[Epidemiology and classification of diabetic foot syndrome]. / Epidemiologie und Klassifikation des diabetischen Fusssyndroms.

The diabetic foot syndrome (DFS) is an important complication of diabetes mellitus resulting in severe undesired consequences, such as amputation, disability and reduced quality of life. In Germany there are approximately 300,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years of diagnosis. To achieve a reduction of the amputation rate it is necessary to identify the main causes. The use of the Wagner-Armstrong wound classification is well accepted in Germany. Therapy and diagnosis of the diabetic foot syndrome are almost standardized and all procedures are well established. In addition a professional stage-adjusted wound therapy has to take place in an interdisciplinary collaboration at a centre for wound care.

Preoperative elevation of serum C--reactive protein is predictive for prognosis in myeloma bone disease after surgery.

We investigated whether preoperative levels of serum C-reactive protein (CRP) and its correlation with tumour clinicopathological findings adds prognostic information beyond the time of diagnosis in patients with myeloma bone disease (MM) to facilitate the surgical decision-making process. Six hundred and fifty-eight myeloma patients were evaluated retrospectively for surgery. Clinicopathological variables of patients who underwent surgery (n=71) were compared between patients with preoperative CRP>or=6 mg l-1 and those with CRP<6 mg l-1. Univariate and multivariate analyses were performed to identify prognostic factors after surgery. Patients with an increase of CRP prior to surgery showed inferior survival compared to patients with normal levels. Patients with normal CRP levels at diagnosis but elevations prior to surgery do seem to have a similar unfavourable overall survival (OS) than patients with an increase both, at diagnosis and at surgery. Conversely, patients with normal CRP levels prior to surgery still have the best OS, irrespective of their basic values. Multivariate analysis revealed preoperative CRP levels above 6 mg l-1 Lactate dehydrogenase (LDH) above normal, and osteolyses in long weight bearing bones as independent predictors of survival. These findings suggest that in patients with MM serum levels of CRP increase during disease activity and might be significantly correlated with specific disease characteristics including adverse prognostic features such as osteolyses in long weight bearing bones. Thus, preoperative elevated CRP serum levels might be considered as independent predictor of prognosis and could provide additional prognostic information for the risk stratification before surgical treatment in patients with myeloma bone disease.

[Case report of Ito-syndrome associated with congenital hemihypertrophy from the orthopaedic point of view]. / Fallbericht über das Ito-Syndrom mit angeborener Hemihypertrophie aus orthopädischer Sicht.

We report on the orthopaedic treatment of a patient with the very rare Ito syndrome and congenital hemihypertrophy. The leading symptom is the lamellar depigmentation of the skin for which it is synonymously called incontinantia pigmenti acromians. Further anomalies are found in the central nervous system, as well as the ocular and the musculoskeletal systems. The treatment of the hemihypertrophy and the coexistent dysplasia of the hip with a combination of intertrochanteric shortening osteotomy and a triple osteotomy are specified and further methods are discussed.

Bone mineral density and degenerative changes of the lumbar spine in former elite athletes.

The aim of this study was to assess bone mineral density (BMD) and degenerative changes in the lumbar spine in male former elite athletes participating in different track and field disciplines and to determine the influence of body composition and degenerative changes on BMD. One hundred and fifty-nine former male elite athletes (40 throwers, 97 jumpers, 22 endurance athletes) were studied. Anthropometric (age, body mass index [BMI]) and sport-specific data (personal best, intensity, duration, and time since termination of competitive sports career as well as current sporting activity) were collected. Degenerative changes of the lumbar spine in lateral view were evaluated by using the Kellgren and Lawrence Score. Bone mineral density of the lumbar spine was measured in an anterior-posterior view with dual energy X-ray absorptiometry (DEXA, T-score). Throwers had a higher body mass index than jumpers and endurance athletes. Throwers and jumpers had higher BMD (T-LWS) than endurance athletes. Bivariate analysis revealed a negative correlation of BMD (T-score) with age and a positive correlation with BMD and Kellgren score (p<0.05). Even after multiple adjustment for confounders lumbar spine BMD is significantly higher in throwers, pole vaulters, and long- and triple jumpers than in marathon athletes. Different types of mechanical loading caused by sporting activities seem to influence the BMD of the lumbar spine, even if different body constitutions (i.e. BMI) and age, training history, and degenerative changes in the lumbar spine of former throwers, jumpers, and endurance athletes are taken into consideration.

[Prevalence and correlates of osteoarthritis in Germany. Representative data from the First National Health Survey]. / Prävalenz und Korrelate der Osteoarthrose in der BRD. Repräsentative Ergebnisse des ersten Bundesgesundheitssurvey.

