Neuromyelitis optica spectrum disorders and systemic lupus erythematosus: A case series from a university center.

Neuromyelitis optica spectrum disorders (NMOSD) are immune-mediated inflammatory diseases of the central nervous system (CNS), which preferentially affect the optic nerves and the spinal cord. Anti-aquaporin 4 antibody is a specific serological marker. Systemic lupus erythematosus (SLE) is a rheumatologic disease that may affect the CNS. There are several reports about the coexistence of NMOSD and autoimmune diseases, mainly those of rheumatologic origin. We describe three different cases in which SLE and NMOSD subsequently occurred, drawing attention to the clinical heterogeneity, the challenge and the importance of recognizing this possible association.

[The importance of ultrasonography in orthopedics]. / Stellenwert der Sonographie in der Orthopädie.

After patient history and clinical evaluation, sonography is a first-line modality in the orthopedic diagnostic algorithm together with laboratory results and standard radiographic findings. As an inexpensive investigation without known adverse effects it is used (and also repeated in the course of the disease) for the dynamic control of joint movements, and especially for imaging soft tissues. Sufficient training in the use of ultrasound in the musculoskeletal system is required; individual investigations are relatively time-consuming. The procedure is especially useful in evaluating the shoulder, hand, and knee regions and rheumatic illnesses.

[MR-based 3D-analysis of the pathomechanics of traumatic and atraumatic shoulder instability]. / MR-basierte 3D-Analyse der Pathomechanik der traumatischen und atraumatischen Schulterinstabilität.

AIM: Until now it is unknown to what extent malpositioning of the scapula is a relevant factor in shoulder instability that should be considered in therapy. The objective was to analyse 3D-scapular kinematics and humeral head (de-)centering in patients with atraumatic and/or traumatic shoulder instability and to investigate the correlation between the two factors. METHOD: The shoulders of 28 healthy volunteers and of 14 patients each with atraumatic or traumatic instability were examined in various arm positions - with and without muscle activity - using open MR imaging. After 3D reconstruction, analyses of scapular kinematics and glenohumeral translation were performed. RESULTS: In atraumatic unstable shoulders, the scapular position [30 degrees of abduction: scapulo-humeral rhythm: 3.5 +/- 2.6 : 1 vs. healthy 2.4 +/- 1.3 : 1; internal rotation: 59 +/- 9 degrees vs. healthy 49 +/- 3 degrees (p < 0.05)] and humeral head position was significantly decentered in both planes (p < 0.05). While the correlation between the two factors was high during passive elevation (r = 0.60-0.87), it was low during muscular activity (r = 0.25-0.62). In patients with traumatic instability no alterations of the scapula kinematics were observed. Significant humeral head decentering (p < 0.05) occurred only during abduction and external rotation. CONCLUSIONS: Patients with atraumatic instability demonstrated significant alterations of scapular kinematics and decentering of the humeral head. In traumatic instability a decentering occurred only in specific arm positions with no changes in scapula position. Because of the high correlation between the two factors, physiotherapeutic strategies for the scapula-stabilising muscles should be adapted to the direction of instability.

[Swan-neck and buttonhole deformities on rheumatic long fingers]. / Die Schwanenhals- und die Knopflochdeformität an den rheumatischen Langfingern.

Patients suffering from rheumatoid arthritis in many cases develop typical swan-neck and buttonhole deformities. In the further course of the disease we observe several stages. In the beginning active and later passive correction are still possible, while ultimately a fixed contracture is present. The activities of daily life may be severely reduced. The pathology of the swan-neck deformity is initiated at the level of the metacarpophalangeal joint, while at the origin of the buttonhole deformity the synovitis of the proximal interphalangeal joint is obvious. In the early stages, synovectomy and balancing of the soft tissues are surgically indicated. In advanced stages, complicated soft tissue reconstruction in combination with alloarthroplasty or arthrodeses may become necessary to allow for sufficient finger function.

[Resorbable pin refixation of an osteochondral fracture of the lateral femoral condyle due to traumatic patellar dislocation: case management, follow-up and strategy in adolescents]. / Pin-Refixation der lateralen Femurkondyle bei traumatischer osteochondraler Fraktur nach Patellaerstluxation: Case Management und Follow-up beim Jugendlichen.

