The use of a non-invasive extendable prosthesis at the time of revision arthroplasty.

Aims: The use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses. Patients and Methods: All patients who had a noninvasive growing endoprosthesis inserted at the time of a revision procedure were identified from our database. A total of 21 patients (seven female patients, 14 male) with a mean age of 20.4 years (10 to 41) at the time of revision were included. The indications for revision were mechanical failure, trauma or infection with a residual leg-length discrepancy. The mean follow-up was 70 months (17 to 128). The mean shortening prior to revision was 44 mm (10 to 100). Lengthening was performed in all but one patient with a mean lengthening of 51 mm (5 to 140). Results: The mean residual leg length discrepancy at final follow-up of 15 mm (1 to 35). Two patients developed a deep periprosthetic infection, of whom one required amputation to eradicate the infection; the other required two-stage revision. Implant survival according to Henderson criteria was 86% at two years and 72% at five years. When considering revision for any cause (including revision of the growing prosthesis to a non-growing prosthesis), revision-free implant survival was 75% at two years, but reduced to 55% at five years. Conclusion: Our experience indicates that revision surgery using a noninvasive growing endoprosthesis is a successful option for improving leg length discrepancy and should be considered in patients with significant leg-length discrepancy requiring a revision procedure. Cite this article: Bone Joint J 2018;100-B:370-7.

Passage of an Anterior Odontoid Screw through Gastrointestinal Tract.

Purpose. Anterior screw fixation has become a popular surgical treatment method for instable odontoid fractures. Screw loosening and migration are a rare, severe complication following anterior odontoid fixation, which can lead to esophagus perforation and requires revision operation. Methods. We report a case of screw loosening and migration after anterior odontoid fixation, which perforated the esophagus and was excreted without complications in a 78-year-old male patient. Results. A ventral dislocated anterior screw perforated through the esophagus after eight years after implantation and was excreted through the gastrointestinal (GI) tract. At a 6-month follow-up after the event the patient was asymptomatic. Conclusion. Extrusion via the GI tract is not safe enough to be considered as a treatment option for loosened screws. Some improvements could be implemented to prevent such an incident. Furthermore, this case is a fine example that recent preoperative imaging is mandatory before revision surgery for screw loosening.

What is the morbidity of a non-invasive growing prosthesis?

AIMS: Extendible endoprostheses have been available for more than 30 years and have become more sophisticated with time. The latest generation is 'non-invasive' and can be lengthened with an external magnetic force. Early results have shown a worryingly high rate of complications such as infection. This study investigates the incidence of complications and the need for further surgery in a cohort of patients with a non-invasive growing endoprosthesis. PATIENTS AND METHODS: Between 2003 and June 2014, 50 children (51 prostheses) had a non-invasive growing prosthesis implanted for a primary bone sarcoma. The minimum follow-up was 24 months for those who survived. Their mean age was 10.4 years (6 to 14). The incidence of complications and further surgery was documented. RESULTS: The mean follow-up was 64 months (20 to 145). The overall survivorship of the patients was 84% at three years and 70% at five years. Revision-free survival was 81.7% at three years and 61.6% at five years with competing risk analysis. Deep infection occurred in 19.6% of implants at a mean of 12.5 months (0 to 55). Other complications were a failure of the lengthening mechanism in five prostheses (9.8%) and breakage of the implant in two (3.9%). Overall, there were 53 additional operations (0 to 5 per patient). A total of seven patients (14%) underwent amputation, three for local recurrence and four for infection. Their mean limb length discrepancy was 4.3 mm (0 to 25) and mean Musculoskeletal Tumor Society Score functional score was 26.5 (18 to 30) at the final follow-up. CONCLUSIONS: When compared with previously published early results, this mid-term series has shown continued good functional outcomes and compensation for leg-length discrepancy. Infection is still the most common complication: post-operative wound healing problems, central line infection and proximal tibial location are the main risk factors. Cite this article: Bone Joint J 2016;98-B:1697-1703.

