Impact of prior treatment on outcome of transformed follicular lymphoma and relapsed de novo diffuse large B cell lymphoma: a retrospective multicentre analysis.

Transformation of follicular lymphoma (FL) into aggressive disease and relapse of de novo diffuse large B cell lymphoma (DLBCL) are considered highly unfavourable events. However, most published data were acquired when rituximab was not routinely used. We retrospectively analysed 50 patients with transformed FL (tFL) in a multicenter study and compared them to 50 individuals with relapsed DLBCL (rDLBCL) who all obtained rituximab for the treatment of their disease. Our goal was to identify factors that predict a more favourable prognosis. After a median follow-up of 5.4 years from diagnosis, there was no significant difference in median overall survival (OS) from the date of transformation (tFL) or date of the first relapse (rDLBCL) (1.9 versus 3.9 years, P = .542). Of note, 5-year OS of patients with tFL was 46 %. Follicular lymphoma patients, treatment naïve prior to transformation, fared significantly better than pretreated patients (median not reached versus 1.4 years, P = .014). Regarding rDLBCL, female gender (13.9 versus 1.8 years, P = .019) and absence of rituximab prior to the first relapse (14.0 versus 1.8 years, P = .035) were favourable prognostic factors in a uni- and multivariate analysis. Only a proportion of patients received high-dose chemotherapy with autologous stem cell transplantation (HDT-ASCT), i.e. 38 and 52 % of patients with tFL and rDLBCL, respectively. Our data indicate that a favourable prognosis is conferred by treatment naivety in tFL and by rituximab naivety in rDLBCL. In contrast, we did not find a prognostic impact of HDT-ASCT in our series.

Transformation and additional malignancies are leading risk factors for an adverse course of disease in marginal zone lymphoma.

BACKGROUND: Marginal zone lymphoma (MZL) is a non-Hodgkin lymphoma that occurs as extra nodal, nodal, or splenic. While MZL is generally considered an indolent disease, a substantial percentage of patients follow an unfavorable course. The objective of this retrospective analysis was to identify predictors for a reduced overall survival (OS), or conversely an increased OS. PATIENTS AND METHODS: One hundred and ninety-seven MZL patients were analyzed. Apart from assessing previously published risk factors, concomitant morbidity at diagnosis, transformation into aggressive lymphoma, and occurrence of additional malignancies were evaluated. RESULTS: Next to the known risk factors, i.e. above 60 years of age and elevated serum lactate dehydrogenase (LDH), we demonstrate that transformation into aggressive lymphoma, as well as additional malignancies, are important independent risk factors for a shortened OS in a multivariate analysis, irrespective of the MZL localization. Impressively, in the group of patients lacking LDH elevation, transformation, and/or additional malignancies, only 1 of 63 patients died during follow-up compared with 37 of 87 patients in the high-risk group (HR = 22.8; 95% confidence interval 3.1-167.0; P = 0.002). CONCLUSIONS: Our analysis proposes novel risk factors and warrants for a continuous follow-up to detect the occurrence of transformation and additional malignancies early on.

[Predictive quality of the injury severity score in the systematic use of cranial MRI]. / Prädiktorqualität des Injury Severity Score bei systematischem Einsatz der kraniellen Kernspintomografie.

