High complication and revision rates after total femoral replacement: a retrospective single center analysis of indication, function, and complication.

INTRODUCTION: Total femoral replacement (TFR) is a limb salvage procedure performed for large bony defects. However, it is often associated with major complications and reduced function. Data on limb preservation rates and functional outcomes after TFR are limited. The primary objective of this study is to assess indications, functional outcomes, and complications after TFR. MATERIALS AND METHODS: We retrospectively analyzed all patients after TFR between 2006 and 2016. All patients received a modular mega endoprosthesis (MUTARS®). Patients were grouped according to their initial indication for TFR: (1) fracture, (2) tumor, or (3) infection. We evaluated (i) patient survival, (ii) postoperative function with the Musculoskeletal Tumor Society Score (MSTS), knee strength, range of motion, and (iii) complications. RESULTS: Between 2006 and 2016, TFR was performed in 22 patients with a mean age of 64 +/-17 years. Indications for TFR were tumor (n = 6), infection (n = 8) and fracture (n = 8). The mean follow-up (f/up) was 18 months. At final follow-up, mean MSTS was 24%. Mean knee flexion strength was reduced 63% compared to the contralateral leg (p = 0.004). At time of final f/up, 5 patients (22%) died, 5 (22%) underwent secondary hip exarticulation, and 12 (54%) suffered a major complication. At f/up, 11 patients had infections. Of these 11 patients, 5 died, 4 were treated with debridement, and 5 were treated with hip exarticulation. Fifteen patients survived with preserved limbs at f/up. CONCLUSION: TFR is a salvage procedure with limited functional outcome and high complication rates. Nevertheless, the majority of our cohort could be treated successfully with limb salvage.

[Injury prevention in amateur football with FIFA 11+ : What is implemented on the football pitch?] / Verletzungsprävention im Amateurfußball mit FIFA 11+ : Was kommt auf dem Sportplatz an?

BACKGROUND: The warm-up and injury prevention program FIFA 11+ was developed to reduce injuries in recreational and amateur level football. Despite systematic education it is uncertain what amount of knowledge is passed down to the lower recreational level football players and what exercises are implemented in the daily routine. This study presents the summarized experiences of German coaches about the implementation of exercises on the football pitch. MATERIAL AND METHODS: In this study 142 coaches who participated in 1 (of 5) of the 2­day courses between 2013 and 2017 were sent a questionnaire. The questionnaire consisted of 24 questions, which were developed by the football union of Lower Saxony. Incomplete questionnaires were excluded from the study. RESULTS: A total of 121 questionnaires could be analyzed, which is a response rate of 85.2%. The mean time period between the 2­day training and answering the questionnaire was 29 months. Of the participating coaches 82.6% indicated that they use the program regularly (22% of the coaches use it twice a week or more frequently, 34% use it only once a week) and 6% of the coaches use additional programs to prevent injuries. A total of 86% of the participants believed in a reduction in the incidence of injuries induced by the FIFA 11+ concept, 89% of the participants rated the FIFA 11+ program as good ors very good, 91% rated the teaching concept as good or very good and 94% of the participants would recommend the 2­day advanced course to others. DISCUSSION: The prevention program as well as the advanced training concept were evaluated very positively. Most coaches use the program regularly. Nevertheless, many coaches use the FIFA 11+ exercises less than the recommended twice a week. Most coaches praised the good structure of the program, but also wished for the possibility of variations. CONCLUSION: The prevention program FIFA 11+ is seen by coaches in recreational and amateur football as an effective tool to prevent injury. Implementation on the football pitch is regular but not as frequent as the evidence-based recommendations in the training concept.

Serum uric acid is not independently associated with plasma renin activity and plasma aldosterone in hypertensive adults.

