[S2k-Guideline on Meniscus Diseases: from Aetiology to Scoring]. / S2k-Leitlinie Meniskuserkrankung: Von der Ätiologie bis zum Scoring.

The number of patients with meniscal injuries is increasing constantly, but the treatment algorithms are undergoing continuous change. The effects of meniscal surgery, as well as the indications for the procedure, are currently a matter of heated debate. Various German speaking associations addressing topics related to the knee have joined forces to develop guidelines for the diagnosis, evaluation and therapy of meniscal lesions. The hope is that this first of two publications will shed light on some of the ongoing issues and offer guidance to health care professionals treating these patients.

Magnetic resonance imaging analysis of the bioabsorbable Milagro interference screw for graft fixation in anterior cruciate ligament reconstruction.

Ligament graft fixation with bioabsorbable interference screws is a standard procedure in cruciate ligament replacement. Previous screw designs may resorb incompletely, and can cause osteolysis and sterile cysts despite being implanted for several years. The aim of this study was to examine the in vivo degradation and biocompatibility of the new Milagro interference screw (Mitek, Norderstedt, Germany). The Milagro interference screw is made of 30% ss-TCP (TriCalcium phosphate) and 70% PLGA (Poly-lactic-co-glycolic acid). In the period between June 2005 and February 2006, 38 patients underwent graft fixation with Milagro screws in our hospital. Arthroscopic ACL reconstruction was performed using hamstring tendon grafts in all the patients. MR imaging was performed on 12 randomly selected patients out of the total of 38 at 3, 6 and 12 months after surgery. During the examination, the volume loss of the screw, tunnel enlargement, presence of osteolysis, fluid lines, edema and postoperative screw replacement by bone tissue were evaluated. There was no edema or signs of inflammation around the bone tunnels. At 3, 6 and 12 months, the tibial screws showed an average volume loss of 0, 8.1% (+/-7.9%) and 82.6% (+/-17.2%, P < 0.05), respectively. The femoral screws showed volume losses of 2.5% (+/-2.1%), 31.3% (+/-21.6%) and 92.02% (+/-6.3%, P < 0.05), respectively. The femoral tunnel enlargement was 47.4% (+/-43.8%) of the original bone tunnel volume after 12 months, and the mean tunnel volume of the tibial tunnel was -9.5% (+/-58.1%) compared to the original tunnel. Bone ingrowth was observed in all the patients. In conclusion, the resorption behaviour of the Milagro screw is closely linked to the graft healing process. The screws were rapidly resorbed after 6 months and, at 12 months, only the screw remnants were detectable. Moreover, the Milagro screw is biocompatible and osteoconductive, promoting bone ingrowth during resorption. Tunnel enlargement is not prevented in the first months but is reduced by bone ingrowth after 12 months.

[Results of a prospective multicenter trial for treatment of acromioclavicular dislocation]. / Ergebnisse einer prospektiven Multicenterstudie zur Behandlung der Schultereckgelenksprengung.

OBJECTIVE AND METHODS: The treatment of the acromioclavicular joint dislocation is a topic of constant debate. Objective of the study was to analyze if operative treatment of Rockwood types 3 and 5 acromioclavicular joint dislocations is superior to nonoperative treatment. Treatment outcomes of 100 patients (91 male, 9 female, median age 33.7 +/- 8.6) from 4 different hospitals/departments of trauma surgery were analyzed. Clinicofunctional, radiological, as well as subjective parameters were taken into consideration. RESULTS: Clinicofunctional outcome of the operative treatment of acromioclavicular joint dislocation was very good in 91.2 % of patients. 87.7 % of the operated patients had a subjectively stable joint. The patients operated on for the acromioclavicular joint dislocation were capable of exercising after 13 weeks post surgery. versus 25.3 weeks in nonoperatively treated patients. The operated patients had a Rowe score and Constant score as high as 90.7 and 91.8 respectively, reflecting an excellent treatment outcome. CONCLUSION: Operative anatomic reconstruction of the injured acromioclavicular joint leads to very good clinicofunctional outcomes. The operative technique plays only a minor role in achieving these outcomes. The rate of complications is low for all operative techniques listed here. Demanding patients and multimedia education of patients are the reasons for a majority of operated patients in this study (97 %).