AIM: The ABBREVIATED INJURY SCORE (AIS) for the head is mostly coded on the basis of cranial computed tomography (CT). It defines, to a large extent, the predictive potency of the INJURY SEVERITY SCORE (ISS). The present study investigates whether the predictive capacity of the ISS can be improved by the systematic use of data from cranial MRI. METHOD: 167 patients, who had been in a coma for at least 24 hours following trauma, underwent an MRI examination within 8 days. All had been found to have an intracranial injury on initial CT. 49 % had also suffered extracranial injuries. The GLASGOW OUTCOME SCALE (GOS) was determined 6 months post trauma. AIS, ISS and GOS values were rated as ordinal measurements. A contingency table was used as the statistical method of analysis, with a significance assumed as p < 0.05 (Chi (2) test). RESULTS: The median ISS based on CT was 16 and did not correlate with the GOS. 63 % of the patients revealed brain stem lesions on MRI. If these were coded with an AIS of 5, the median ISS increased significantly to 29. Thus, the correlation to the GOS was now significant. At ISS scores of 5-9, 18 % of the patients died; at scores of 50-54 the rate of favourable treatment outcomes still amounted to 50 %. Since it is now known that brain stem lesions can also have a favourable prognosis, the AIS coding was modified and adapted to the mortality of the singular types of lesion. Hence the median ISS again decreased to 16. The correlation to the GOS was significant, and the predictive potency of the ISS further improved. The prognostic potency of the REVISED INJURY SEVERITY CLASSIFICATION (RISC) score was improved by use of adapted MRI data. CONCLUSION: If visible brain stem lesions on MRI were coded according to the AIS guidelines, there was a significant increase in the ISS which correlated significantly to the GOS. If the AIS coding was adjusted to the prognostic significance of individual brain stem lesions, there was a further improvement in the prognostic potency of the ISS. The study encourages the inclusion of data obtained from MRI diagnostics in the ISS calculation. There are alternative ways.

Achilles tendinosis is associated with sprouting of substance P positive nerve fibres.

OBJECTIVES: To identify and characterise nerve fibres and inflammatory alterations in painful Achilles tendinosis and thus gain evidence about the origin of pain in Achilles tendinosis. METHODS: The composition of 10 tendon samples from patients with a prior history of painful Achilles tendinosis and 10 samples from patients with spontaneously ruptured tendons but no previous pain was compared by immunohistochemistry and conventional histology. RESULTS: The presence of granulation tissue was shown in 8/10 cases of Achilles tendinosis. Nociceptive substance P (SP) positive nerve fibres were significantly increased, and an inflammatory infiltration comprising B and T lymphocytes was found. Additionally, small foci with iron positive haemosiderophages, indicating prior microtraumatic events, were found in 6/10 samples. None of the spontaneously ruptured tendons contained granulation tissue or haemosiderophages. Inflammatory infiltration in these patients consisted almost exclusively of granulocytes and SP positive nerve fibres were decreased. The density of sympathetic nerve fibres did not differ in the two conditions. CONCLUSION: Achilles tendinosis is associated with the presence of granulation tissue, haemosiderophages, and SP positive nerve fibres, which may transmit the clinically pertinent pain. Achilles tendinosis may be caused by repeated microtraumata with ensuing organisation that is accompanied by sprouting of nociceptive SP positive nerve fibres.

[Efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect]. / Effektivität der Physiotherapie in Eigenregie bei Rotatorenmanschettendefekten.

AIM: Although the outcome of surgical treatment of rotator cuff tears is well documented in the literature, less is known about the efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect. METHODS: A series of 30 patients (38 shoulders) with rotator cuff tears seen by ultrasonography were included in this prospective study. Rotator cuff tears were divided into partial defects (group A), full thickness tears of the supraspinatus tendon (group B), and massive rotator cuff defects (group C). Treatment consisted of a home program of stretching and strengthening exercises that were performed by the patients daily for a period of 12 weeks and controlled by a physician every 2 weeks. Range of motion, a modified constant score, and impingement signs at initial examination and after 12 weeks were compared. RESULTS: All groups experienced improvement in range of motion. The Constant scores improved significantly (p < 0.05) in all groups (A: 13.0 [+/- 7.9 SD], B: 13.2 [+/- 11.4 SD], and C: 17.5 [+/- 6.6 SD]). Impingement signs showed a downward trend in all groups. DISCUSSION: The results of this study show that patients with rotator cuff defects do benefit from simple home exercises independent from the size of the defect.

[Procedures for treatment of joint mechanics impairment in the rotating Endo-model knee prosthesis]. / Vorgehensweise bei Schäden der Gelenkmechanik beim Rotationsknieprothesen-Endo-Modell.