BACKGROUND AND AIMS: In experimental investigations conducted in rats, raising serum uric acid (SUA) levels resulted in the stimulation of intrarenal renin expression. Studies in humans exploring the association of SUA with plasma renin activity (PRA) yielded conflicting results. Moreover, little is known about the relationship of SUA with plasma aldosterone concentration (PAC). The study aimed to assess the relationship between SUA levels, PRA, and PAC and the influence of age, gender, body mass index (BMI), and hyperuricemia on these relationships in subjects with essential hypertension (EH). METHODS AND RESULTS: We enrolled 372 hypertensive patients (mean age 45 ± 12 years, men 67%) with uncomplicated EH that was not pharmacologically treated. The study population was divided in tertiles according to SUA levels. While PRA did not differ significantly across the three tertiles, PAC was higher in subjects belonging to the uppermost tertile of SUA than those in the lower ones (p = 0.0429); however, this difference lost statistical significance after adjustment for age, sex, BMI, and serum creatinine. Univariate correlation analyses showed significant associations of SUA with PRA (r = 0.137; p = 0.008) and PAC (r = 0.179; p < 0.001). However, these relationships were not significant after correcting for confounding factors in multiple linear regression analyses. We did not observe statistically significant effect modification by gender, age, BMI, and hyperuricemia. CONCLUSION: SUA levels are weakly associated with PRA and PAC in adults with untreated EH. These relationships were lost after adjustment for age, sex, BMI, and serum creatinine.

Effect of intraoperative weight-bearing simulation on the mechanical axis in total knee arthroplasty.

PURPOSE: Successful outcome after total knee arthroplasty (TKA) requires precise realignment of the mechanical axis. The intraoperative assessment of the mechanical axis is difficult. Intraoperatively, the effect of weight bearing on the lower limb mechanical axis is ignored. We developed a custom-made mechanical loading device to simulate weight-bearing conditions intraoperatively and analysed its effect on the mechanical axis during TKA. METHODS: Measurements of the mechanical axis were obtained during 30 consecutive primary TKAs in osteoarthritic patients using image-free knee navigation system. Half body weight was applied intraoperatively using our device to quantify the effect of intraoperative load application on the mechanical axis, thus receiving indirect information about soft tissue balancing. Furthermore, the intraobserver and interobserver reliability of navigated mechanical axis measurement with and without load was determined. RESULTS: Before TKA, mean mechanical axis was 4.0° ± 4.9° without load. Under loading conditions, the mean change of the mechanical axis was 2.1° ± 2.8°. Repetitive measurements of the senior surgeon and junior surgeon revealed a high intraobserver (ICC 0.997) and interobserver reliability (ICC 0.998). The registration of the mechanical axis without and with application of intraoperative loading demonstrated no significant differences during insertion of the trial components (SD 0.29 ± 0.29) and after the definitive component cementation (SD 0.63 ± 0.44). CONCLUSIONS: Intraoperative quantification and analysis of the mechanical lower limb axis applying defined axial loading by our custom-made loading apparatus is reliable. Ligament stability was unbalanced before TKA and balanced after TKA. For TKA, intraoperative simulation of weight bearing may be helpful to quantify, control and correct knee stability and its influence of mechanical axis.

[Biopsy and approach routes for bone tumors. Where and how much is sufficient?]. / Biopsie und Zugangswege bei Knochentumoren. Wo und wie viel ist genug?

Although biopsies are a key step in the diagnosis of bone tumors, they are often still referred to as a minor intervention which can be carried out by any surgeon as an outpatient procedure or quickly carried out between other more important tasks. A biopsy should, however, be regarded as the final part of the diagnostic procedure preceded by careful evaluation of the clinical course and analysis of the required imaging studies. Although the biopsy procedure seems technically simple to perform, an incorrectly performed biopsy can become an obstacle to correct tissue analysis (sampling error) and adequate tumor resection and may reduce the patient's chances of survival. The principles by which an adequate and safe biopsy of bone tumors should be planned and executed are reviewed and the surgical approaches to different anatomical locations are presented.

[New therapy approaches for giant cell tumors]. / Neue Therapieansätze beim Riesenzelltumor.