AIM: Intraarticular osteochondral fractures resulting from traumatic patellar dislocation in children are reported most frequently between 13 and 15 years of age. Fracture localization concerns, apart from loose intraarticular bodies, the inferiomedial patellar facet and the lateral femoral condyle. Osteochondral fractures of the lateral femoral condyle with more than 50 % of its surface are extremely rare and reported infrequently. METHOD: We report a traumatic patellar dislocation in a 14 year old patient that let to an osteochondral fracture of the lateral femoral condyle. MRI-scan demonstrated an extensive fracture size concerning more than 50 % of the condylar surface with intraarticular dislocation. Initially arthroscopic surgery followed an open reduction and internal refixation of the osteochondral fragment with resorbable, poly-p-dioxanon pins. RESULTS: Follow-up MRI-scan revealed 7 weeks after surgery an adequate repositioning of the fragment with correct pin placement. Second-look arthroscopy demonstrated an osteochondral reintegration of the fragment within a period of 7 months after prior surgery. CONCLUSION: Resorbable poly-p-dioxanon pins as a mean for refixation of an osteochondral, intraarticular fracture in an adolescent, with an arthroscopic confirmed acceptable result, seem to be a considerable therapy option.

Pelvic emergency clamps: anatomic landmarks for a safe primary application.

The application of the pelvic clamp as a tool for emergency stabilization of unstable pelvic ring fractures has proved to be a life-saving procedure. Using correct technique, the pelvic clamp can be applied within a few minutes after the patient's admission. To avoid severe complications (eg, pin perforation into the pelvis) during the application, anatomic landmarks for the correct pin placement have to be defined. The surface landmarks that are presently recommended for the correct pin placement are not always reliably found due to deformation of the body surface caused by swelling and hematoma. Our experience with 43 emergency applications of the pelvic C-clamp showed that reliable anatomic landmarks on the bony surface of the innominate bone could be identified to ensure correct pin placement. The ideal insertion point of the pins is an anatomic region on the lateral cortex of the ileum, where an easily palpable "groove" is formed by angulations of the lateral cortex of the iliac wing. Being increasingly used as an entry point for percutaneous transiliosacral screw fixations of sacroiliac joint injuries and sacral fractures, this region, which is close to the sacroiliac joint, represents an ideal point for maximum compression of the posterior pelvic ring. With the described technique, this "groove" can be identified easily even in emergency situations by blunt palpation with an instrument, avoiding the time-consuming use of a fluoroscope in most cases.

[Ten year follow-up after single incision anterior cruciate ligament reconstruction using patellar tendon autograft]. / 10-Jahres-Ergebnisse nach arthroskopischer vorderer Kreuzbandrekonstruktion mit dem Patellarsehnentransplantat.

AIM: We evaluated 74 patients 10 years after arthroscopically assisted ACL reconstruction using the central third of the patellar tendon as autograft. METHOD: IKDC, Tegner and Lysholm scores were used for clinical evaluation. Ligament stability was tested using the Rolimeter instrument. For statistics we used the Chi square test. RESULTS: At follow-up the Tegner activity level was 5.2, the Lysholm score was 93.6 points. Subjective assessment for function was rated normal or nearly normal in 83.7 %, for stability in 71.6 %. The side-to-side difference measured with the Rolimeter was normal in 87.8% and nearly normal in 12.2 %. Pivot shift was proven to be negative in 94.6 %. 29.7 % of patients showed degenerative changes in X-rays at follow-up. There was a significant correlation between time interval from injury to surgery and the grade of degenerative changes. Arthrosis significantly correlates with the rate of meniscus injury. Acute operative treatment increases the rate of arthrofibrosis significantly. CONCLUSION: To avoid osteoarthrosis we recommend an early (subacute) ACL reconstruction and meniscus refixation in the case of meniscus injury.

[Is meniscal repair an adequate procedure to prevent early osteoarthritis in athletes with chronic anterior knee instabilitity?]. / Kann die operative Meniskusrefixation bei Sportlern mit persistierender chronisch ventraler Instabilität das Entstehen einer Früharthrose verhindern?

