side the fracture was not dislocated. For therapy this patient underwent a total hip replacement on the left hand side and an internal fixation on the other side. Especially during pregnancy changes of the bone are diagnosed late due to the side effects of radiation. This case report indicates that MR imaging and other non-ionising techniques should be considered if such symptoms persist in spite of therapy.

A novel rat tail collagen type-I gel for the cultivation of human articular chondrocytes in low cell density.

Collagen type-I matrix systems have gained growing importance as a cartilage repair device. However, most of the established matrix systems use collagen type-I of bovine origin seeded in high cell densities. Here we present a novel collagen type-I gel system made of rat tail collagen for the cultivation of human chondrocytes in low cell densities. Rat tail collagen type-I gel (CaReS, Arthro Kinetics, Esslingen, Germany) was seeded with human passage 2 chondrocytes in different cell densities to evaluate the optimal cell number. In vitro, the proliferation factor of low density cultures was more than threefold higher compared with high density cultures. After 6 weeks of in vitro cultivation, freshly prepared chondrocytes with an initial cell density of 2x10(5) cells/mL showed a proliferation factor of 33. A cell density of 2x10(5) cells/mL was chosen for in vitro and in vivo cultivation using the common nude mouse model as an in vivo system. Chondrocytes stayed viable as a Live/Dead fluorescence assay and TUNEL staining revealed. During in vitro cultivation, passage 0 cells partly dedifferentiated morphologically. In vivo, passage 0 cells maintained the chondrocyte phenotype and demonstrated an increased synthesis of collagen type-II protein and gene expression compared to passage 2 cells. Passage 2 cells did not redifferentiate in vivo. Cultivating a cell-seeded collagen gel of bovine origin as a control (AtelocollagenTM, Koken, Tokyo, Japan) did not lead to superior results with regard to cell morphology, col-II protein production and col-II gene expression. With the CaReS collagen gel system the best quality of repair tissue was obtained by seeding freshly isolated chondrocytes.

Comparison of modern marker proteins in serum and synovial fluid in patients with advanced osteoarthrosis and rheumatoid arthritis.

Numerous studies have focused on the significance of modern marker proteins in the synovial fluid of the knee joint and in the serum both, for osteoarthritis (OA) and rheumatoid arthritis (RA). The relationship between the serum concentrations and the concentrations in the synovial fluid is still unclear. Synovial fluid and serum samples were obtained from 13 patients with advanced OA and from 8 patients with severe RA and concentrations of MMP-1, MMP-3, MMP-13, TIMP-1, COMP and MIA/CD-RAP were determined. All values were normalized against the total protein concentrations. Serum concentrations of MMP-13 in the RA-group were statistically higher than the synovial values (P<0.05). MMP-13 was the only marker protein that revealed distinct higher levels in the serum than in the synovial fluid. The study design allows only conclusions about advanced stages of RA and OA. Longitudinal investigations may provide further information about the value of MMP-13 as a potential marker to monitor the course of RA and OA.

Electrical potentials derived from articular cartilage: the significance of polarization potentials.

Changes of electrical potentials in cartilage tissue under mechanical compression have been detected in several studies. As polarization potentials are known to occur at the interface between metals and electrolytes, the question remains open whether the measured electrical potentials in relation to mechanical compression are interfered with polarization potentials. Using a porcine model, whole knee joints were explanted and exposed to uniaxial loading of up to 250 N. Under similar conditions, a tube filled with normal saline was prepared with three gold-plated electrodes. Changes of voltage derived from the electrodes placed in normal saline could be detected only when the force was applied instantly by a hydraulically controlled pump. In comparison, mechanically induced electrical potentials could be derived from cartilage tissue when exposed to both sudden force and force induced more slowly by an electric engine. While the electrical response derived from cartilage tissue correlated with the extent of the applied force, there was no such correlation between the potential changes from normal saline and the applied mechanical force. In conclusion, polarization potentials derived from metal electrodes in contact with electrolyte solution are pressure dependent. However, those electrical potential changes obtained from the cartilage tissue under compressive force revealed no obvious influence by polarization potentials.