BACKGROUND: Giant cell bone tumors (GCT) are benign but partially locally aggressive osteolytic tumors which typically occur around the knee joint in the epiphysis and metaphysis of long bones after maturation of the skeleton is completed. Due to the locally aggressive growth behavior with destruction of the bone structure, the rare possibility of pulmonary metastases in recurrent cases and a very rare possibility of malignancy, GCTs were previously also described as semimalignant bone tumors. THERAPY: The established therapy of these tumors at the typical locations consists of intralesional curettage, extension of resection margins using a high speed trephine and defect reconstruction with bone cement. The local recurrence rate is high (10-40 %) and lowest after using thermal extension of resection margins with a high speed trephine and defect reconstruction with bone cement. For uncommon localizations, such as the spinal column and the sacrum as well as in cases of recurrence, surgical treatment is more complicated. HISTOLOGY: Histologically, GCTs consist of osteoclastic giant and oval-shaped stromal cells which show a high expression of receptor activator of nuclear factor-κB ligand (RANKL) and decisively contribute to the osteolytic activity of the tumor. Novel pharmaceutical therapy approaches with human monoclonal RANKL antibodies interfere in this osteodestructive process in an inhibitory manner and can represent alternative treatment options just as the osteosupportive therapy with bisphosphonates. CONCLUSION: After unsatisfactory attempts at surgical treatment of GCT patients, the new treatment option with denosumab is a promising alternative due to its effect as a monoclonal RANKL inhibitor.

SAXS study on myoglobin embedded in amorphous saccharide matrices.

We report on Small Angle X-ray Scattering (SAXS) measurements performed on samples of carboxy-myoglobin and met-myoglobin embedded in low hydrated matrices of four different saccharides (trehalose, sucrose, maltose and lactose). Results confirm the already reported occurrence of inhomogeneities, which are not peculiar of trehalose samples, but appear also in maltose and lactose, and in some cases also sucrose, being dependent on the sample hydration and on the presence of sodium dithionite. This behaviour confirms our previous interpretation about the nature of the inhomogeneities, and prompt it as a possible general behaviour for highly concentrated sugar matrices.

[The critical incident reporting system as an instrument of risk management for better patient safety]. / "Clinical Incident Reporting System" als Instrument des Risikomanagements für mehr Patientensicherheit.

The probability that an inpatient will be harmed by a medical procedure is at least 3% of all patients. As a consequence, hospital risk management has become a central management task in the health care sector. The critical incident reporting system (CIRS) as a voluntary instrument for reporting (near) incidents plays a key role in the implementation of a risk management system. The goal of the CIRS is to register system errors without assigning guilt or meting out punishment and at the same time increasing the number of voluntary reports.

Modified rerouting procedure for failed peroneal tendon dislocation surgery.

UNLABELLED: Recurrent dislocation of the peroneal tendons following operative treatment is relatively uncommon, but can be difficult to treat. We asked whether subligamental transposition of the peroneus brevis tendon, fibular grooving, and reattachment of the superior peroneal retinaculum for failed peroneal tendon dislocation surgery would achieve a stable fixation of the peroneal tendons and whether there would be restrictions of ROM or instability of the hindfoot. We reviewed six female patients (mean age, 24.5 years) with general laxity of joints preoperatively and at 6 weeks and 3, 6, and 12 months postoperatively. Within 1 year postoperatively no recurrence was found. In two ankles the extension was restricted 5 degrees to 10 degrees . In another pronation and supination was restricted 5 degrees each. Stability of the ankle increased in four patients and stayed unchanged in two. AOFAS score increased from a mean value of 36 +/- 20.6 preoperatively to 90 +/- 7 postoperatively at 1 year. We conclude transposition of the peroneus brevis tendon is a reasonable treatment for failed peroneal tendon dislocation surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study (prospective case series). See Guidelines for Authors for a complete description of levels of evidence.

[Hannover-Polytrauma-Longterm-Study HPLS]. / Hannover-Polytrauma-Langzeit-Studie HPLS (I).