We retrospectively evaluated the clinical outcome of arthroscopic assisted meniscal suture repair in athletes on different competitive sports levels with stable joint function and persisting anterior knee instability. Return to former sports levels and early osteoarthrotic changes were especially focussed. Examination included 50 athletes (32 men, 18 women) who underwent meniscal repair in inside-out technique during the period of 1989 to 1998. 23 patients had isolated full-thickness meniscal tears, 27 an associated rupture of the anterior cruciate ligament which was reconstructed in 13 cases with a patellar-tendon autograft. 3 study groups were formed referring to the athletes preoperative sports level evaluated with Tegner's score. Reexamination included Lysholm score, IKDC score and Fairbank's score. With a mean age of 32.1 years (range 13-53 years) and an average follow-up of 6.3 years 72 % of the patients (n = 36) showed a stable joint function on reexamination. With no persisting anterior knee instability 86 % of the professional athletes returned to former full sports activities on competitive levels. Non competitive athletes returned in all cases (100 %) to their former level. Fairbank's score increased by 0.1 observing minimal osteoarthitic signs. However, persisting anterior knee instability showed on reexamination poor results. Only one third of all athletes were able to return to former activity levels. Osteoarthritic changes were observed in all patients. Professional athletes had the most severe osteoarthritic changes with a significant (p = 0.03) increase of 0.8 in Fairbank's score. The results demonstrate that complete recovery on sports activities after meniscal repair is not possible without reconstruction of the anterior cruciate ligament. Isolated meniscal repair shows poor results in persisting anterior knee instability and does not prevent increasing osteoarthritic changes in athletes.

[Can meniscal suture repair in athletes prevent early development of osteoarthritis without compromising the preinjury sports activity level]. / Kann die Meniskusrefixation bei Sportlern die frühzeitige Entwicklung einer Arthrose verhindern ohne das prätraumatische Leistungniveau zu verringern? - Eine radiologische und klinische Studie -

In a retrospective study we evaluated the outcome of arthroscopic assisted meniscal repair in athletes on different competitive sports levels. Examination included early osteoarthritic changes and full recovery in sports activities. Fifty athletes were followed up with an average of 6,5 years after meniscal refixation from 1984 through 1998. Twenty-three patients had isolated full-thickness meniscal tears, twenty-seven an associated rupture of the anterior cruciate ligament. Preoperative sports levels were evaluated with Tegners score. Reexamination included Lysholm score, IKDC score and Fairbanks score. With no persisting anterior knee instability 86 % of the professional athletes returned to former full sports activities on competitive levels. Noncompetitive athletes returned in all cases (100 %) to their former level. Fairbanks score increased by 0,1 observing minimal osteoarthitic signs. However, persisting anterior knee instability showed on reexamination poor results. Only one third of all athletes were able to return to former activity levels. Osteoarthritic changes were observed in all patients. Professional athletes had the most severe osteoarthritic changes with an increase of 0,8 in the Fairbanks score. The results demonstrate that complete recovery on sports activities is not possible without reconstruction of the anterior cruciate ligament. Isolated meniscal repair shows poor results in persisting anterior knee instability and does not prevent increasing osteoarthritic changes in athletes.

[Non-hodgkin-lymphoma of low malignancy (immunocytoma) and arthritis of the glenohumeral joint]. / Erstdiagnose eines niedrig malignen Non-Hodgkin-Lymphoms (Immunozytom) bei Arthritis des Glenohumeralgelenks.

AIM: Oligo- or monarthritis is reported as an uncommon complication of both acute and chronic leukemia. Childhood leukemias are complicated more frequently by leukemic arthritis (LA) than adult cases. LA occurs rather in acute than in chronic leukemia and can present at any stage of the disease. Proposed pathogenic mechanisms of arthritis in leukemia are leukemic infiltration of synovial tissue and resulting periosteal and capsular inflammation. As the primary manifestation of chronic lymphocytic leukemia (CLL) and immunocytoma (IC), LA is extremely rare. In such cases osteoarthritis may then be misdiagnosed as the source of joint disease. METHOD: We report a case of glenohumeral arthritis with complete rotator cuff tear and humeral head migration in an 88-year-old patient. Surgery exposed joint effusion, synovitis and chondromalacia with glenohumeral joint destruction. RESULTS: Histopathological examination revealed an articular chondrocalcinosis and bone marrow infiltration by an immunocytoma (B-cell non-Hodgkin lymphoma of low malignancy). CONCLUSION: Although LA is an uncommon complication in CLL and IC, it may be considered in elderly patients with lymphocytosis and arthritis.