BACKGROUND: The purpose of the paper was to generate up-to-date, representative osteoarthritis prevalence data for individual population subgroups and to identify potential risk factors. MATERIAL AND METHODS: A cross-sectional study, the "First National Health Survey", investigated the prevalence of osteoarthritis, comorbidity and health-relevant behaviours of the post-unification German population on the basis of interviews with physicians and medical evaluations conducted in the period from October 1997 to March 1990. The study was based on a net sample comprising 6205 subjects aged 18-79 years. RESULTS: The three main correlates for osteoarthritis are age, obesity and occupational stress factors. Osteoarthritis patients are more likely to have osteoporosis, thyroid disease, chronic bronchial disease, hypertension and elevated blood lipids, but do not tend to have a higher incidence of diabetes. CONCLUSION: Our data show the importance of preventive behavioural approaches such as weight management and workplaces designed to limit joint overuse.

[Pressure distribution after scarf osteotomy for hallux valgus surgery]. / Druckverteilungsmessung nach Scarf-Osteotomie bei Hallux valgus.

AIM: This study evaluates the pressure distribution, the radiological and clinical results in patients before surgery and 6 months after scarf osteotomy for hallux valgus. METHODS: 29 patients were examined before surgery and 6 months after surgery for symptomatic hallux valgus. Pedographic analysis was performed by dividing the footprint of the patients into 8 regions of interest. For each region the maximum mean pressure and the peak pressure were evaluated. Moreover, clinicofunctional results (AOFAS score) and radiological results were evaluated. RESULTS: 6 months postoperatively, maximum mean pressure increased significantly under the medial forefoot where as the peak pressure in this region revealed indifferent results. Significant improvement of clinicofunctional results and a significant reduction of the intermetatarsal and metatarsophalangeal angle could be seen. CONCLUSION: These results confirm the clinical and radiological findings of other studies, but this study shows for the first time an increase of pressure under the first ray of the foot after hallux valgus surgery and an adaptation to the pressure distribution of normal feet.

Long-term survival after surgical intervention for bone disease in multiple myeloma.

BACKGROUND: We describe the surgical treatment, outcome and long-term survival of patients with multiple myeloma (MM) in response to conventional (CC) or high-dose (HDT) chemotherapy. PATIENTS AND METHODS: Eighty-four patients diagnosed with MM were recruited for the study (51 male, 33 female; median age 62 years) and consecutively surgically treated in a single institution during a 12-year period. The main end point of the study was overall survival after surgery. Cox regression analysis was used to estimate the effect of factors that may predict survival. RESULTS: Spinal surgery was performed in 54 cases, and 30 patients were surgically treated at the extremities. The post-surgical complication rate was low (17%; 14/84 patients). The median overall survival time was 47 months. Patients receiving HDT had a longer 5-year overall survival rate than patients receiving CC (51% versus 33%). Univariate predictors of mortality included age >65 years [risk ratio (RR) 1.62; P=0.023], osteolyses in long weight-bearing bones (RR 2.23; P=0.007) and an elevated C-reactive protein level >5 mg/l (RR 1.82; P=0.016); the latter remained significant as a predictor in multivariate analysis (RR 2.66; P=0.0209). CONCLUSIONS: Given the high number of patients reaching 5-year overall survival and the low post-surgery complication rate, surgery should pursue a long-term stable reconstruction of the affected bone.

[Bone and soft-tissue tumors of the foot and ankle]. / Knochen- und Weichteiltumoren des Fusses und Sprunggelenkes Epidemiologie, Versorgungsstrategie und klinisch-funktionelle Ergebnisse nach operativer Therapie.

BACKGROUND: This study reports the epidemiology of bone and soft-tissue tumors of the foot and ankle, presents therapy strategies, and evaluates mid-term clinicofunctional outcome after surgery for malignant tumors. METHODS: Two hundred four patients with tumors of the foot and ankle were analyzed (163 benign and 41 malignant). Epidemiology and surgical therapy are reported. RESULTS: The most frequent tumors were exostosis, bone cyst, and osteoid osteoma for benign tumors and metastases and chondrosarcoma and Ewing's sarcoma for malignant tumors. In more than 90% of the benign tumors, local resection could be carried out, whereas in malignant tumors, ablative procedures and arthrodeses were almost as common as limb- and joint-sparing techniques. However, follow-up revealed good functional results and a 5-year survival rate of 84% for patients with primary malignant tumors. CONCLUSION: Tumors of the foot and ankle require a thorough therapeutic strategy. Mid-term functional results and survival rate after surgical treatment are good, although a high percentage of ablative procedures or fusions could not be avoided in our patients.

