Acetabular Reconstruction Using Multiple Porous Tantalum Augments: Three-Quarter Football Augment.

Reconstruction of a large acetabular bone defect is a complex problem in revision hip arthroplasty. The authors report a novel method of reconstructing an uncontained acetabular defect (Paprosky type IIIb) using multiple tantalum augments. A 73-year-old female patient presented to our institution with a chronically dislocated primary left total hip arthroplasty with radiographs demonstrating migration of acetabular component and formation of pseudoarthrosis within the left ilium. Extensive arthrolysis and anatomic reconstruction of the acetabular bone defect were performed using the novel method of multiple tantalum augments. Postoperatively, recovery was initially complicated by multiple dislocations requiring an exchange to an elevated liner, however subsequently achieved good function.

[Case report of an osseous (and lymphogenic) thymic carcinoma in an adult]. / Kasuistik eines ossär (und lymphogen) metastasierten Thymuskarzinoms beim Erwachsenen.

A Thymic carcinoma in adults is rare. We present the case of a 47-year-old man, who was treated conservatively for spondylolisthesis L5/S1 in our institution for several years. In the further course, the patient complained about pain exacerbation with acute lower back pain. Cross-sectional scanning showed a tumor of the lumbar vertebral body three. A biopsy of this mass revealed a metastatic thymic carcinoma of the squamous cells. After palliative therapy, the patient died 9 months after initial diagnosis.

Prolonged suppressive antibiotic therapy is successful in the management of prosthetic joint infection.

INTRODUCTION: Prosthetic joint infection (PJI) remains one of the major challenges facing orthopaedic surgeons. There is a paucity of evidence on non-operative management of PJI. We present the results of prolonged antibiotic suppression therapy (PSAT) in PJI from a single centre. METHODS: A retrospective study was performed. Twenty-six patients were included. Two patients were excluded due to the lack of follow-up data. Failure was defined as admission for sepsis from the joint or amputation. RESULTS: Average age was 72 years (range 35-93). Mean Charlson co-morbidity index was 4.3. Mean follow-up was 3.2 years (range 1.3-5.7). Staphylococcal species were isolated in 11 cases (44%) (MRSA 1, MSSA 5, Staph. epidermidis 4 and Staph Pasteuri 1). Other bacteria included E. Coli (2), Streptococci spp. (3), Propionebacterium acnes (1) and Pseudomonas aeruginosa (1). Four cases were polymicrobial infection (16%), and no organisms were identified in two cases (8%). Candida albicans was identified in one case. All cases of bacterial infection were treated with prolonged oral doxycycline or amoxicillin. Twenty patients (80%) received 6 weeks of intravenous antibiotics prior to commencing prolonged oral antibiotics. Two patients experienced persistent symptoms and required amputation (both TKA). Two patients experienced sepsis but were treated successfully with IV antibiotics alone. The success rate of PSAT was 84% (21/25) successful at an average 3.2-year follow-up. DISCUSSION AND CONCLUSION: Prolonged suppressive antibiotic therapy is a viable option for the management of PJI with a low incidence of complications.

Heterotopic Ossification in Orthopaedic and Trauma surgery: A Histopathological Ossification Score.

Heterotopic Ossification (HO) is a potential long-term complication in orthopaedic surgery. It is commonly classified according to the Brooker classification, which is based on radiological findings. To our knowledge the correlation of histological features to the Brooker grade is unknown as is the association between HO and the indication for revision. The aim of this paper is to analyze the ossification grade of HO tissue in patients undergoing revision hip and knee arthroplasty and to propose a histologically based classification system for HO. We also assess the relationship between the grade of HO and the indication for revision (septic and aseptic revision). From January to May 2019 we collected 50 human HO samples from hip and knee revision arthroplasty cases. These tissue samples were double-blinded and sent for histopathological diagnostic. Based on these results, we developed a classification system for the progression of HO. The grade of ossification was based on three characteristics: Grade of heterotopic ossification (Grade 1-3), presence of necrosis (N0 or N1) and the presence of osteomyelitis (HOES-Score Type 1 to 5). Demographic data as well as surgical details and indication for surgery was prospectively collected from clinical records. Fifty tissue samples were harvested from 44 hips and 6 knee joints. Of these 33 exhibited Grade I ossifications (66%), followed by 11 Grade II (22%) and one Grade III (2%). Necrosis was noted in two tissue samples (4%) and 2 more had osteomyelitis findings according to HOES-Score. Six samples (12%) with radiologically suggestive of HO turned out to be wear-induced synovitis, SLIM Type 1. Of these cases 16 were septic (32%) and 34 aseptic (68%) revisions. Most of the HO tissue samples were classified as a low-grade. High-grade ossification-Score is rare. Higher grades of ossification seem to be associated with septic revision cases. Wear-induced synovitis potentially influences HO development. A histological scoring system for ossification grading can be derived from the data presented in this study.