[Diagnostic procedure for uveitis patients: reduction of costs by a targeted assessment of laboratory tests based on clinical findings]. / Abklärung bei Uveitis: Kostenreduktion durch befundorientiertes diagnostisches Vorgehen.

BACKGROUND: Interdisciplinarity is an essential prerequisite for extensive and high-quality diagnostic work-up, therapy, and care of patients with inflammatory rheumatic disease. The ophthalmological status significantly narrows down the possible causes for the primary disease and facilitates an effective diagnostic approach. METHODS: We developed an assessment procedure according to the individual clinical findings to use as an ideal diagnostic strategy for an interdisciplinary center. To permit comparability we first introduced this new diagnostic tool in November 2002 (intervention), replacing the existing cost-intensive standard diagnostic procedure for uveitis patients. RESULTS: The average costs for laboratory tests (calculated according to GOA numbers, scale of fees for physicians) were reduced from 670+/-11 euros per patient before the intervention to 238+/-18 euros per patient after the intervention. Before intervention 16 of 31 (52%) could be assigned to a specified disease compared to 27 of 53 (51%) after the intervention. With our strategy we were able to obtain a 64% reduction of costs in the diagnostics of uveitis patients without a deterioration of our diagnostic quality. CONCLUSION: It is possible to reduce costs and still improve the care of uveitis patients by using a targeted assessment according to the individual clinical findings.

Repair of meniscal tears with the absorbable Clearfix screw: results after 1-3 years.

INTRODUCTION: Total meniscus resection usually leads to osteoarthritis of the knee joint. Preservation and refixation of the injured menisci are therefore of great clinical importance. MATERIALS AND METHODS: The present study examines 40 meniscal injuries in 37 patients that were arthroscopically treated with Clearfix meniscal screws (Mitek, Norderstedt, Germany) in the period from August 1999 to December 2002. The mean patient age was 27.7 (range 16-62) years. Nine patients were female. A total of 24 patients (27 meniscal tears) also had an anterior cruciate ligament (ACL) lesion, and 5 patients had cartilage injuries. Twenty-two patients were treated within the first 2 weeks following the trauma, 10 patients within 8 weeks, and 5 patients after 8 weeks. The lesions were a bucket-handle tear of the medial meniscus in 11 cases and a bucket-handle tear of the lateral meniscus in 2 cases. The posterior horn of the medial meniscus was torn in 13 cases, and the pars intermedia in 3 cases. The posterior horn of the lateral meniscus was torn in 8 cases, and the pars intermedia in 3 cases. The mean tear length was 2.9 (+/- 1.5) cm and was fixed with an average of 1.8 (+/- 0.7) screws. In 7 cases, the anterior horn was treated with an additional meniscal suture. A total of 35 patients were examined after an average of 18 (range 7-45) months. RESULTS: In the event of a moderate outcome, MRI was performed as part of the follow-up investigation. The average Lysholm score was 93 (+/- 7.4), the Tegner activity index was 6.3 (+/- 2.0) before the accident and 5.8 (+/- 2.0) at the follow-up, the Marshall knee score was 47 (+/- 3.8). The VAS pain assessment was 1.6 (+/- 1.3) and the VAS function assessment was 7.9 (+/- 1.6). Of the 7 patients with a moderate result, 2 patients without additional ligament lesions suffered re-ruptures after and 13 months, respectively. The other 5 patients with a moderate result each had multiple accompanying injuries or pre-existing damage to the affected knee joint. CONCLUSION: The Clearfix screws achieved a clinical success rate of 82% in isolated meniscal tears in stable knee joints and a clinical success rate of 100% with additional ACL reconstruction. In view of the good clinical results and the simple procedure for use, the implant should be recommended for meniscal refixation.

Cathepsin D in ovarian cancer: prognostic value and correlation with p53 expression and microvessel density.