Primary malignant tumours of bone and soft tissue in the elderly.

AIMS: This study reports outcome, functional results and quality of life of 45 elderly patients with age over 70 after surgery for primary malignant bone and soft tissue tumours. METHODS: There were 24 primary malignant bone tumours and 21 soft tissue sarcomas. The most frequent diagnoses were: chondrosarcoma, malignant fibrous histiocytoma and liposarcoma. Local tumour resection with and without osteosynthesis, endoprostheses, and amputations had been performed for surgery. The patients were prospectively followed in a tumour register. RESULTS: Complication and revision rate, functional outcome using the Musculoskeletal Tumor Society score, 5-year survival rate, median survival time and quality of life according to the Life Satisfaction Index A and the global health and quality-of-life scale of the QLQ-C30 revealed results that are only slightly inferior to those reported in younger tumour patients. CONCLUSIONS: The results of this study generally justify even extensive tumour surgery in the elderly patient over 70 although outcomes are not quite as good as those reported for younger adults. However, especially in the old patient indications like general condition and comorbidity should be given due consideration before any decision is made on whether surgery should be performed and if so what surgical technique should be applied.

Complications following operative treatment of primary malignant bone tumours in the pelvis.

AIM: To report the complication rates of limb-salvage reconstruction in the pelvis. Detailed analyses about the type, treatment and outcome of post-operative complications, various reconstruction options are presented. METHODS: Factors that might influence the occurrence of complications were evaluated of 50 consecutive surgically treated patients. RESULTS: The mean follow-up was 57 months. Limb-salvage procedures were used in 42/50 patients, amputations in 8/50 patients. After limb-salvage procedures complications occurred in 32/42 patients, after hemipelvectomy in 6/8 patients. The 1 and 5-year overall survival rate was 92 and 68%, respectively. CONCLUSION: There is a high complication rate in reconstructive techniques using hemipelvic autografts and/or allografts. These procedures are appropriate only in well selected patients. The complication rates following endoprosthetic reconstruction are comparably low.

[Outcome between surgical and non-surgical treatment of metastatic tumors of the spine: a retrospective study of 259 patients]. / Vergleich zwischen operativen und nicht-operativen Verfahren bei Wirbelsäulenmetastasen: Eine retrospektive Studie an 259 Patienten.

AIM: The purpose of this study was to evaluate the clinical outcome of patients with metastatic tumors of the spine after surgical and non-surgical treatment. METHODS: The charts of 259 patients with metastatic tumors of the spine were reviewed retrospectively to define predictors of outcome. Our data included patient demographics, primary tumor, location of the metastatic tumor within the spine, indication for surgical or non-surgical treatment, type of surgical and non-surgical intervention, post-treatment outcome in terms of neurology, use of adjuvant radiation therapy or systemic therapy. RESULTS: The most frequent indication for surgical treatment was the combination of neurological deficit (ND), pathological vertebral fracture, and pain (50 %). Surgical intervention was performed by the posterior approach in 67 %, by the anterior approach in 13 %, and by an anterior/posterior approach in 10 %. The post-surgical outcome, depending on the type of surgical approach in terms of ND, was for the posterior approach 29 % improved, for the anterior approach 53 % improved, and for the anterior/posterior approach 15 % improved. DISCUSSION: Our data suggest that the indications for metastatic tumor surgery in the spine depend on the location of the metastatic tumor in the spine, clinical symptoms, and prognosis.

Equal quality of life after limb-sparing or ablative surgery for lower extremity sarcomas.

This study investigated quality of life (QoL) and function of 124 patients with lower extremity sarcoma who underwent either amputation or limb-salvage surgery (LSS) in order to assess potential differences in subjective treatment outcome. The results reflect similar QoL in both treatment groups. However, in contrast to patients with LSS, who described QoL in terms of a high physical performance status with sports and recreational activities, amputees' QoL was strongly associated with their social acceptability. High QoL in amputees brings into question the expectations held with time-consuming advanced technical skills for LSS by physicians.

[Tibial realignment with external fixator]. / Tibiakopfumstellung mittels Fixateur externe.

