[Prevention of venous thromboembolism in musculoskeletal surgery]. / Thromboseprophylaxe in der muskuloskelettalen Chirurgie.

Musculoskeletal surgery is associated with a high risk of venous thrombosis and pulmonary embolism. The introduction of direct oral anticoagulants (DOAK) has broadened the possibilities for prevention of venous thromboembolism in the course of orthopedic and trauma surgery. Addressing this recent development, the Austrian Societies of Orthopedics and Orthopedic Surgery (ÖGO), Trauma Surgery (ÖGU), Hematology and Oncology (OeGHO) and of Anaesthesiology, Reanimation und Intensive Care Medicine (ÖGARI) have taken the initiative to create Austrian guidelines for the prevention of thromboembolism after total hip and knee replacement, hip fracture surgery, interventions at the spine and cases of minor orthopedic and traumatic surgery. Furthermore, the pharmacology of the DOAK and the pivotal trial data for each of the three currently available substances - apixaban, dabigatran, and rivaroxaban - are briefly presented. Separate chapters are dedicated to "anticoagulation and neuroaxial anesthesia" and "bridging".

[Consensus diagnosis and therapy of soft tissue sarcoma]. / Konsensus Diagnose und Therapie von Weichteilsarkomen.

Soft tissue sarcomas are heterogeneous tumours and relatively uncommon. There have been advances over the past years concerning pathology, clinical behaviour, diagnosis strategies and the treatment. To summarize these advances as well as making it public is one of the goals of the following consensus guidelines. But why do we need special guidelines for Austria? There are international guidelines published by the European Society of Medical Oncology (ESMO) and the National Comprehensive Cancer Network (NCCN). The cause is that we need an explanation of the matrix the ESMO and the NCCN gave according to our clinical practice, the local requirements and facilities in Austria. The following recommendations were drawn up following a consensus meeting of sarcoma specialists from the three high volume centres located at the medical universities in Austria. All fields of involved physicians from diagnosis to therapy worked together to know that soft tissue sarcomas are an interdisciplinary challenge and multimodal treatment is essential. For this reason, these guidelines not only explain but also give the state of the art and clear recommendations. One of the most important guidelines is that any patient with a suspected soft tissue sarcoma should be referred to one of the three university centres and managed by a specialist sarcoma multidisciplinary team. We hope that the consensus is helpful for the clinical practice and improves the quality of care for patients with soft tissue sarcomas in Austria.

The history of the anterior approach to the hip.

The anterior approach is a safe, reliable, and feasible technique for total hip arthroplasty, permitting optimal soft tissue preservation. Since Hueter first described this interval, many surgeons have approached the hip anteriorly to perform a myriad of surgical procedures. The anterior approach allows optimal muscle preservation, and it is a truly internervous approach to the hip. An understanding of the evolution of the anterior approach to the hip will help the orthopedic community understand these advantages and why so many have used this approach in the treatment of hip pathology and for the implantation total hip arthroplasty.

[Minimally invasive total hip arthroplasty via direct anterior approach]. / Minimalinvasive Hüftendoprothetik über den anterioren Zugang.

OBJECTIVE: Minimally invasive total hip arthroplasty via direct anterior approach aims at reducing soft-tissue damage, diminishing blood loss and postoperative pain, shortening stay in hospital, accelerating rehabilitation, and keeping scars small. INDICATIONS: The technique is suitable for primary and secondary osteoarthritis as well as fractures of the femoral neck. Complex distortions of the proximal femur should be exempted. CONTRAINDICATIONS: Complex malalignment of the proximal femur. SURGICAL TECHNIQUE: The femoral neck is exposed in the interval between tensor fasciae latae, glutei medius and minimus muscles laterally, and sartorius and rectus femoris muscles medially. After osteotomy of the neck and extraction of the head the acetabulum is reamed to prepare for cup prosthesis. Following peritrochanteric capsulotomy the externally rotated, adducted and elevated femor is broached. Cemented and cementless implants may be used. POSTOPERATIVE MANAGEMENT: The patients are allowed to walk full weight bearing beginning on the 1st postoperative day. As soon as they are able to safely master the transfers and stairs, they are discharged. RESULTS: The method is a safe procedure that allows correct placement of acetabular and femoral components. It may be performed in a reasonable time, the blood loss is little. The procedure preserves the muscles and leads to small, cosmetically pleasing scars. Patients usually do not suffer from pronounced pain, rehabilitation is accelerated. They therefore agree in an short postoperative stay in hospital.