OBJECTIVE: Overexpression of ubiquitous lysosomal aspartyl protease cathepsin D (CD) is involved in the progression of cancer. This study investigates the prognostic value and the association of cathepsin D expression with clinicopathological parameters, p53 expression, and angiogenesis in ovarian cancer. METHODS: Cathepsin D was determined immunohistochemically in 43 ovarian tumors of low malignant potential (LMP) and 80 invasive tumors FIGO stage I-IV. Results were correlated with clinicopathological characteristics, p53, and microvessel density (MVD). Survival analysis of cathepsin D expression and MVD was performed in invasive tumors. RESULTS: Epithelial tumor cathepsin D expression was more common in LMP tumors (65.1%) compared to invasive tumors (43.7%; P = 0.02). In LMP tumors, stromal cathepsin D was associated with mucinous tumors (P = 0.01), whereas in invasive tumors, epithelial cathepsin D expression was associated with clear cell tumors (P = 0.003). Invasive tumor cathepsin D had a negative relation to p53 expression. In LMP tumors, stromal cathepsin D correlated with microvessel density (P = 0.03). Stromal cathepsin D expression was an independent prognostic factor for disease-free survival (DFS) in patients with invasive cancer (P = 0.03, Cox regression), while cathepsin D expression missed to be of prognostic value for overall survival (OS) in invasive ovarian cancer. MVD had no influence on survival in invasive ovarian cancer (P > 0.05). CONCLUSION: Our study demonstrates a prognostic value of cathepsin D expression in invasive ovarian cancer, while cathepsin D expression in LMP tumors seems to be linked to angiogenesis. The relation among cathepsin D, p53 expression, and angiogenesis demonstrates biological differences between invasive ovarian cancer and LMP tumors.

[Long-term results after conservative treatment of pediatric femoral shaft fractures]. / Konservative Behandlung der isolierten Oberschenkelfraktur im Kindesalter. Langzeitergebnisse.

The principles of treatment for fractures of the femoral shaft in children include conservative and operative management. Traditionally, these fractures have been treated conservatively with skeletal traction. More frequent consideration is being given to the psychological and economical outcome. At what age of the patient surgery can be performed is still open to debate. From 1988 to 1999, 52 children with closed femoral shaft fractures were treated conservatively in the Klinik für Unfallchirurgie, Plastische und Wiederherstellungschirurgie der Universität Göttingen (until 1994 Klinik für Allgemeinchirurgie). Overhead traction was applied in 27 children with a mean age of 19.9 months (group I), and a 90-90 skeletal traction was performed in 25 children with a mean age of 47 months (group II). This treatment was followed by spica casting on an outpatient basis. At a mean follow-up of 6 11/12 years (2 4/12-12 5/12) in 33 children all fractures were healed and no malalignment with clinical relevance could be observed. In four patients the limb overgrowth was 15-20 mm. The assessment of psychological and somatic aspects revealed disturbances in the family environment. The average length of hospitalization was much shorter in group I (mean: 17.4 days) than in group II (mean: 23.7 days). Our study confirms the good long-term results after conservative treatment of femoral shaft fractures in children up to 6 years. Social and psychological problems due to the prolonged period of hospitalization as well as the high costs of skeletal traction favor surgical treatment for children older than 3-4 years.

[The cannulated blade plate 90 degrees for displaced proximal humeral fractures in elderly patients]. / Die durchbohrte Winkelplatte 90 Grad bei der dislozierten proximalen Humerusfraktur im hohen Lebensalter.

Aim of the study was to analyse the results following osteosynthesis of proximal humerus fractures with cannulated blade plate 90 degrees (Synthes, Mathys Medizinaltechnik AG, Bettlach, Schweiz) in elderly patients. Between 6/1998 and 12/1999 we treated 20 patients (12 female, 8 male) > 65 years (65-92 y, 75 y) with the cannulated blade plate (fracture type according to AO: 8 x 11-A3, 5 x 11-B1, 3 x 11-B2, 1 x 11-B3 und 3 x 11-C2). Regarding to mechanical and functional advantages we modified the 90 degrees angulation of the implant by bending intraoperatively up to 110-120 degrees. Early post-op physiotherapy was permitted. The radiological results of all patients were evaluated and in 13 patients a clinical follow-up (median 8 months) was obtained. According to the Constant-score 62 points on average were achieved, which corresponds to a satisfactory result (contralateral shoulder 92 points). Complications due to the implant were loosening of the blade plate in 3 cases (A3, B2, C2) and 1 perforation of the blade plate (C2). The consecutive reoperation consisted in a compound osteosynthesis with the blade plate (A3, B2) in 2 cases, a prosthetic replacement and a removal of the implant (C2) in 1 case respectively. Neither infection, major nerve and vessel trauma nor avascular necrosis occurred. The cannulated blade plate 90 degrees represents a justified alternative in the treatment of displaced fractures of the proximal humerus in elderly patients. Commendable indications are fracture types A and B according to AO with stable fixation of the blade plate in the humeral head, which allow early physiotherapy and avoid an alteration of the rotator cuff. C-type fractures tend to complications (2/3).