The sensitivity of ultrasound screening examination in detecting heterotopic ossification following spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To analyze the role of sonography in detecting heterotopic ossification (HO) following spinal cord injury (SCI). SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr University Bochum, Germany. METHODS: Between January 2003 and December 2013, 217 patients with HO of the hips met the inclusion criteria and were included in the final analyses. The diagnosis of HO was carried out in all cases using our hospital protocol. Primary outcome measure was to calculate the sensitivity of ultrasound screening examination in detecting HO following SCI. RESULTS: The diagnosis of HO was confirmed in 217 patients after a mean interval of 64.8 days (range from 8 to 295; s.d.=40.4) via computerized tomography or magnetic resonance imaging scan. In 193 out of 217 patients, suspicious HO signs were noted in the ultrasound screening examination (sensitivity=88.9%). CONCLUSIONS: The use of ultrasound for screening for HO in SCI patients is reliable and has a high sensitivity.

Ankylosing spondylitis does not increase the risk of neurogenic heterotopic ossification in patients with a spinal cord injury: a retrospective cohort study.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The present study was performed to analyze the impact of ankylosing spondylitis (AS) in developing heterotopic ossification (HO) in patients following spinal cord injury. SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. MATERIALS AND METHODS: Between January 2003 and December 2015, 67 patients with AS and SCI were included in the study. The control group consisted of 141 patients with SCI and without AS. The definitive diagnosis of HO was made via magnetic resonance imaging or computed tomography. Primary outcome measure was to analyze the impact of AS on the development of HO. RESULTS: Fifteen out of 67 AS patients (22.4%) had a diagnosed HO. In the control group, 28 of 141 patients (19.9%) suffered from HO. Patients with AS had no significant higher risk for HO development compared with patients without AS (RR=1.16; 95% CI=0.65-2.09). However, patients with a complete neurological deficit had a twofold higher risk for HO development (RR=2.55; 95% CI=1.26-5.16). CONCLUSIONS: AS does not increase the risk for HO development in patients with spinal cord injury.

In-hospital outcomes following single-dose radiation therapy in the treatment of heterotopic ossification of the hip following spinal cord injury-an analysis of 444 cases.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The objective of the study was to analyse the efficacy of single-dose radiation therapy in the treatment of heterotopic ossification (HO) following spinal cord injury (SCI). SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: Patients who were treated for HO around the hips following SCI at our institution between January 2003 and December 2013 were included in this retrospective cohort study. A total of 444 HO cases around the hip were treated with single-dose radiation therapy after a mean time interval of 4.9 days (0-97 days; s.d.=8.1) after HO diagnosis. Primary outcome measures were the number of HO relapses and the occurrence of adverse side effects related to the radiation therapy. RESULTS: After a mean time interval of 63.2 days (8-295 days; s.d.=39.6) subsequent to SCI HO occurred in 207 male (84.8%) and 37 female (15.2%) patients with a mean age of 46.4 years (18-81 years, s.d.=18.2). In 200 patients both hips were affected, whereas the remaining 44 HO occurred unilateral. None of the patients suffered primary side effects due to the radiation therapy. However, in 13 out of 244 patients (5.3%), HO relapse occurred. After repeated single-dose radiotherapy, one patient suffered joint ankylosis and therefore required surgical resection. CONCLUSION: Our results present that single-dose radiation therapy is a safe option in the treatment for spinal cord-injured patients suffering from HOs of the hips.

Heterotopic ossification of the shoulder joint following spinal cord injury: an analysis of 21 cases after single-dose radiation therapy.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Heterotopic ossification (HO) affecting the hips is a common complaint of patients suffering traumatic spinal cord injury. However, the incidence of HO of the shoulder is considerably rare. In this context, we report on our results of 13 patients with a total of 21 cases of shoulder HO and single-dose radiation therapy. SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: The study group consists of 12 male and 1 female patient with a mean age of 55.5 years (range from 24 to 81 years; s.d.=14.5). Primary outcome measures were defined as the number of HO relapses and the number of side or adverse effects in relation to the radiation therapy. RESULTS: At the time of latest follow-up during hospitalization, the mean shoulder flexion was 92.1° while mean abduction was 94.5°. The average external rotation was 26.4°. No HO recurrence occurred and none of the patients suffered any adverse effects related to radiation therapy. CONCLUSIONS: In conclusion, single-dose radiation therapy in the treatment of shoulder HO due to spinal cord injury is an effective and reliable method, although the risk of secondary side effects related to the radiation therapy remain unknown.