Serum sclerostin levels in renal cell carcinoma patients with bone metastases.

Sclerostin has been proposed as a potent inhibitor of bone formation. Sclerostin antibodies are under clinical development to treat osteoporosis and metastatic bone disease. Serum sclerostin level is elevated in multiple myeloma, an osteolytic malignancy, where it might serve as predictive marker for the use of sclerostin-directed antibodies. As renal cell carcinoma (RCC) patients often present with osteolytic metastases, we aimed to investigate serum sclerostin levels in RCC patients. Our study included 53 RCC patients (19 with bone metastases, 25 with visceral metastases and 9 with localized disease) and 53 age- and gender-matched non-osteoporotic controls. Frozen serum samples were subjected to sclerostin quantitative sandwich ELISA. The mean serum sclerostin levels of RCC patients and controls were 45.8 pmol/l and 45.1 pmol/l, respectively (p = 0.86). Analysis of variance showed no difference between the subgroups of RCC patients with regard to visceral or bone metastases or localized disease (p = 0.22). There was no significant association between eGFR (estimated glomerular filtration rate) and serum sclerostin levels in RCC patients (r = 0.05; p = 0.74) and controls (r = 0.06; p = 0.68). Our results indicate that serum sclerostin levels appear not to be a valuable biomarker to assess the occurrence of bone metastases in RCC patients.

[Congenital esophageal duplication cysts: progressive dysphagia in adulthood]. / Kongenitale zystische Duplikatur des Ösophagus: Progrediente Dysphagie im Erwachsenenalter.

Esophageal duplications are congenital abnormalities of the foregut. We present the case of a 33-year-old woman suffering from progressive dysphagia who had surgery for esophageal duplication. The following three criteria define the cystic lesion: an intimate attachment to the esophageal wall, the presence of a smooth muscle coat and a mucosal lining consisting of squamous and/or ciliated respiratory epithelium. Diverticula, bronchogenic cysts and cystic neoplasms have to be considered in the differential diagnosis. Congenital cystic esophageal duplication is a rare cause of dysphagia in adulthood.

The gall midge Asphondylia borrichiae (Diptera: Cecidomyiidae): an indigenous example of host-associated genetic divergence in sympatry.

Speciation usually is conceptualized as occurring via three biogeographic modes: allopatry, parapatry, and sympatry. Sympatric speciation has been the most controversial because of the difficulty of developing plausible theoretical models in which the homogenizing effects of gene flow are sufficiently overcome to permit genetic divergence to occur in the absence of geographic barriers restricting gene flow. Recently, a number of hypothetical models for sympatric speciation have been advanced and several candidate study systems have provided evidence of sympatric divergence, although many of the systems so identified involve introduced species, especially in the cases of host-race formation in phytophagous insects, which expand their host range and use a novel host. Although these cases demonstrate the reality of sympatric divergence, they do not address which mode of speciation predominates in indigenous communities. Asphondylia borrichiae Rossi & Strong has been proposed as a potential example of sympatric divergence in a fully indigenous system, based on the results of a host-choice experiment involving three host-plant species. In the current study, we report significant differences in the genetic composition of midge populations collected from each host in situ, supporting the hypothesis of sympatric genetic divergence among the morphologically identical host-associated populations of A. borrichiae and consistent with host fidelity in oviposition choice.

[Granular cell tumor of the stomach]. / Granularzelltumor des Magens.

Granular cell tumors are peripheral neuroectodermal tumors. Within the gastrointestinal tract, they have to be differentiated from gastrointestinal stromal tumors (GIST). We present the case of a 61-year-old patient who was diagnosed with a granular cell tumor of the stomach. The tumor cells showed transmural infiltration form the mucosa into the adipose tissue of the lesser curvature. The tumor cells were diffusely positive for S100-protein and negative for KIT, CD34 und SMA. The MIB1-proliferation index was below 2%. Granular cell tumors rarely occur within the gastrointestinal tract. Oesophagus and colon are most commonly affected. Diagnostic criteria and differential diagnosis of this peculiar lesion are thoroughly discussed.