[Functional results of dynamic gait analysis after 1 year of hobby-athletes with a surgically treated ankle fracture]. / Funktionelle Ergebnisse bei Freizeitsportlern in der dynamischen Ganganalyse 1 Jahr nach operativ versorgten Sprunggelenkfrakturen.

Retrospectively 20 patients with a surgically treated ankle fracture caused by hobby-accidents were examined clinically and radiologically by a score modified to Phillips after 12 months postoperatively. Further they have taken part in a dynamical gait analysis at the same time. A group of 20 healthy adults was used as a control group comparable to age, sex, height and weight. Although 19 patients out of 20 have achieved a good result at the score evaluation and none of them was clinically noticed with any pathological gait, gait analysis has shown a significant slowed gait speed and a decreased stride length. The reduction of the plantarflexor moment at the injured ankle joint immediately following heel contact was yet the most remarkable result of the gait analysis. The changes of gait pattern are interpreted as an adapted and internalized motion pattern caused by pain and behaviour of rest at any time while the mobilisation-phase was going on. It could not document any significant correlation between subjective and clinical parameters and parameters registered by gait analysis. However, a significant correlation of gait-analysed parameters was found between the injured and uninjured side. By dynamical gait analysis it is possible to quantify remarkable gait changes, to obtain objective data, but also to demonstrate asymmetrical loading and motion that were not clinically detectable previously. It follows that it can be relevant to patients with complaints by leading them to specific physiotherapeutical treatment and gait training so that they would be able to carry on their sports-activities again.

[Surgical treatment of fractures of the clavicle--Indication, surgical technique and results]. / Die operative Behandlung der Klavikulafraktur - Indikation, Operationsverfahren und Ergebnis -

UNLABELLED: 46 cases of clavicular fracture (25 of the middle third and 21 of the distal third) are reviewed concerning indications for surgery, surgical technique and postoperative results. In 32 cases surgery was necessary due to dislocation (in 7 cases with a rupture of the coracoclavicular ligaments), 3 times due to a complex trauma of the shoulder joint, 3 times due to a local neurovascular involvement, 3 times due to a delayed fracture healing and 3 times due to a pathological fracture. In two cases an open fracture required osteosynthesis. The most frequent surgical procedure was plate osteosynthesis using the following materials: 3.5 mm LCDC plate, the so called "Balser plate" and the "Ulrich plate", 3.5 mm reconstruction plate, 3.5 mm T-plate and compound plate. In 14 cases autogenous bone grafting was performed. Additional suture of the coracoclavicular ligaments was indicated in 7 patients. In every case early physiotherapy followed the surgical procedure. COMPLICATIONS: in 2 cases an avascular pseudarthrosis emerged after plate osteosynthesis without autogenous bone grafting. In one case a non-union developed due to infection. Moreover we found a loosening of a "Balser plate" and in one patient the development of keloid tissue. The functional outcome according to the Constant score was good. 32 patients achieved 89 out of 100 possible points (average follow up 31 months). In distal clavicle fractures we prefer the use of the "Balser plate" combined with a suture of the coracoclavicular ligaments. Due to the occurrance of delayed fracture healing with pseudarthrosis (2/25) in fractures of the middle third, the indication for surgical treatment has to be discussed. In case of local soft tissue trauma and damage of the periostal blood supply, plate osteosynthesis in combination with autogenous bone grafting should be performed.

[Kickboards - Cause of injury, patterns of injury and prevention]. / Trendsportart Rollerfahren - Unfallursache, Verletzungsmuster und Prävention.

69 patients with kickboard injuries were treated over a 5-month period. 6 patients were admitted to hospital. Fractures (48%), contusions/ lacerations (45%) and capsular/ ligamentuous injuries (27%) were the most prevalent types of injury. Injuries of the elbow, forearm, wrist and hand accounted for 54% of all cases. Ankle (23%), head (6%) and knee were other regions frequently involved. It is concluded that kickboard-driving imposes a severe risk of injuries. The typical kickboard injuries was the fracture of the wrist and the ankle sprain. Protective equipment for the injured regions is very important to prevant injury.