The roles of serum alkaline and bone alkaline phosphatase levels in predicting heterotopic ossification following spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To analyze the usefulness of serum alkaline phosphatase (AP) and bone alkaline phosphatase (BAP), as well as C-reactive protein (CRP) levels in predicting heterotopic ossification (HO). SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil, Ruhr University Bochum, Germany. METHODS: Between January 2003 and December 2013, 87 patients with HO around the hips met the inclusion criteria and were included in the study. Alkaline phosphatase, CRP and BAP were assessed and interpreted at the time of HO diagnosis and after radiation therapy in all patients. RESULTS: At the time of HO diagnosis, 49 out of 87 patients (49.4%) had elevated alkaline phosphatase levels and 39 out of 87 patients (44.8%) had elevated BAP levels. Elevated CRP values were found in 67 patients (77.0%). Within 3 days after single-dose radiation therapy, elevated AP levels persisted in 38 patients (43.7%) and elevated BAP levels in 28 patients (32.2%). CONCLUSIONS: The results obtained show that the determination of CRP, AP and BAP levels may not be considered a reliable screening method for early HO detection, subsequent to spinal cord injury.

Septic single-stage knee arthrodesis after failed total knee arthroplasty using a cemented coupled nail.

Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of single-stage knee arthrodesis using an intramedullary cemented coupled nail without bone-on-bone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA.

[Exoskeletons for rehabilitation of patients with spinal cord injuries. Options and limitations]. / Exoskelette in der Rehabilitation Querschnittgelähmter. Möglichkeiten und Grenzen.

BACKGROUND: Mobile exoskeletons are increasingly being applied in the course of rehabilitation and provision of medical aids to patients with spinal cord injuries. OBJECTIVES AND METHODS: This article gives a description of the currently available exoskeletal systems and the clinical application including scientific and medical evidence, to derive recommendations regarding clinical practice of the various exoskeletons in the rehabilitation of patients with spinal cord injuries. RESULTS: The different systems represent a useful adjunct to the therapeutic regimen depending on the medical objectives. Posture-controlled exoskeletons in particular enable mobilization of patients with neurological gait disorders via direct motion support. In addition the neurologically controlled exoskeleton HAL® leads to functional improvements in patients with residual muscular functions in the chronic phase of spinal cord injury in terms of improved walking abilities subsequent to training. However, beneficial effects on bone density, bladder function and perfusion are conceivable but not yet adequately supported by evidence. Positive effects on spasticity and neuropathic pain are currently based only on case series or small clinical trials. CONCLUSION: Although exoskeletons are not yet an established tool in the treatment of spinal cord injuries, the systems will play a more important role in rehabilitation of patients with spinal cord injuries in the future. Neurologically controlled exoskeletons show beneficial effects in the treatment of acute and chronic spinal cord injuries and might therefore evolve to be a useful alternative to conventional locomotion training.

[Development of compartment syndrome after intravenous administration of an X-ray contrast medium. Recommendations on acute therapy regimens]. / Kompartmentsyndrom nach paravasaler Applikation von Röntgenkontrastmittel. Empfehlung zum akuten Therapieregime.

The incidence of extravasation of contrast medium is reported in the literature to be between 0.2 % and 0.9 %. A rare consequence of this could be compartment syndrome of the affected limb which requires immediate treatment.We report the case of a patient who developed acute compartment syndrome of the forearm after intravenous injection of radiographic contrast medium in a radiovolar vein during a computed tomography (CT) scan for multiple trauma. The clinical symptoms with pain, loss of range of motion and sensitivity functions, measurement of compartment pressure and radiological images confirmed the diagnosis. After emergency dermatofasciotomy of the forearm the full range of motion and sensitivity functions could be restored.

Computer-assisted navigation of a complex femoral shaft fracture: instruction in three steps--a technical note.

The procedure of computer-assisted navigation of femoral shaft fractures is well described. Nevertheless, its use is less common. An unclear disposal and longer operation times might be two reasons. The aim of this technical note is to render assistance concerning the ideal disposal of the setup.

[Non-traumatic anterior knee dislocation in a patient with osteoarthritis of the knee]. / Atraumatische anteriore Kniegelenksluxation bei Pangonarthrose.