UNLABELLED: From the period of September 2000 to March 2006 Hannover Reinsurance and the Department of Traumatology of the Hanover Medical School conducted a retrospective observational study of the long-term outcome of patients after polytrauma. The follow-up period was on average 17 +/- 5 years. The goal of the study was to determine the social, financial, medical and psychological long-term outcome after a severe accident. Of the 1560 enrolled patients 519 patients died in the observed period, 397 patients were followed up but could not be examined, 637 patients (female n = 158, male n = 479) were examined and answered detailed questionnaires concerning their social, financial medical and psychological situation. 6 patients did not fullfil the input criteria and one patient had two polytraumata. The average age at the time of accident was 26.5 years (+/- 12.3). RESULTS: Financial losses were observed in 41.1% of all males and 44.4% of females. 21.7% of all male (female 18.4%) had no financial protection at all. Due to the accident 30.1% of all men were unemployed and 19.8% permanently disabled (women 27.4% and 27.6% respectively). Psychological treatment almost doubled after discharge from rehabilitation centres. Even 20 years after the accident extra-mortality was substantially increased by 79%. CONCLUSION: Ten to twenty years after polytrauma significant financial, social and medical impairments are still present.

Fatty degeneration of the deltoid muscle associated with displaced proximal humerus fractures.

INTRODUCTION: The use of reverse shoulder arthroplasty (RSA) has increased dramatically over the last two decades, with many surgeons now indicating RSA for the acute management of displaced proximal humerus fractures (PHF) in the elderly. RSA relies on adequate deltoid muscle function to obtain a good outcome, yet no literature to date exists which discusses preoperative assessment of deltoid structure prior to RSA. The purpose of this study was to assess for preoperative fatty deltoid-degeneration in patients with displaced PHF. MATERIALS AND METHODS: We reviewed the axial CT scans of 100 consecutive patients with a displaced PHF. Fatty degeneration within each of the three deltoid-heads was graded at three levels, according to Goutallier and colleagues. Fractures were classified according to Neer. RESULTS: Seventy-nine percent of the patients were female, 75% showed 3 or 4 parts fractures. The average cross-sectional area of the posterior deltoid was greatest-representing 37%, 40% and 42% of total area at each level, respectively. Severe fatty degeneration (Stages 3 and 4) was observed in the posterior deltoid only (26%). Absence of fatty degeneration (Stage 0) was observed in < 25% of cases. The Inter-Observer-Reliability for the continuous variables proved to be high. CONCLUSION: Preoperative deltoid fatty degeneration is common in displaced PHF in the elderly. Because CT is commonly obtained to assess fracture morphology and for preoperative planning purposes, it is an ideal tool to assess the deltoid additionally. Future studies are warranted to determine whether preoperative fatty infiltration of the deltoid correlates with mid and long term functional outcomes when RSA is used acutely to manage a PHF. LEVEL OF EVIDENCE: Level IV-consecutive case series.

Cell lineages in liver carcinogenesis: possible clues from studies of the distribution of alpha-fetoprotein RNA sequences in cell populations isolated from normal, regenerating, and preneoplastic rat livers.

We analyzed in isolated rat liver cell populations and in fetal and neoplastic livers the distribution of RNA sequences which hybridize with alpha-fetoprotein (AFP) complementary DNA clones. Parenchymal and nonparenchymal cell populations were isolated from normal, regenerating, preneoplastic, and bile duct-ligated rat livers. We found that oval cells, fetal liver, and a primary hepatocellular carcinoma contain the full length 2.3-kilobase AFP messenger RNA (mRNA); in normal adult rat liver, 2.3-kilobase AFP mRNA is found at low levels in an unidentified subpopulation of nonparenchymal cells but is not detected in hepatocytes; both parenchymal and nonparenchymal cells from normal or preneoplastic livers contain in variable proportion a smaller AFP RNA which hybridizes only with complementary DNA clones containing sequences located near the 5' end of the rat AFP gene; during liver regeneration induced by CCl4, elevation of the full length AFP mRNA occurs in nonparenchymal cells but seemingly not in hepatocytes. The results suggest that some cells in the nonparenchymal cell fraction of normal adult rat liver might retain the capacity to produce the 2.3-kilobase AFP mRNA found in large amounts in fetal livers, oval cells, and hepatic tumors. Although the nature of these cells remains to be determined, we suggest that such cells might be the source of the small amounts of AFP synthesized in normal rat liver and may constitute the proposed but as yet uncharacterized "facultative stem cell" compartment in rat liver.

TA1, a highly conserved oncofetal complementary DNA from rat hepatoma, encodes an integral membrane protein associated with liver development, carcinogenesis, and cell activation.