External fixation is a proved method for high tibial osteotomies. It is easy to access, allows postoperative corrections of the alignment, and can be removed without additional narcosis. Disadvantages are the frequent infection of the pin tracks and discomfort in bearing compared to internal fixation. In our own study no difference between unilateral and bilateral fixation could be found regarding loss of correction and complications. The advantage of unilateral fixation is the possibility of doing an open-wedge procedure by unilateral continuous callus distraction (hemicallotasis). This is indicated if medial collateral instability can be compensated by the open-wedge technique. The occurrence of neural injuries was significantly less frequent after hemicallotasis. Regular radiological and clinical control of the axis is necessary to prevent loss of correction, which was significantly more frequent in open-wedge osteotomies.

[Experiences with vascular pedicled fibula in reconstruction of osseous defects in primary malignant bone tumors]. / Erfahrungen mit der gefässgestielten Fibula in der Rekonstruktion von ossären Defekten bei primär malignen Knochentumoren.

To bridge large bone defects after resection of primary malignant bone tumors, an autologous free vascularized fibular graft was used in 31 patients (15 x upper limb, 16 x lower limb). The median bone defect measured 16 cm (7-29.5 cm). At the lower extremity the vascularized fibular transplant was reinforced with an allograft and different osteosyntheses. At the upper limb stabilization of the transplant was obtained exclusively by plate osteosynthesis or condylar plate. Applications and the authors' experiences are described and discussed in terms of clinical outcome, graft union, functional outcome, and complications for each localization. After a median of 48 months, ten complications at the upper limb and eight complications at the lower limb, respectively, were seen requiring secondary surgical revision. Major complications such as perioperative deaths or secondary amputations were not observed. Functional evaluation showed better results for the lower than for the upper extremity, due mainly to en bloc resection of proportionally large amounts of soft tissues around the shoulder girdle for local tumor control. Despite the demanding operative procedure and a large number of controllable complications, the good functional outcome and high patient satisfaction indicate that the free vascularized fibular graft is an option for limb-sparing surgery of primary malignant bone tumors.

[Intraoperative extracorporeal irradiation and replantation in local treatment of primary malignant bone tumors]. / Intraoperative extrakorporale Irradiation und Replantation (IEIR) in der lokalen Behandlung primär maligner Knochentumoren.

In 13 patients with primary malignant bone tumors (10 Ewing's sarcoma, 1 parosteal osteosarcoma, 1 adamantinoma recurrence, and 1 MFH) local therapy was performed as intraoperative extracorporeal irradiation and replantation (IEIR) of the involved bone segment (5 tibia, 2 femur, and 6 pelvis). Of the 13 patients (69%), 9 are alive at the time of the follow-up (5 CDF, 4 AWM(treated)) and 4 patients died of disease (DOD). Up to now during the follow-up of 32 months (6-57), no local recurrence was observed in the replanted bone segments. The complication rate was very high (18 complications in 11 of the 13 patients, including 6 cases with complication V degrees according to Ruggieri with loss of the reconstruction). The typical complication is severe local infection necessitating removal of the replant. In cases of mechanical failure, the replanted segment could mostly be preserved by surgical revision and autologous bone grafting. If serious complications can be managed or avoided, functional results can be achieved. IEIR must be seen as an extraordinary reconstruction procedure in cases where established procedures such as endoprosthesis, biological reconstructions, or rotationplasties cannot be used or are refused by the patient.

[Amputation or limb salvage? Assessing quality of life after tumor operations of the lower extremity]. / Amputation oder Extremitätenerhalt? Beurteilung der Lebensqualität nach Tumoroperationen an der unteren Extremität.

The purpose of this study was to compare quality of life and subjective well-being between patients who underwent either amputation or limb-salvage procedures for lower extremity sarcomas in order to determine if this aspect can be considered in the decision on the type of surgery. Sixty-six patients were evaluated at least 1 year after surgery and systemic therapy for lower extremity sarcomas. Self-report questionnaires such as the Quality of Life Questionnaire (QLQ-C30), the Life Satisfaction Questionnaire (FLZ), and the Enneking Score (MSTS) were used. There were no differences in quality of life and subjective well-being between the two groups. Scores of the symptom scale (14.1 vs 13.2), the global quality of life (70.9 vs 71.0) as well as scores of the function scale (51.7 vs 50.3) were similar. Small differences in scores were found in social functioning but not in scores of physical, cognitive, and emotional functioning. Global subjective well-being in both groups was also similar (219.5 vs 223.7). High satisfaction was found in marital life and partnership as well as in self-assessment. The least satisfaction was found in finances. Results in functional outcome after limb-salvage procedures (77% vs 65%) were better. Although more complications were reported after limb-salvage procedures, they did not seem to have any impact on quality of life ( p=0.235, r(p)=0.112) and subjective well-being ( p=0.856, r(p)=0.140) of the patients whereas a correlation to function could be shown ( p<0.001, r(p)=0.595; p=0.015, r(p)=0.304). Additionally, a correlation between subjective well-being and the location of either amputation or reconstruction ( p=0.039, r(p)=- 0.309) could be shown. These findings demonstrate that the type of surgery has no influence on quality of life and subjective well-being after lower extremity sarcomas. Thus the decision for either limb-salvage procedures or amputation cannot be based on quality of life and subjective well-being but must be determined by oncological criteria.