[Biomechanical tests of a new scaffold for the cultivation of chondrocytes]. / Biomechanische Testung einer neuen Trägermatrix für die Kultivierung von Chondrozyten.

AIM: Scaffolds for the cultivation of chondrocytes are of increasing importance. So far, only little is known about their biomechanical properties. The present preliminary study addresses the biomechanical characteristics of a new collagen type I scaffold for the cultivation of chondrocytes. MATERIAL AND METHODS: Human chondrocytes were amplified in a monolayer and then cultivated in a 3D-scaffold over a period of up to 6 weeks. The biomechanical tests addressed the properties under uniaxial compression including stiffness and viscoelastic characteristics (creep and retardation). The obtained values were normalized against the thickness of the specimens and expressed as ratios. In addition, we present histological and quantitative PCR results (for collagen type II and aggrecan). RESULTS: The maximum force (or penetration force) revealed its highest values after a period of seven days. At this time the median value was 40 mN/mm. In the following period, a marked drop of the values was observed (19.8 mN/mm). With respect to the creep properties, we did not find any major changes over the period of six weeks. The median values were between 0.24 and 0.29 mm/mm. There were no significant differences between the samples seeded with chondrocytes and those which served as controls. A re-expansion of the samples was found with median values between 0.026 and 0.049 mm/mm (retardation). However, the original thickness was not reached after a period of 30 seconds with relief of the strain. Again, major differences of the values with respect to the duration of cultivation were not observed. Light microscopy revealed collagen type II and proteoglycans only in the pericellular region. CONCLUSION: In this study not all of the biomechanical properties of the cultivated tissue were investigated. The limitation of the tests to stiffness and viscoelastic properties was reasonable in view of a potential routine use. In addition, it may facilitate a comparison between different matrix systems. In our study, the cultivation of cells within the collagen matrix did not alter the mechanical properties of the scaffold.

[Teutschländer disease. A rare benign differential diagnosis of proliferative space-occupying lesions in the periarticular soft tissue]. / Morbus Teutschländer. Eine seltene benigne Differenzialdiagnose proliferativer Raumforderungen im paraartikulären Weichteilgewebe.

The tumoral calcinosis (synonym: Teutschländer disease) is a very rare benign metabolic dysfunction of unknown etiology. It manifests principally as massive subcutaneous soft tissue deposits of calcium phosphate near the large joints and is also characterized by slow progressive growth. Causally, a disturbance of the calcium and phosphate metabolism/balance with, among others, autosomal dominant heredity is suspected. It appears frequently in the black African population in all age groups, but preferentially in the 1st and 2nd decades of life. Medical help is most frequently sought because of increasing tumor size causing displacement and consecutive pain as well as decreased joint play. We present here a case of Teutschländer disease in a 50-year-old woman on long-term hemodialysis and describe the clinical, radiological, and pathological signs of this rare disease. Subsequently, speculative etiology, differential diagnostic considerations as well as the therapeutic interventions for tumoral calcinosis are discussed taking into consideration the current literature.

[Posteromedial bowing of the lower leg and neuroblastoma with possible neurofibromatosis type I: a case report and literature review]. / Posteromediale Unterschenkelverbiegung und Neuroblastom bei Verdacht auf Neurofibromatose Typ I: Kasuistik und Literaturübersicht.

BACKGROUND: The posteromedial bowing of the tibia is a rare condition that is not yet known to be related to neurofibromatosis. The case of a three month-old boy with the tentative diagnosis of neurofibromatosis is described. He developed paraplegia due to an abdominal neuroblastoma at the age of 9 months. This led us to a review of the literature. METHOD: 122 cases of posteromedial bowing of the tibia in 20 publications of the years 1949 - 2000 were analysed under special respect to gender, side of affection, shortening of the lower leg, treatment and possible cause. RESULTS: The posteromedial bowing of the lower leg seems to affect more boys as well as the left side. As far as described in all but one case it was the first delivery. Regularly, a limb shortening and pes calcaneovalgus is to be found. 99 children were treated conservatively, 21 got an operation of the affected side. In 19 performed osteotomies no pseudarthrosis occurred. One case of a fracture due to an adequate trauma without healing problems is described.