Complete knee dislocation is a rare and severe injury and usually follows high-energy trauma. Non-traumatic knee dislocations are exceedingly rare, while severe overweight appears to be the main cause of the knee dislocation. We here report on a spontaneous knee dislocation in a patient with severe osteoarthritis of the left knee. A 68-year-old woman was admitted to our hospital for an elective total knee replacement. One year prior to admission, a planned joint replacement was not performed due to an existing ulcus cruris. After healing of the ulcus cruris, the patient presented with progressive pain and instability of the left knee without any trauma. The clinical examination showed a multidirectional instability of the left knee with a restricted range of motion (ROM) with 0-0-40 degrees for extension and flexion. The performed radiological examination revealed an anterior knee dislocation of the left knee. Intraoperative findings suggest a non-traumatic aetiology. We suspect that osteoarthritis of the left knee has caused the dislocation. Therefore, we recommend, even in usually "harmless" osteoarthritis, close clinical and radiological follow-up examinations to detect and treat possible complications.

Infection rates in patients undergoing primary knee arthroplasty with pre-existing orthopaedic fixation-devices.

BACKGROUND: Prior knee surgery in the setting of knee arthroplasty (KA) can influence the overall outcome of the procedure and render the operation more technically challenging. The effects of residual fixation devices on subsequent procedures about the knee are ill-defined. Some authors claim an increase in periprosthetic infection in this cohort of patients. The objective of this study was to evaluate the overall incidence of periprosthetic infections in patients undergoing primary KA with pre-existing osteosynthetic hardware in situ. METHODS: The current investigators retrospectively reviewed 124 patients undergoing knee arthroplasty and removal of orthopaedic fixation devices, due to prior high tibial osteotomies, fracture fixation or cruciate ligament reconstruction. The exclusion criterion was a prior history of infection of the fixation device. The mean follow-up time was 5.4 years (range 15 months to 9 years). Nine patients were lost to follow-up. RESULTS: Joint aspiration was performed two weeks prior to surgery in 53 patients (42.4%) and intra-operative samples were obtained in 106 patients (84.8%), which did not show any bacterial growth. A subacute periprosthetic infection occurred after seven months in only one patient. CONCLUSION: The results of the current study demonstrate that previously implanted osteosynthetic fixation devices do not significantly increase the risk of developing periprosthetic knee infections. A two-stage procedure with implant retrieval prior to total knee arthroplasty is not clinically indicated in the cohort described, amongst whom an infection rate of 0.9% was revealed.

[The pressure-sensitive swelling in the knee as a sign for a monoclonal gammopathy of undetermined specificity (MGUS)]. / Die druckdolente Schwellung in der Kniekehle als Wegweiser einer monoklonalen Gammopathie unklarer Spezifität (MGUS).

AL amyloidosis (AL-A) is seen in about 6-15 % of patients with multiple myeloma. In contrast, the sporadic occurrence of AL-A is a rarity. The presence of amyloid is often found in the respiratory tract followed by the lung, the eyelids, the skin and the lower urinary tract, while the presence in soft tissues or bone is rather uncommon. We here describe a 71-year-old woman who presented with a pressure-sensitive swelling in the left knee at our hospital. The clinical examination on admission showed a tumourous alteration of the popliteal soft tissues without any signs of neurological deficits. However, the range of motion (ROM) of the left knee was restricted with 0-0-100 degrees for extension and flexion. A dialysis-dependent renal insufficiency, heart insufficiency with the necessity of permanent anticoagulation and glaucoma were noted as pre-existing illnesses. Further diagnostic examinations including ultrasound and magnetic resonance imaging (MRI) of the left knee revealed a solid tumourous structure with a radiological suspicion of pigmented villonodular synovitis. A complete surgical extirpation of the tumourous structure was performed. The further performed diagnostic examinations including histological and immunohistochemical analyses showed evidence of an AL-A tumour. A monocloncal gammopathy of unknown specificity (MGUS) was detected as an origin for the AL-A. This case underscores the necessity of complete extirpation and histological and immunohistochemical analyses of any soft tissue tumour. Possible previously existing rare malignant diseases can be detected only in this way.

Characteristics and differences in necrotizing fasciitis and gas forming myonecrosis: a series of 36 patients.