[External or internal fixation for arthrodesis of the ankle -- a comparative study of perioperative and long-term results]. / Vergleich zwischen externer und interner Fixation bei Arthrodese des oberen Sprunggelenks. Perioperative und langfristige Ergebnisse.

SUBJECT: This study evaluates the results of external and internal fixation techniques for arthrodesis of the ankle. METHODS: Perioperative and subjective, clinical, and radiological long-term results (average follow-up: 9 years) in 55 patients following arthrodesis of the ankle due to posttraumatic arthritis were compared in two groups with different fixation techniques--compression arthrodesis with external fixator (AO) or internal screw fixation. RESULTS: Patients with external fixation revealed a significantly higher deep infection rate, which was treated conservatively, while the rates of nounion, revision surgery due to infection, and total revision surgery did not show any difference in the two groups. CONCLUSION: Both surgical techniques applied mostly guarantee a safe and stabile fixation in arthrodesis of the ankle and provide convincing long-term results without showing a difference in comparing the outcome.

Pattern of periprosthetic bone remodeling around stable uncemented tapered hip stems: a prospective 84-month follow-up study and a median 156-month cross-sectional study with DXA.

Bone resorption in the proximal femur is commonly seen after total hip arthroplasty (THA). With dual energy X-ray absorptiometry (DXA), the amount of bone mass (BMD) after implantation of a total hip stem can be precisely determined. However, prospective evaluation of the change of bone mass around the stem is only available for selected stems and short-term follow-up (up to 36 months). We analyzed BMD in patients who had undergone uncemented THA by DXA. Only patients with good clinical outcome (Merle d' Aubigné score > 12) were included to obtain normative data for regular bone response. Two separate studies were performed: a prospective longitudinal study over 84 months with baseline values acquired within the first postoperative week (group A) (n = 26 patients) and a separate cross-sectional study, median follow-up 156 (124-178) months (group B) (n = 35 patients). Regions of interest were defined according to Gruen (ROI 1-7) and as net average ROI (net avg) for the periprosthetic femoral bone. After the initial remodeling process (12 months), BMD was compared to the 84-month (longitudinal) and the 156-month (cross-sectional) follow-up values to determine long-term periprosthetic changes of bone mineral density. The longitudinal study (group A), after the initial bone remodeling, showed no relevant further bone loss for women and men with BMD values 1.19 +/- 0.15 and 1.40 +/- 0.19, respectively, 12 months (women 89.8%, men 93.6%), and 1.19 +/- 0.13 and 1.36 +/- 0.18, respectively, after 84 months (women 90.0%, men 91.3%) (P = 0.98, P = 0.08,) respectively. The distribution of the BMD around the stem changed during the first 12 months. The ROIs around the proximal stem (ROI 1 and 7) showed the lowest absolute values at the 12-month follow-up and BMD in ROI 7 decreased most during the further follow-up until 84 months. The cross-sectional study (group B) showed no significant difference in BMD (net avg) values at a median of 156 months follow-up compared to the 12-month values (group A) (women: P = 0.77, men: P = 0.44). Initial BMD, implant diameter, and body mass index did not influence BMD loss (net avg) in this study, whereas age showed a weak correlation with BMD loss. The results show that after the initial remodeling process, no relevant further bone loss (net avg) occurs up to 84 months postsurgery, and values after a median of 156 months are similar. Normative long-term changes in the periprosthetic bone can be demonstrated in defined ROIs after implantation of a tapered corundum-blasted titanium stem with a good clinical result.

[Eikenella corrodens-induced spondylitis. Detection with 16s-RNA polymerase chain reaction]. / Eikenella-corrodensinduzierte Spondylitis. Nachweis mittels 16s-RNA-Polymerasekettenreaktion.

Isolation of the relevant organism in patients with spondylitis even after an open biopsy is successful only in 75-90%. The rare case of an Eikenella corrodens-induced spondylitis is presented, which could only be identified using 16S ribosomal DNA polymerase chain reaction following unsuccessful microbiological cultivation. Eikenella corrodens is a facultative anaerobic gram-negative organism, which is mostly found in the oropharynx of healthy patients.