A double offset broach handle for preparation of the femoral cavity in minimally invasive direct anterior total hip arthroplasty.

A direct anterior approach is in use for minimally invasive total hip arthroplasty. This approach uses an intermuscular and internerval plane between the sartorius, rectus femoris, and tensor fasciae latae. Although preparation of the acetabulum and implantation of the acetabular component is an easy task with the available instruments, preparation of the femoral canal through this single incision is more demanding. Instrumentation of the femur involves careful preparation of the dorsal capsule, positioning of the operated leg, and leverage of the femur. A broach handle with lateral and anterior offset for the direct anterior approach has been developed to reduce the need for leverage of the proximal femur for preparation of the cavity.

Assessment of talar flattening in adult idiopathic clubfoot.

BACKGROUND: The radius/length (R/L) ratio was developed to evaluate the convexity of the talar dome in idiopathic clubfoot. However, the index has not been tested for its reliability and reproducibility. METHODS: The R/L ratio was determined by three independent observers on the radiographs of 21 adult patients with idiopathic clubfoot and 30 adult subjects with normal feet. The reproducibility and the reliability of the R/L ratio were calculated. RESULTS: For the normal feet the reproducibility and the reliability of the R/L ratio was high (correlation coefficient > 0.87). For the patients with clubfoot, the reliability and reproducibility depended on the severity of talar flattening. For a radius of less than 45 mm the mean intraobserver correlation coefficient was 0.74 (range 0.54 to 0.83) and the mean interobserver correlation coefficient was 0.58 (range 0.49 to 0.75). For a radius of more than 45 mm no statistically significant intraobserver and interobserver correlations were found. CONCLUSION: The current results indicate that the R/L ratio of talar flattening is reliable and reproducible for mild talar deformity but not for severe flattening (radius of more than 45 mm).

Reproducible assessment of radiolucent lines in total knee arthroplasty.

The Knee Society Total Knee Arthroplasty Radiographic Evaluation and Scoring System was introduced to encourage uniform reporting of radiographic outcome. However, the method for evaluation of radiolucent lines has been shown to be unreliable. Because it has been shown that reducing the complexity of classification systems increases reliability and reproducibility, we questioned whether a simplification of the Radiographic Evaluation and Scoring System would improve reliability and reproducibility. A new system for assessment of radiolucent lines was introduced, and the interobserver reliability and intraobserver reproducibility were studied in 100 patients with 120 total knee replacements. For the new system the mean kappa intraobserver reproducibility coefficient was 0.71 (range, 0.62-0.85) for the femoral component, 0.86 (range, 0.80-0.96) for the tibial component, and 0.58 (range, 0.46-0.75) for the patella prosthesis. The mean interobserver reliability coefficient among three observers was 0.61 (range, 0.45-0.72) for the femoral component, 0.82 (range, 0.73-0.88) for the tibial component, and 0.58 (range, 0.43-0.72) for the patella prosthesis. The new system for assessment of radiolucent lines increased reliability and reproducibility and should supplement the Knee Society's Radiographic Evaluation and Scoring System.

The frontal pelvic plane provides a valid reference system for implantation of the acetabular cup: spatial orientation of the pelvis in different positions.

BACKGROUND: The frontal pelvic plane has traditionally served as the reference plane for implantation of the acetabular cup during total hip arthroplasty, with referencing performed with the patient supine on the operating table. During daily activities in an upright position, the frontal pelvic plane changes from a horizontal to a vertical orientation. If this change in orientation is accompanied by a substantial change in pelvic inclination angle, it would mean that the use of the frontal pelvic plane as a reference plane for implantation of the acetabular cup would not be valid for proper alignment of the cup. To evaluate this possibility, we measured the change of inclination of the pelvis from the supine to the standing position. SUBJECTS AND METHODS: We evaluated 120 patients, first positioned in a standing position and then supine on a table. Three pelvic landmarks were digitized percutaneously, and the spatial coordinates were calculated with regard to pelvic orientation in the horizontal and the vertical plane. RESULTS: We found a mean inclination of 6.7 degrees in the standing position and 5.6 degrees in the supine position. Patients who were more than 60 years of age who did not have coxarthrosis had a greater inclination angle (8.7 degrees ) while standing. Pelvic orientation was stable with regard to the supine and standing positions. These results were independent of sex, level of arthrosis, or status after implantation of a total hip replacement. INTERPRETATION: The frontal pelvic plane is a valid reference plane for implantation of the acetabular cup.