BACKGROUND AND AIMS: Necrotizing fasciitis (NF) and gas forming myonecrosis (GFM), both being subtypes of necrotizing soft tissue infection (NSTI), are life threatening conditions sharing certain similarities. Despite the necessity of early and radical surgical debridement in necrotizing infections, the distinction between these entities is of clinical relevance since gas forming myonecrosis in a number of cases results from an underlying abdominal cause and the focus of infection can be missed. This study was to evaluate the incidence and risk factors as well as the mortality rate in patients with NSTI and GFM. MATERIAL AND METHODS: All patients with NSTI treated in the authors' hospital between January 2005 and Decem-ber 2009 were enrolled in the study. Medical records, histological slides, microbiological and laboratory parameters as well as Computerized Tomography (CT) and magnetic resonance imaging (MRI) scans were reviewed for all patients. Differences between NF and GFM regarding hospital stay, number of surgical interventions and pre-existing comorbidities as well as mortality rate were analyzed. The laboratory risk factor for necrotizing fasciitis (LRINEC) score was calculated in all patients on admission. RESULTS AND CONCLUSIONS: Thirty patients (17 female, 13 male) with necrotizing fasciitis with a mean age of 55 years (SD 15.5) were included in the study. There was no statistically significant difference between survivors and deceased patients comparing the LRINEC score (n.s.). Patients with necrotizing fasciitis secondarily involving the trunk had a significantly higher mortality rate (OR 11.2; 95% CI=1.7-72.3). In the majority of cases (12 cases), minor skin lesions were identified as the site of origin. Amongst all necrotizing soft tissue infections six patients (female n=3; male n=3) with a mean age of 61.5 years (SD 12.2) with non-clostridial gas forming myonecrosis were identified. Three patients had a history of malignancy and in three patients the infection was secondary to major surgery. The mean LRINEC score was 8.5 (SD 1). Three patients (50%) died due to GFM. Early diagnosis and appropriate intervention is critical to provide accurate treatment decisions. Eradicating the differing primary sources of infection in GFM and NF will have a positive impact on outcome.

[Underdiagnosed disco-ligamentous lesion in the cervical spine of a paraglider]. / Übersehene disko-ligamentäre Zerreißung an der HWS bei einem Gleitschirmflieger.

INTRODUCTION: Paragliding is an increasingly popular airborne sport with numerous associated injuries. We here describe the case of an experienced paraglider who, after a fall from 15 meters, presented with an initially underdiagnosed disco-ligamentous lesion of the cervical spine. PATIENT AND METHOD: We report on a 51-year-old male paraglider, who was referred to our hospital four days after a fall from 15 meters. Initial treatment was performed in a regional hospital. The performed clinical and radiological examinations including computerized tomography showed, besides a fracture of the radius, no further abnormalities. RESULTS: The patient was discharged home four days after injury. Due to persistent pain in the cervical spine and parasthesia, the patient was referred to the practicing orthopaedic surgeon. The performed MRI and CT including the sagittal and coronal planes showed a disco-ligamentous lesion of the cervical spine. The patient was transferred immediately to our hospital for surgical treatment. The initial existing neurological symptoms resolved postoperatively and the patient was discharged home in a well condition. DISCUSSION: Injuries of the cervical are extremely rare in paragliders. Nevertheless, this case underscores the importance of adequate clinical and radiological examinations. We report the case of our patient to increase awareness among physicians and training staff working in emergency rooms.

[Handling modern imaging procedures in a high-tech operating room]. / Handling moderner Bildgebung in einem Hightech-Operationssaal.

Operating rooms are the central unit in the hospital network in trauma centers. In this area, high costs but also high revenues are generated. Modern operating theater concepts as an integrated model have been offered by different companies since the early 2000s. Our hypothesis is that integrative concepts for operating rooms, in addition to improved operating room ergonomics, have the potential for measurable time and cost savings. In our clinic, an integrated operating room concept (I-Suite, Stryker, Duisburg) was implemented after analysis of the problems. In addition to the ceiling-mounted arrangement, the system includes an endoscopy unit, a navigation system, and a voice control system. In the first 6 months (9/2005 to 2/2006), 112 procedures were performed in the integrated operating room: 34 total knee arthroplasties, 12 endoscopic spine surgeries, and 66 inpatient arthroscopic procedures (28 shoulder and 38 knee reconstructions). The analysis showed a daily saving of 22-45 min, corresponding to 15-30% of the daily changeover times, calculated to account for potential savings in the internal cost allocation of 225-450 EUR. A commercial operating room concept was evaluated in a pilot phase in terms of hard data, including time and cost factors. Besides the described effects further savings might be achieved through the effective use of voice control and the benefit of the sterile handle on the navigation camera, since waiting times for an additional nurse are minimized. The time of the procedure of intraoperative imaging is also reduced due to the ceiling-mounted concept, as the C-arm can be moved freely in the operating theater without hindering cables. By these measures and ensuing improved efficiency, the initial high costs for the implementation of the system may be cushioned over time.