[Pelvic fracture with shock-inducing retroperitoneal bleeding and concomitant lower extremity ischemia syndrome: discussion of management exemplified by a case report]. / Beckenfraktur mit schockierender arterieller retroperitonealer Blutung und gleichzeitigem Extremitäten-Ischämiesyndrom: Diskussion des Managements anhand eines Fallbeispieles.

BACKGROUND: Initial treatment of severe pelvic fracture consists of appropriate resuscitation and early pelvic reposition and stabilization. Concomitant retroperitoneal arterial bleeding in a hemodynamically unstable patient in combination with lower extremity ischemia make early management decisions very difficult and the mortality rate of this entity of injuries is extremely high. CASE REPORT: We report on a successful treatment of a 36 year old skier, referred in hemorrhagic shock, who had sustained a severely displaced both column fracture of the right acetabulum, an unstable pelvic ring injury on the left and a retroperitoneal bladder rupture. He developed complete ischemia of the right lower extremity. Angiography revealed an obliteration without extravasation of the external iliac artery and allowed treatment of a right superior gluteal artery disruption by embolization. The right lower extremity ischemia was revascularized with a subcutaneous femoro-femoral bypass graft. Delayed internal fixation of the right acetabulum and exploration of the iliac vasculature was done through an ilio-inguinal approach. Simultaneously, the cross-over bypass could be removed. After 18 months, the patient recovered without any ischemic symptoms, but continues with a mixed sciatic nerve lesion. DISCUSSION AND CONCLUSIONS: The combination of severe retroperitoneal arterial bleeding and total ischemia of the lower extremity requires immediate surgical therapy. Direct exploration of the retroperitoneum, however, can be fatal and should be avoided if the iliac vessels are angiographically intact or if a hemorrhage is controllable by an embolization procedure. Extraanatomic temporary revascularization of the lower extremity should be envisaged when a lower leg ischemia due to obliteration or compression of major intrapelvic vessels cannot be directly and immediately treated.

[Secondary peritonitis after negative computerized tomography in blunt abdominal trauma]. / Sekundäre Peritonitis nach negativem Computertomogramm (CT) beim stumpfen Abdominaltrauma.

Diagnostic peritoneal lavage has widely been replaced by emergency sonography in the evaluation of blunt abdominal trauma. CT is generally performed in cases without major hemodynamic instability in order to define non-operative treatment of injuries of the parenchymatous organs or to precise the extension of retroperitoneal, spinal and pelvic lesions. Despite the good results of this method for the mentioned indications, the low sensitivity of CT for lesions of hollow viscus should not be forgotten. We report 3 cases of lesions of the small bowel (2 perforations and 1 mesenteric lesion with ischemic bowel wall) which were not visible, even retrospectively, at the CT. Despite discrete clinical signs, these lesions were only diagnosed at the stage of obvious secondary peritonitis. These cases should remind us the limits of CT in the evaluation of abdominal visceral lesions in blunt trauma.

[Biliary pancreatitis--a good indication for laparoscopic cholecystectomy]. / Biliäre Pankreatitis--eine gute Indikation zur laparoskopischen Cholezystektomie.