Hepatocellular carcinoma is characterized by changes in gene expression associated with cell growth and differentiation. Cell surface antigenic changes have also been described based on differential antibody reactivity between normal and neoplastic liver. We obtained a novel tumor-associated cDNA designated TA1 on the basis of its differential expression between hepatoma cells and normal liver. Sequence analysis predicted a 723-base pair open reading frame with the deduced amino acid sequence encoding an integral membrane protein containing multiple hydrophobic transmembrane domains. Database searches revealed TA1 as the likely rat homologue of E16, a recently cloned human cDNA associated with lymphocyte activation. Although noncoding sequences diverged significantly, the 95% conservation of the predicted proteins between species strongly suggests an important, although as yet undefined, function in normal cells. TA1 transcripts were detected in normal adult rat tissues including testes, brain, ovary, spleen, mammary gland, and uterus with the highest steady-state expression in placenta. Although no expression was detected in normal liver, all rat hepatomas examined expressed an abundant 3.2-kilobase transcript. TA1 expression was closely associated with progression in this tumor model and suggests this molecule, originally linked to cell activation, also plays a role in the malignant phenotype.

Expression of a highly conserved oncofetal gene, TA1/E16, in human colon carcinoma and other primary cancers: homology to Schistosoma mansoni amino acid permease and Caenorhabditis elegans gene products.

The peptides encoded by the rat liver oncofetal cDNA TA1 and the human lymphocyte activation gene E16 display a high degree of homology with coding regions recently identified in Schistosoma mansoni and Caenorhabditis elegans. Previous studies showed that up-regulation of TA1/ E16 expression was associated with rat hepatocarcinogenesis and human tumor cell lines; therefore, we analyzed several primary human tumors including a panel of 20 colon carcinomas to evaluate the relationship of TA1/E16 RNA and protein expression to neoplasia. A 4.0-kb transcript was detected in all but one colorectal carcinoma but not in normal colon or specimens of inflammatory bowel disease. Steady-state TA1/E16 mRNA levels varied considerably between carcinomas and did not correlate simply with mitotic index, modified Dukes' stage, or tumor size. TA1/E16 message also was detected in adenocarcinomas from breast, endometrium, salivary gland, and esophagus. Western blot analysis using antibodies against TA1/E16-deduced peptides identified major reactive bands of approximately 35 and 19 kDa in neoplasms but not in normal tissue. Immunoperoxidase staining localized the protein primarily to the supranuclear region of colon carcinoma cells, whereas normal epithelial cells were negative. Heterogeneous staining was found in villous adenomas with focal intramucosal adenocarcinoma but was negative in tubular adenomas, suggesting that expression of TA1/E16 may correlate with neoplastic progression in the colon. Up-regulation of this gene in various human cancers suggests a common role in the carcinogenic process and possible application as a tumor marker.

Thermoablation of Bone Tumors.

UNLABELLED: The aim of this article is to review the significance of percutaneous thermal ablation in the treatment of bone tumors. We describe available ablation techniques as well as advantages and disadvantages in specific settings. In detail, radiofrequency ablation (RFA), microwave ablation (MWA), laser ablation, high intensity focused ultrasound (HIFU) and cryoablation are presented. In the second part of this review curative and palliative indications for the treatment of benign and malignant bone tumors are discussed. This includes especially RFA, laser or cryoablation for the treatment of osteoid osteoma, as well as the palliative treatment of painful bone metastases, for example, by means of MWA or MR-guided HIFU. KEY POINTS: • The various thermoablative techniques demonstrate specific advantages and disadvantages.• Radiofrequency ablation is the evidence-based method of choice for treating osteoid osteoma.• Laser ablation is primarily suited for the treatment of small lesions of the hands and feet.• The intrinsically analgesic effect of cryoablation is advantageous when treating painful lesions.• Palliative treatment of painful bone metastases can for example be performed using MWA or MR-guided HIFU, by itself or combined with cementoplasty. Citation Format: • Ringe KI, Panzica M, von Falck C. Thermoablation of Bone Tumors. Fortschr Röntgenstr 2016; 188: 539 - 550.

Diagnostic benefit of echocontrast enhancement for the insufficient transtemporal bone window.