Malformation of the acetabular fossa as a cause of intrapelvic injury in total hip arthroplasty: a report of 2 cases.

We report 2 cases of bone defects of the acetabulum. The first case was a patient who underwent a total hip arthroplasty. An intraoperative bleeding occurred because of an injury of an intrapelvic artery. Preoperative radiographs did not show this bone defect. A similar abnormality of the acetabulum was found in a series of 30 pelves that were dissected for a cadaver study. In this case, the bone defect was located in the center of the right acetabulum.

High-dose-rate intraoperative brachytherapy (IOHDR) using flab technique in the treatment of soft tissue sarcomas.

BACKGROUND: Adjuvant radiotherapy has been shown to improve local control in patients with soft tissue sarcoma. Additional brachytherapy represents a means of enhancing the therapeutic ratio, as biological and dosimetric advantage over single external-beam irradiation (EBRT) can be expected. High-dose-rate intraoperative brachytherapy (IOHDR) as a boost therapy should therefore be able to further diminish the rate of local recurrence even when performing marginal resection. There are sparse data on IOHDR using flab applicators as adjuvant boost to EBRT in combination with marginal resection of soft tissue sarcomas. PATIENTS AND METHODS: Within a period of 8 years, we prospectively studied 39 adult patients treated by marginal resection, IOHDR using the flab technique and EBRT for soft tissue sarcomas. There were 32 high-grade and seven low-grade tumors, 35 were > 5 cm. Mean follow-up was 26 months (range 3-59 months). RESULTS: We could not detect any local recurrences. No treatment-related loss of limb or life occurred. There were no neurologic or vascular complications, all patients maintained functioning extremities as evidenced by a mean Musculoskeletal Tumor Society (MSTS) functional score of 88.5 (70-100). Treatment-related wound morbidity occurred in eleven patients necessitating revision surgery in eight. Metastatic disease developed in seven patients, six of them had died. The 2-year actuarial disease-free survival was 84%. CONCLUSIONS: IOHDR using the flab technique in combination with EBRT and marginal resection is an efficient treatment technique leading to optimal local control rates and limited functional impairment.

Eosinophilic granuloma of the bone: ultrasonographic imaging.

Eosinophilic granuloma is a rare disease of unknown aetiology that affects the bones. Two cases of eosinophilic granuloma are presented. Ultrasonographic, CT and histopathological findings are described. Ultrasonographic-guided core-needle biopsy was performed. Treatment was initiated by installing steroid suspension into the lesions, which resulted in complete healing of the bone in both cases.

Differentiation of malignant and benign musculoskeletal tumors: combined color and power Doppler US and spectral wave analysis.

PURPOSE: To assess the use of combined color Doppler ultrasonography (US), power Doppler US, and spectral wave analysis (SWA) in differentiating malignant and benign musculoskeletal tumors. MATERIALS AND METHODS: Seventy-nine musculoskeletal tumors (34 malignant, 45 benign) were examined with color and power Doppler US and SWA. Two radiologists independently assessed US images and SWA findings. Echotexture and vessel characteristics such as stenoses, occlusions, loops, shunts, trifurcations, vascular pattern, and resistive index were evaluated. All tumors were subject to US-guided or open biopsy for histologic correlation. RESULTS: Combined color and power Doppler US and SWA revealed four major (stenosis, occlusion, trifurcation, vascular pattern) and three minor (shunt, self loop, resistive index) vessel characteristics, which proved helpful in differentiating benign from malignant lesions. Echotexture showed moderate sensitivity (82% [28 of 34 tumors]) and low specificity (38% [17 of 45 tumors]). When comparing several combinations of vessel characteristics, a combination of any two major characteristics demonstrated the best results (sensitivity, 94% [33 of 39 tumors]; specificity, 93% [three of 45 tumors]). Combining more than two characteristics resulted in lower sensitivity. CONCLUSION: Combined color and power Doppler US and SWA may enable assessment of vascular architecture and altered flow of musculoskeletal tumors. Vascular architecture analysis enables differentiation of benign and malignant lesions and evaluation of musculoskeletal tumors.