Recently the indication for laparoscopic cholecystectomy has been enlarged to include biliary pancreatitis. While a majority of reports recommend early open cholecystectomy for biliary pancreatitis the use of laparoscopic cholecystectomy in this disease has not yet been discussed. We retrospectively reviewed 52 patients with biliary pancreatitis being admitted to our ward in the last five years. Cholecystectomy was performed in 48 patients. Ten had undergone laparoscopic cholecystectomy. Postoperative complications occurred in 8 of the 48 patients (16.6%). Four patients (8.3%) died due to necrotizing pancreatitis or rupture of pseudocysts. We found a correlation between morbidity and mortality and the prognostic score as well as the presence of pseudocysts. We conclude that biliary pancreatitis is a good indication for laparoscopic cholecystectomy in patients with a low prognostic score. The presence of pseudocysts in our view is no contraindication for laparoscopy. Although it may increase postoperative morbidity. Choledocholithiasis has to be ruled out either by preoperative ERCP or during laparoscopy with intraoperative cholangiography.

[Characteristics of tumor diseases in patients with colorectal cancer]. / Bedeutung von Tumorkrankheiten bei Patienten mit kolorektalem Karzinom.

Medical histories for the years 1978 to 1988 were reviewed to ascertain associations between colorectal cancers and extraintestinal malignancies. 61 out of 838 patients (7.3%) had an extraintestinal malignancy before the colorectal cancer. In males the rate was 5.4% and in females 10.4%. In males a high association was shown between cancers of the large bowel and urogenital cancers. In females colorectal cancer was associated with breast and gynecologic cancers. We conclude that patients with gynecologic and urologic tumors have an increased risk to develop cancers of the large bowel and that these high risk patients should undergo long-term follow-ups.

Systematic assessment of massive bleeding of the lower part of the gastrointestinal tract.

A study of 83 patients admitted with massive bleeding in the lower part of the gastrointestinal tract is presented using a diagnostic approach primarily of angiography and colonoscopy with the adjunctive investigations of scintigraphy, small intestine series and computed tomographic scan. The source of bleeding was identified preoperatively in 74 patients. Nine patients had a diagnostic laparotomy and the cause was found in an additional seven. A source was not identified in two patients at exploration and a blind resection was not performed. The two patients have not had recurrent bleeding four and nine years postlaparotomy. The sites of bleeding were colon in 44 patients, small intestine in 24 and the anorectum in 11. Sixty-five patients were treated operatively, two by angiographic embolization and two by endoscopic electrocoagulation. Fourteen patients were managed conservatively. The mortality rate was 10.8 percent and five patients rebled after treatment. We conclude that a thorough systematic assessment of patients with bleeding in the lower part of the gastrointestinal tract is important to localize the site of the hemorrhage. Exploratory laparotomy is the final diagnostic modality, and if a source has not been identified, a blind colonic resection should not be performed.

[Dose standardized management of patients with occlusive jaundice reduce morbidity and mortality?]. / Ein standardisiertes Management von Patienten mit Verschlussikterus reduziert die Morbidität und Mortalität?

Patients with obstructive jaundice have a high incidence of complications. Invasive techniques required for definitive diagnosis and treatment compound the situation. In a prospective randomised trial we studied 54 patients over a 12-month period. All had obstructive jaundice (bilirubin greater than 100 mg/%). Prior to treatment, the trial protocol required correction of fluid balance (CVP), administration of albumin and vitamin K and an adequate urine output. Antibiotics were administered in accordance with a strict regime. The overall mortality was 7.5%, in elective cases with a mortality of 4%, in emergency cases with a mortality of 100%. The surgical treated patients had a higher incidence of complications than patients with interventional procedure, but not a higher mortality. Patients with obstructive jaundice will benefit from an adequate pre-treatment resuscitation and a standardised treatment policy after elimination of the obstruction.

[Is surgical bile duct revision in choledocholithiasis still indicated?]. / Ist die chirurgische Gallengangsrevision bei Choledocholithiasis noch indiziert?