In cases of mechanical damage of the Endo model rotating knee prosthesis, it is not necessary to change the complete prosthesis. Isolated replacement of the mechanics is possible. We changed a sled prosthesis of a 66-year-old patient to a rotating knee prosthesis because of ligament instability. After the patient fell and traumatized the operated knee, she experienced pain during weight bearing and instability. Because clinical and fluoroscopic examinations verified instability of the prosthesis, we decided to change the mechanics of the rotating knee prosthesis. In conclusion, mechanical damage of a rotating knee prosthesis is a rare complication. Operative treatment is easy to manage if replacement parts and instruments to change the mechanics have been organized preoperatively.

[Therapy of femoral head osteonecrosis: results of a national survey]. / Die Therapie der Osteonekrose des Femurkopfes: Ergebnisse einer bundesweiten Umfrage.

AIM: The therapy for osteonecrosis (ON) of the femoral head is controversially discussed in the literature. The aim of this study was to ascertain the current treatment concepts of ON in Germany and to compare them with the results reported in the literature. METHODS: 219 Departments of Orthopedic Surgery were asked for their treatment strategies in an anonymous country-wide survey regarding the etiology, diagnosis and therapy (conservative, operative) of ON. Univariate analyses were performed and means, medians and rates were calculated. RESULTS: 43 % of ON were idiopathic, 28 % were due to alcoholism and another 17 % were seen after steroid intake. All departments performed biplanar X-rays for diagnosis of ON and 78 % of departments obtained additional magnet resonance imaging. In the early stages of ON (stage I, II) 33 % of orthopedic clinics recommend a conservative treatment (protected weight bearing, high energy shock wave, pulsed electromagnetic fields) while 67 % prefer surgery (79 % core decompression, 15 % flexion osteotomy, 6 % total hip arthroplasty). In the later stages (stage III, IV) most clinics perform an operative treatment (11 % core decompression, 10 % flexion osteotomy, 79 % total hip arthroplasty). CONCLUSION: Results of ON of the femoral head are unsatisfactory after protected weight bearing. No randomized clinical trials and no mid-term results are available for high energy shock wave or pulsed electromagnetic fields therapy. In the early stages of ON core decompression shows good results. However, in he later stages with secondary arthritis of the hip, total hip arthroplasty remains the gold standard.

[Adaptive patterns of the rheumatoid wrist after radiolunate arthrodesis]. / Anpassungsformen des rheumatischen Karpus nach radiolunärer Arthrodese.

OBJECTIVE: The aim of this study was the analysis of long-term carpal changes after radiolunate arthrodesis. METHODS: Pre- and postoperative X-rays of 91 wrists in 78 patients with rheumatoid arthritis, who were treated for carpal instability with a radiolunate arthrodesis, were examined concerning the midcarpal joint and the Larsen grade. The mean follow-up was 60 months. RESULTS: After radiolunate arthrodesis the midcarpal joint space remained unchanged in 28%. In 35% secondary arthritis and in 37% further arthritic destruction occurred. The mean Larsen grade increased from 3.2 to 3.8. Six wrists needed complete arthrodesis 25 to 87 months after the primary procedure and one was treated by total wrist replacement. Adaptive changes of the carpus during progressive disease and in secondary arthritis were recognized. Three types of joint lines could be identified: in 35% of the wrists a "perilunar", in 22% a "radio-midcarpal" and in 3% a purely "midcarpal" joint line. In 40% no specific joint line could be identified. CONCLUSION: After radiolunate arthrodesis the carpus remains unchanged in the long run in nearly a third of cases. But even if secondary arthritis or further arthritic destruction occurs as in the remaining cases, the carpus shows an amazing capacity for adaptation. A new intracarpal joint line may develop or the midcarpal joint re-establishes itself.

[Navigated implantation of total knee endoprostheses in secondary knee osteoarthritis of rheumatoid arthritis patients as compared to conventional technique]. / Der navigationsgestützte bicondyläre Oberflächenersatz bei der sekundären Gonarthrose des RA-Patienten im Vergleich zur konventionellen Implantationstechnik.