Echocontrast agents (ECA) are known to improve transcranial color-coded duplex (TCCD) imaging, but its diagnostic benefit in the routine clinical setting has not clearly been defined. The authors investigated the diagnostic benefit of ECA application in 54 patients with insufficient transtemporal bone window, consecutively referred to their ultrasound laboratory. According to the precontrast imaging quality, patients were assigned to three categories: A, no intracranial structures or vessel segments visible on B-mode imaging and TCCD (n = 5); and intracranial structures visible on B-mode imaging and vessel segments less than 5 mm in length (B, n = 21), or larger than 5 mm in length (C, n = 28) visible on TCCD. The effect of the echocontrast enhancement was assessed with respect to signal enhancement, imaging quality, and diagnostic confidence. In 49 out of 54 patients (91%), a significant improvement of the imaging quality was noted, enabling 43 (80%) neurovascular diagnoses of sufficient diagnostic confidence. The diagnostic ECA effect was strongly dependent on the precontrast imaging quality: upon echoenhancement, a satisfactory image quality was obtained in none of the patients of category A, as opposed to 16 (76%) and 27 (96%) patients of categories B and C, respectively. In summary, in 80% of our consecutive patient series with insufficient transtemporal bone window, application of ECA allowed for a conclusive TCCD study. Properties of the transtemporal precontrast scans are strongly predictive of the diagnostic benefit and should be taken into the decisive consideration.

[Diagnosis and therapy of soft tissue sarcomas of the extremities]. / Diagnostik und Therapie von Weichteilsarkomen der Extremitäten.

The diagnosis of unclear soft tissue tumors represents a common problem in everyday clinical practice. Magnetic resonance imaging often reveals some first information about soft tissue tumors; however, clarification of the dignity can only be achieved by histopathological examination. Most of the lesions are benign but should be treated as a malignant tumor until this can be excluded as unnecessary surgery or biopsies can complicate treatment and worsen the prognosis. These aspects in particular are summarized and discussed in this article.

Accuracy of digital preoperative planning for total knee arthroplasty.

INTRODUCTION: The accuracy of preoperative planning of the size of total knee arthroplasty (TKA) in literature is only 50%. A problem of conventional radiographic planning with prosthesis templates is varying enlargement of the radiographs. Digital planning and analysis of lower leg geometry revealed improved reliability compared to conventional techniques. The aim of the study was to evaluate the accuracy of digital planning of TKA with special planning software and calibrated radiographs and its interobserver reliability. METHODS: In a prospective study the sizes of 30 TKA were planned with special software by a senior and a junior surgeon independently. For calibration a 30 mm reference ball on the radiographs was used. The planning was compared with the intraoperative chosen size of the TKA. RESULTS: The correlation of the planned femoral component with the chosen size was 87% for the senior and 77% for the junior surgeon. The planning of the tibial component revealed a correlation for the senior surgeon in 90% and for the junior surgeon in 87%. Both component was planned correctly in 77% by the senior and in 63% by the junior surgeon. In 50% the planning of both surgeons matched completely the used prosthesis sizes. The linear κ coefficient of Cohen revealed a good agreement (0.65) and a high interobserver reliability. DISCUSSION: Planning TKA with special planning software with digital, calibrated radiographs is more accurate compared to previous conventional planning. The senior surgeons planning of both component sizes matched in 77% the correct size. Clinical experience improves the accuracy of preoperative planning.

[Rearthrodesis of the radiolunate joint]. / Die radiolunäre Rearthrodese.

Since 1983, radiolunate arthrodesis has been the gold standard for stabilising the rheumatic wrist. Rearthrodesis of the radiolunate joint has not yet been described. In a prospective study on five radiolunate rearthrodeses with a dorsal mini titanium plate and oblique screw, bone healing was achieved in four. Fatigue fracture of the plate occurred in one case of delayed bone healing. After another rearthrodesis using the same technique, bone healing was achieved. Complete fusion of the wrist can be avoided after failed radiolunate fusion using the described operative technique for rearthrodesis of the radiolunate joint. Preserving some wrist mobility is of high value for these multimorbid patients.