Leiomyosarcoma of the vulva. A case report.

BACKGROUND: Leiomyosarcoma of the vulva is a rare mesenchymal tumor. Biologic features of a low grade tumor were investigated by an immunohistochemical workup. CASE: A 38-year-old woman presented with a slowly growing vulvar mass. Surgical treatment was performed, and a low grade leiomyosarcoma of the vulva was diagnosed. Immunohistochemical reactions were performed with monoclonal antibodies against desmin, vimentin, smooth muscle actin, cytokeratin, S-100 protein, estrogen, progesterone and androgen receptor, p53 protein, Ki-67 antigen, leukocyte common antigen and polyclonal antibodies to factor VIII-related antigen. Expression of estrogen, progesterone and androgen receptor was present in addition to a moderate number of Ki-67-positive cells and absence of p53 protein overexpression and lymphatic cell infiltration besides adequate microvessel density for smooth muscle tumors. Since the immunohistochemical markers indicated a less aggressive tumor, any further adjuvant therapy was rejected. The patient was without recurrence 24 months later. CONCLUSION: The immunohistologic profile proved the low histologic grade of vulvar leiomyosarcoma. The findings helped to estimate prognosis and plan therapy.

[Traumatic hemipelvectomy and postoperative quality of life. Report of 2 cases 18 years after trauma]. / Traumatische Hemipelvektomie und die postoperative Lebensqualität. Bericht über 2 Fälle 18 Jahre nach dem Trauma.

Report and progress of 2 traumatic hemipelvectomies in motor-cyclists with excluding extraperitoneal tearing of half of the pelvis and disrupture of the pelvic vessels for 18 years. The purpose of this case study was the analysis of the quality of life, the clinical complications and the reintegration of the 2 patients 18 years after traumatic hemipelvectomy.

Preperitoneal lipoleiomyoma of the abdominal wall in a postmenopausal woman.

OBJECTIVE: Extrauterine leiomyomas are rare events. These tumors may be easily misdiagnosed as ovarian tumors at the clinical investigation. We present the first case of an otherwise healthy postmenopausal woman, hysterectomized 20 years ago, who developed a preperitoneal lipoleimoyoma in the 30-year-old scar of a Pfannenstiel incision. The patient received continuous hormone replacement therapy (HRT) for 5 years with 1.25 mg conjugated estrogen and 5 mg medrogeston per day. METHODS: In sections of the tumor, immunohistochemical reactions with antibodies against actin, desmin, vimentin, estrogen and progesterone receptors and factor VIII related antigen was performed. RESULTS: Histologic findings revealed cellular fascicles of spindle-shaped smooth muscle cells in a whorled arrangement. Mitotic figures were absent. Central degenerative changes and focal edema were observed. Between muscle fascicles, a significant amount of fat cells (20% of tumor volume) was visible. Leiomyocytes showed immunohistochemicaly positive reactions with actin, desmin, vimentin, and steroid hormone receptors. Based on these findings, the tumor was diagnosed as lipoleiomyoma. CONCLUSIONS: Origin of the tumor of smooth muscle cells of vessels located in the abdominal wall and development under influence of oral steroids seems most probable. HRT appears to promote the development of extrauterine leiomyomas in postmenopausal women.

Trends in vulvar neoplasia. Increasing incidence of vulvar intraepithelial neoplasia and squamous cell carcinoma of the vulva in young women.

OBJECTIVE: To determine trends in the epidemiology of vulvar intraepithelial neoplasia (VIN) and squamous cell carcinoma (SCC) of the vulva in a Central European sample during the last decade. STUDY DESIGN: A total of 366 women with VIN 2 and 3 (n = 128) or vulvar SCC (n = 238) presented within two four-year periods separated by one decade (1985-1988 and 1994-1997). We performed a retrospective analysis of the clinicopathologic records of the cohorts. RESULTS: The number of women with high grade VIN (n = 29 vs. 99) tripled during the last decade, while the incidence of vulvar SCC remained stable. In women < or = 50 years old, the incidence of high grade VIN increased by 392% (n = 12 vs. 59) and of invasive vulvar cancer by 157% (n = 7 vs. 18). In the earlier cohort there were 7/126 (5%) women with invasive vulvar SCC under the age of 50 and, in the latter cohort, 18/112 (16%, P < .01). CONCLUSION: Over the past decade a striking increase occurred in the incidence of VIN and an increase in invasive vulvar SCC in young women.