Hyperbaric oxygenation as a successful therapeutic approach in oral wound dehiscence after operative stabilization of an unstable post-traumatic odontoid non-union.

The non-operative treatment of unstable traumatic Anderson's type II odontoid fractures has a high risk potential to develop non-unions. Even after operative stabilization literature reveals non-union rates up to 20%. Acute life threatening complications are tetraplegia and apnoea. Long-term complications induce chronic myelopathy resulting from persistent myeloradicular compression. We report the case of a patient with a 17-year-old post-traumatic pseudarthrosis of the dens axis following conservative treatment of an unstable type II fracture. By that time, the female patient, then 37 years old, was admitted to our hospital with early signs of cervical tetraplegia. After initial reposition and short-term immobilization with a halothoracic vest we performed a ventrodorsal atlantoaxial spondylodesis. Failure of anterior cervical plate stabilization and autologous graft resorption without a solid segmental fusion instigated a secondary surgical intervention. Postoperative therapy-resistant oral wound dehiscence showed an exposed autograft and osteosynthetic material. The reported positive effect of hyperbaric oxygenation on wound healing in problem cases led us to attempt this means of therapy. With a daily exposure to hyperbaric oxygenation, the dehiscence closed within 25 days. As a result of our experience in this case, hyperbaric oxygenation should be considered as a therapeutic option in postoperative complication management in orthopaedic surgery.

Surgical removal of a distinct subcutaneous metastasis of multilocular hepatocellular carcinoma 2 months after initial percutaneous ethanol injection therapy.

Subcutaneous tumor seeding after percutaneous ethanol injection therapy (PEI) for hepatocellular carcinoma is a rarely seen complication. It is reported due to needle track seeding during PEI after a distance of 6-46 months. Metastatic tumor spread is described subcutaneously, to the chest wall, abdominal wall and diaphragm. We report the case of a 76-year-old patient with chronic hepatitis B infection and cirrhosis which let to a multilocular hepatocellular carcinoma who underwent PEI. This patient developed 2 months after primary PEI a subcutaneous tumor formation confined to the right lower chest wall. Surgical tumor resection was performed. The histopathological evaluation confirmed subcutaneous seeding of the preknown hepatocellular carcinoma with a maximum of 30 mm in diameter. As a risk of PEI subcutaneous metastasis of the primary tumor should be considered even in early stage of therapy and close follow-up of the patient during treatment is required. Surgical tumor resection to ensure the curative intention of PEI is advisable.

[Multiorgan resection in combination with intraoperative, hyperthermic chemotherapy in recurrent fibrolamellar hepatocellular carcinoma. An individual therapeutic concept for a 21-year-old patient]. / Multiviszerale Resektion in Kombination mit intraoperativer, hyperthermer Chemotherapie beim Rezidiv des fibrolamellären, hepatozellulären Karzinoms. Ein individuelles, therapeutisches Konzept bei einem 21jährigen Patienten.