INTRODUCTION: The operative treatment of a secondary gonarthrosis due to RA claims high quality in soft tissue balancing and accurate alignment in total knee arthroplasty (TKA) which are essential for good long-term results. The efficiency of an imageless computer-assisted implantation in TKA was evaluated and compared with conventional technique. METHOD: The authors implanted each 40 TKA either using the imageless computer-assisted or classical surgeon-controlled technique. The quality of implantation was studied on postoperative long leg coronal and lateral x-rays. RESULTS: A postoperative leg axis between 3 degrees varus and 3 degrees valgus was obtained in 37 patients (92.5%) in the study group and 30 patients (75%) in the control group. Complications influencing the clinical outcome did not occur. CONCLUSION: The use of the imageless Vector-Vision navigation system provides the patient a good chance for longterm survival. Especially the ligament balancing tool appears to be useful. Cutting errors can be detected and intraoperatively corrected.

[Plantar fibromatosis: therapy by total plantarfasciectomy]. / Plantarfibromatose: Therapie mit totaler Plantarfasziektomie.

Morbus Ledderhose is a rare fibromatous disease of the plantar fascia. Clinical features include palpable solitary or multiple nodules and cords, mainly affecting the medial part of the plantar fascia. When clinical symptoms occur, conservative options include stretching, orthotics, nonsteroidal antirheumatic drugs, local cortisone-injections and physiotherapy. Operative treatment is indicated in case of persistent pain or if conservative measures fail. The standard procedure includes a partial fasciectomy of the plantar aponeurosis. There is a high recurrence rate with an increased risk of complications and more aggressive ingrowth into anatomical structures after partial resection. Therefore we recommend a complete fasciectomy not only in recurrent disease, but also as the primary procedure of choice.

A comparison of two indices for ulnar translation and carpal height in the rheumatoid wrist.

The indices for ulnar translation described by Chamay et al. (1983, Annales de Chirurgie de la Main, Vol. 2, pp. 5-17), and Bouman et al. (1994, Journal of Hand Surgery Vol. 19B, pp. 325-329), and for carpal height described by Youm et al. (1978, Journal of Bone and Joint Surgery, Vol. 40A, pp. 423-431) and Bouman et al. (1994) were compared in pre- and postoperative wrist X-rays of 91 patients with rheumatoid arthritis undergoing radiolunate arthrodesis. Both indices described by Bouman had a higher applicability and sensitivity than the Chamay and Youm indices and are recommended for use with the rheumatoid wrist. However false-negative values may result when the Bouman index for ulnar translation is used to follow up radiolunate arthrodesis.

Prosthetic joint infections with osteomyelitis due to Candida albicans.

We report the case of a 78-year-old woman who suffered from a severe soft tissue and bone infection of her left knee 3 years after a total knee-joint replacement without loosening of her endoprosthesis. Cultures from joint aspiration and tissue specimen identified Staphylococcus aureus and Candida albicans. Direct microscopic examination of vital spongy bone and fibrous tissue revealed microabscesses and seeds of yeasts inside the fatty marrow and interface. After removal of the prosthesis several soft tissue and bone specimens were taken during planned re-operations. The histological examination showed no morphological changing, no reduction or extinction of the yeast cells under fluconazole therapy with a dosage of 6 mg kg(-1) body weight (400 mg daily). Curing of the fungal infection with eradication of the yeasts in the bony specimens was achieved with higher doses of 12 mg kg(-1) body weight (800 mg day(-1)) over a 2 month regimen in combination with repeated surgical debridements.

[Total elbow arthroplasty. Indications, operative technique and results after implantation of an Acclaim elbow prosthesis]. / Der endoprothetische Gelenkersatz des EllenbogengelenksIndikationen, operative Technik und Ergebnisse der Acclaim((R))-Prothese.