Modified true-color computer-assisted image analysis versus subjective scoring of estrogen receptor expression in breast cancer: a comparison.

BACKGROUND: Hormone receptor expression can be quantified by computerized image analysis in immunohistochemically stained specimens. When comparing semiquantitative scoring with computerized image analysis a review of the literature shows contradictory findings concerning the correlation of these two methods. Recent technical approaches have been developed with true-color computer-assisted image analysis facilitating new measurement designs. We performed a study with a new approach using the principle of semiquantitative assessment of hormone receptor content and measuring two different binary images (immunohistochemically stained nuclear area and total nuclear area). MATERIAL AND METHODS: Eighty formalin-fixed, paraffin-embedded and immunohistochemically stained breast cancer specimens were assessed for estrogen receptor expression by true color computer-assisted image analysis and by conventional light microscopy scoring according to Remmele (immunoreactive score (IRS) = staining intensity (SI) x percentage of positive cells (PP)). The results of both methods were correlated. RESULTS: Mean optical density (MOD) and subjective scoring of SI as well as stained nuclear area vs. total nuclear area and subjective scoring of stained cells (PP) showed a high correlation (Spearman correlation coefficient: 0.95, p-value: 0.0001 and 0.64, p-value: 0.0001, respectively). CONCLUSION: On the basis of this new technical approach our results confirm the correlation of semiquantitative hormone receptor scoring and quantitative computer-assisted image analysis. We believe that by automating electronic analysis in the near future we will be able to establish reliable observer-independent evaluation of immunohistochemical variables ensuing comparability in multi-center trials and cost efficiency.

Prognostic significance of tumor angiogenesis in epithelial ovarian cancer.

Since angiogenesis is considered essential for tumor growth and the development of metastasis, we assessed the correlation of microvessel density (MVD) with overall survival in patients with epithelial ovarian cancer. Histologic slides were immunostained for CD34-antigen. MVD was determined within each tumor by enumeration under a light microscope at 200x magnification and an examination area of 0.25 mm2. The Cox proportional-hazards model was used for multivariate analysis. In 63 patients with epithelial ovarian cancer the 5-year survival rate (OS-%) was as follows: 55.0% (+/-12.5) in 18 patients whose tumors had an MVD < 10/field, and 23.6% (+/-6.7) in 45 patients whose tumors had an MVD(10/field (log-rank P = 0.038). MVD showed a significant influence on survival in univariate analysis, but failed to attain a significant value after adjustment for established prognostic parameters such as patients' age at diagnosis, stage of disease, and histologic grading. High MVD was significantly associated with advanced patients' age at diagnosis. This and a considerable heterogenity in the vascular architecture of ovarian carcinoma tissue might be the reasons why MVD did not reveal prognostic significance in multivariate analysis. In contrast to a variety of solid neoplasms, MVD does not seem to be a useful predictor of survival in patients with epithelial ovarian cancer.

Leiomyoma of the round ligament in a postmenopausal woman.

OBJECTIVE: Leiomyoma of the round ligament of the uterus is a rare condition. We present the first case of a postmenopausal, previously hysterectomised, woman who received combined hormonal replacement therapy and developed a leiomyoma of the right round ligament. METHOD: In sections of the tumor, immunohistochemical reaction with monoclonal antibodies against smooth muscle actin, desmin, vimentin, estrogen receptor and progesterone receptor was performed. RESULTS: The leiomyoma showed bizarre histologic appearance in absence of mitotic figures and degenerative changes. Leiomyocytes presented a positive immunohistochemical reaction with monoclonal antibodies against smooth muscle actin, desmin vimentin and progesterone receptor in absence of estrogen receptor. CONCLUSION: Progestin as part of a combined hormonal replacement therapy may play an important role in promoting the development of leiomyoma in hormonal responsive tissue of the round ligament in postmenopausal women.