The fibrolamellar karzinoma of the liver (FLC) as an uncommon variant of the hepatocellular karzinoma (HCC) is an indolent growing tumor. In its prior manifestation the FLC occurs at the adolescence and young adult stage. Early stage diagnosis and aggressive surgical treatment achieve better long-term results than usual resection of the HCC. Usually the FLC is, caused by its inconspicuous clinical appearance, diagnosed at a stage too advanced for effective surgical treatment. Especially the young patient's age and the remaining therapeutic options for palliative or curative treatment postulate a difficult decision for the surgeon. When a subtotal hepatectomy cannot be performed, total hepatectomy with liver transplantation is a valuable option. Palliative treatment protocols include systemic chemotherapy, ethanol instillation and chemoembolisation. We report the case of a 21-year-old male patient who presented with a recurrent intrahepatic FLC, peritoneal karzinomatosis confined to the right lower abdomen including gastric, splenic, diaphragmatic and colon transversum metastasis 14 months after primary surgery. We selected this patient as a reasonable candidate for an extended resection in trying to offer the optimal therapeutic modality. Thus we performed a right hemihepatectomy, near complete resection of the right diaphragm, total gastrectomy with lymphadenectomy including en bloc resection of spleen, colon transversum, omentum majus and peritonectomy of the paravesical region. Furthermore hyperthermic intraperitoneal chemotherapy was carried out the next day. The patient's postoperative course remained uncomplicated with fast recovery. Presently, 6 months after surgery, the patient has no evidence of recurrence.

Dose thresholds and duration of the local anhidrotic effect of botulinum toxin injections: measured by sudometry.

BACKGROUND: Local injections of botulinum toxin type A (BTX-A) have been used successfully to treat focal hyperhidrosis, but because experimental data were lacking, doses have been chosen arbitrarily or empirically. OBJECTIVES: To analyse dose dependency and duration of BTX-A-derived suppression of sweat gland activity. METHODS: Employing a standardized scheme (four injections, square 2 x 2 cm), different doses of BTX-A [Dysport(R); 2.5-120 mouse units (MU)] were injected subcutaneously at the lateral aspects of both of the lower legs in 15 healthy volunteers. Sweat tests were performed before, and 3 weeks and 6 months after, BTX-A injections. Sweating was visualized by staining with iodine starch, and quantified by capacitance hygrometry after carbachol iontophoresis, the quantitative sudomotor axon reflex test (QSART). RESULTS: Iodine starch staining indicated a threshold dose of 10 MU (2.5 MU cm-2) leading to visible anhidrotic skin spots after 3 weeks in all subjects. This was maintained for 6 months with doses of 50 MU (12.5 MU cm-2) or higher, but the size of the anhidrotic skin area decreased over time (P < 0.001) indicating partial recovery at the edges. After 3 weeks QSART was significantly reduced (P < 0.02) and completely suppressed by doses of 80 MU (20 MU cm-2) or more, although after 6 months QSART increased again to pre-BTX-A levels (P < 0.001). Both methods indicated that the suppression of sweating is dose dependent (QSART: r = -0.70, P < 0.001; iodine starch staining: r = 0.74, P < 0.001). CONCLUSIONS: Our findings suggest that BTX-A effectiveness can be quantified by testing sudomotor function. For the first time threshold doses for the suppression of sweating have been defined.

[The macroscopic aspect of rotator cuff tears in traumatic and nontraumatic rupture cases]. / Der makroskopische Aspekt der Rotatorenmanschettenruptur bei traumatischen und atraumatischen Rupturformen.

The decision whether a rotator cuff tear has a traumatic or degenerative origin still causes some controversy. Especially in medical expert appraisals the etiology of the rotator cuff tear plays an important role referring to insurance services for the patient. The purpose of this paper is to compare the intraoperative pathomorphologic shape of the cuff tear in traumatic and degenerative cases. This study reports of 56 patients with rotator cuff tears which were divided in primarily acute, subacute traumatic and degenerative study groups referring to their history of present illness. We considered the location of the tear, the shape and the size. Furthermore the grade of retraction of the supraspinatus tendon, its quality and the shape of the long head of biceps were examined. The results showed that in general the shape of the tear gives only in some cases significant information whether the etiology is traumatic or not. The isolated rupture of the subscapularis muscle and the hematoma at the edge of the tendon is significant for the trauma. In comparison with the degenerative study group the tenosynovitis and the dislocation of the long head of biceps is in our study significant for traumatic tears.

[Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate]. / Hüftkopfnekrose nach Kondylenplattenosteosynthese einer proximalen Oberschenkelschaftfraktur.

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of sub-trochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.

Multivisceral resection and intraperitoneal chemotherapy in recurrent intra-and extrahepatic HCC.

Full text is available as a scanned copy of the original print version.