Total elbow arthroplasty has become a reliable treatment option for patients with rheumatoid arthritis as well as primary or posttraumatic arthrosis. The aim of this study is to present the indications, operative technique and results for the implantation of an Acclaim elbow prosthesis. Case reports are given to demonstrate the indications for prosthesis implantation. Furthermore, the follow-up results are reported for 65 patients after implantation of an Acclaim prosthesis. Pre- and postoperative pain were evaluated using the visual analogue scale. The pain level decreased from 8.0 to 2.3 postoperatively. After implantation of an elbow prosthesis, there was a significant improvement in the range of motion. The mean flexion increased from 103 degrees preoperatively to 140 degrees postoperatively. An increase of 10 degrees was found for both supination and pronation. Complications included temporary ulnary nerve irritation in seven patients, intraoperative fractures in four cases and postoperative elbow dislocation in one case. In conclusion, total elbow arthroplasty results in a reduction of pain and an improvement in elbow movement. However, selection of the right patient is important. Patients are advised not to lift heavy objects or to perform hard physical work. If patients' compliance can not be ensured preoperatively, no total elbow arthroplasty should be performed.

[Imaging in rheumatoid arthritis of the elbow]. / Die Bildgebung beim rheumatischen Ellenbogen.

Early specific radiologic changes of rheumatoid arthritis can usually be detected in the hands and feet. Later stages of the disease process show a typical centripetal spread of the affected joints, i.e., shoulder, elbow, and knee. For prognostic assessment of cubital rheumatoid arthritis, conventional radiography still remains the gold standard. X-rays allow objective scoring and thus classification into standardized stages. A concentric destruction of the rheumatic joint as compared to deformity in the degenerative joint is the typical radiologic symptom to look for. For soft tissue assessment, ultrasound (US) should be the diagnostic tool of choice. Due to the thin surrounding soft tissue layer, as well as the advanced high-resolution technology, bony structures can also be well demonstrated in any plane. In the early arthritic stages, particularly the small changes, e.g., minimal erosions of the cortical area, are very well detectable by US. The use of "color" allows good evaluation of the synovial inflammatory status. Modern imaging methods such as computer- assisted tomography (CAT) scan and magnetic resonance imaging (MRI) are restricted to a few set indications and should not be chosen for routine examination. More invasive methods such as arthrography are no longer indicated for assessment of cubital rheumatoid arthritis.

[Unrecognized and untreated rupture of the Achilles tendon-operative treatment in cases of unstable scar tissue]. / Die nicht erkannte und unbehandelte AchillessehnenrupturOperative Therapie bei insuffizienter Narbe.

Although the clinical picture of an acute rupture of the Achilles tendon is clear, it remains unrecognized or falsely evaluated in up to 10% of all cases. Wrong management without surgical intervention or adequate immobilization frequently leads to unstable scar tissue, requiring completely different therapy and rehabilitation than in the case of an acute injury. Between 6/2000 and 3/2002 11 patients (average age 53 years, M:F=9:2) with a neglected rupture of the Achilles tendon undergoing reconstruction of unstable scar tissue were evaluated in a prospective study. The preoperative cardinal symptoms were loss of strength and stress pain. The length of the unstable scar tissue measured 3.5 cm on average (2.0-6.0 cm). After resection of the scar lesion, a broad central gastrocnemius aponeurotic flap was performed in nine cases,whereas two cases underwent a central tendon shift. As a result of the surgical tendon reconstruction,we noted a 40% mean increase of strength in the final examination. This improvement was associated with less pain and a comparable range of motion. Protracted wound secretion and superficial wound necrosis were recorded on one and two occasions, respectively. Ultrasound and X-ray as preoperative imaging diagnostic tools in addition to the clinical picture appear to be sufficient for proper indication and planning of surgical intervention. The broad central aponeurotic flap has proven to be the most successful method in our patients. In cases of a short distal end, the "grip-box plasty" with a central tendon shift is indicated. Even lesions up to 6 cm can thus be repaired with autologous tissue.

[Diagnosis and therapy of necrotizing fasciitis]. / Diagnose und Therapie der nekrotisierenden Fasziitis.

Necrotizing fasciitis is a soft tissue infection with a lethality ranging up to 80%. Infection causes the activation of interleukin, tumor necrosis factor alpha, and gamma-interferon through a triggering mechanism. This results in a capillary thrombosis with necrosis of the fascia, cutis, and subcutis. The patient's history often reveals a triggering event in the form of a recent minimal trauma or operative procedure. In a fulminant necrotizing fasciitis, the development of sepsis with consecutive multiple-organ failure mainly determines the outcome of the disease. Diagnosis is made initially upon clinical findings with a rapid progression of the disease and confirmed later by histologic and microbiologic findings. Radical surgical debridement within the first 24 h with postoperative treatment in an intensive care unit represents the cornerstone of therapy. Between January 1992 and March 2001, we treated 15 patients with necrotizing fasciitis. Lethality was 33%. There was a significant correlation between risk factors (present in 86% of the patients) and morbidity. Diagnosis and therapy should be performed by an experienced surgeon. In this contribution, we discuss the most important criteria that lead to the diagnosis and the therapeutic consequences.

[Intraoperative spinal sonography]. / Intraoperative Sonographie des Myelons - Spinalkanalstenose durch Fraktur oder Tumor.

AIM: Our intention was to examine the value of ultrasonography in the case of spinal stenosis caused by bony fragments or a tumour. Pre- and postoperative computed tomographies were compared with intraoperative ultrasound images. METHOD: Intraoperative sonography during spinal surgery was used after laminotomy or laminectomy in twenty patients with a stenosis of the spinal canal, caused by fragments or tumours. RESULTS: The posterior vertebral wall as well as tumour-tissue and myelon can be well distinguished by sonography. The dural sheath remains sonographically visible as a white line between tumour-tissue and myelon even in the case of immense compression. Small bony fragments or herniated disc material are also visible in the spinal canal. Thin surgical instruments can be guided into their target region under ultrasonographic control. When the restored epidural space can be demonstrated sonographically, this proves complete decompression of the spinal cord. CONCLUSION: Intraoperative ultrasound is an unrestricted repeatable real-time method for the surgeon to control the restoration and the width of the spinal canal. The extent of the operation depends on the results of the intraoperative sonography.

Lipoastrocytoma: a rare low-grade astrocytoma variant of pediatric age.

We report on two children with cerebral gliomas showing extensive lipomatous change of tumor cells. One tumor was a large mass occupying the temporal and occipital lobes of the left hemisphere; the other was a cystic lesion with a mural nodule in the left frontal lobe. Histologically, both tumors were composed of glial cells that contained fat droplets coalescing into a single large droplet, thus resulting in an appearance similar to adipocytes. Immunohistochemistry showed GFAP positivity of tumor cells, which was maintained in the cytoplasmic rim of lipidized cells. Synaptophysin and neurofilaments were negative. Ki-67/Mib1 labeling index was low. Electron microscopy showed intracytoplasmic lipid vacuoles, abundant intermediate filaments and a basal lamina surrounding the cell bodies. Molecular genetic analysis of one tumor revealed no TP53 mutation (exons 4-10), no loss of CDKN2A, and no amplification of EGFR, CDK4 or MDM2. Both patients are alive and well after 3 and 7 years, respectively. However, one of them had to be re-operated on circumscribed local recurrences. Our cases represent a rare variant of low-grade astrocytoma that may be designated as "lipoastrocytoma".

[Timing of soft tissue reconstruction in severe crush injury of the upper extremity]. / Zeitpunkt der Weichteilrekonstruktion bei schweren Quetschtraumen im Bereich der oberen Extremität.

Complex injuries of the distal forearm and the hand by industrial machines often require extensive reconstructive procedures. Crush injuries with soft tissue damage extending over the limits of visible injury require a special approach. Large soft tissue defects often have to be covered by extensive flap procedures. The optimum point of time for plastic reconstruction is an essential question and represents a controversial issue in the literature. To be able to compare different patient cohorts in the future, we classify crush injuries into five clinically relevant categories. In the course of this review article, three different cases of severe crush injuries of the upper extremity are representatively discussed. Two patients were reconstructed in a secondary procedure, one patient in the acute phase. Definite coverage of soft tissue defects in severe crush injuries should be performed secondarily after 5-7 days since the extent of damage in this special form of trauma can often only be judged after a few days and the reconstruction of bones, vessels and tendons is completed.