Endoscopic papillotomy with stone extraction is increasingly performed for the management of common bile duct stones either before cholecystectomy or as a sole procedure leaving the gallbladder in situ. We have therefore evaluated the method of operative common duct exploration. 94 cases with bile duct stones treated by cholecystectomy and common bile duct exploration were reviewed. The 30-day mortality was 2.1% with an overall morbidity of 19%. A retained stone was found on postoperative T-tube cholangiography in 6 patients and in all cases was removed percutaneously via the T-tube track. Patients were divided into three age groups (less than or equal to 60, 61-75, greater than 75 years). In each patient various risk factors were recorded. Correlation was made between age, risk factors and patient's morbidity. No correlation was found between age and morbidity. Patients with up to two risk factors had a morbidity of 10%. With three to four risk factors the morbidity increased to 19%, reaching 47% in patients with five and more risk factors. Cholecystectomy with common bile duct exploration is a safe procedure even in the elderly patient. Careful evaluation of risk factors is necessary. Endoscopic papillotomy with or without cholecystectomy should be considered in high risk patients.

[Percutaneous transhepatic inserted self-expanding metal endoprosthesis in the palliative treatment of malignant obstructive jaundice]. / Perkutan-transhepatisch eingelegte selbstexpandierende Metallendo-prothesen in der palliativen Behandlung des malignen Verschlussikterus.

Prospective studies comparing biliary-enteric bypass with implantation of endoprostheses in palliation of malignant obstructive jaundice showed no significant difference. A new self-expandable metal endoprosthesis was introduced to ameliorate the results in terms of early complication and occlusion rate. Between December 1988 and April 1991 we treated 35 patients (32 with malignant obstructive jaundice) by 50 self-expandable endoprostheses. The implantation was successful in 96% of patients. The early complication rate was 37% and the 30-day mortality 14%. In 89% of the patients relief of jaundice after 3 months was found. Recurrent jaundice and cholangitis occurred in 39%, whereas reoperation was necessary in 25%. 16 of 26 patients (61%) with malignant obstructive jaundice where alive after an average of 7.5 months. We found no advantage of the self-expandable endoprostheses compared with conventional plastic stents. Implantation of a self-expandable metal endoprosthesis may be an alternative to surgical bypass in selected cases. It would be interesting to evaluate the endoscopic route of insertion and to compare the results with palliative surgery in randomized studies.

[Prospective study of the early postoperative course of splenic rupture: spleen preservation versus splenectomy]. / Prospektive Studie über den frühpostoperativen Verlauf nach Milzruptur: Milzerhaltung versus Splenektomie.

The haematological and immunological changes after splenectomy have been the subject of intensive research in recent years. As a consequence there has been a clear trend towards splenic salvage. Due to the availability of improved diagnostic investigations (sonography, CT) nonoperative treatment with close observation has become increasingly important in adults. 75 patients with documented splenic injury were prospectively evaluated over a 45-month period with an emphasis upon splenic preservation. Unstable patients had operative exploration with attempt at splenorrhaphy or partial splenic resection. Stable patients were managed nonoperatively, regardless of the degree of splenic injury as determined by sonography and/or computed tomography. In 38 patients the spleen was preserved by operative preservation in 20 and nonoperative treatment in 18 patients. 37 patients required splenectomy. Four patients were managed initially by nonoperative treatment, but required exploration for secondary rupture at 7, 7, 10 and 13 days. Delayed splenectomy was performed in three patients and one patient was treated by splenorrhaphy 7 days after admission. Bleeding complications occurred in one patient after splenorrhaphy (bleeding from the pancreatic tail) and the bleeding vessel could be transfixed during the same anaesthetic. Four patients required reexploration after splenectomy for hemorrhage (2) and evacuation of infected haematomas. The Injury Severity Score (ISS) of the splenectomy and splenic preservation group was determined. Splenectomised patients showed in the postoperative follow-up a significantly increased infection rate (40%, p less than 0.02) when compared to patients with splenic preservation (10%) or nonoperative treatment (11%), even when they were matched in respect of multiple trauma using the Injury Severity Score (ISS).

[Technical aspects of spleen saving therapy in splenic trauma]. / Technische Aspekte der milzerhaltenden Therapie beim Milztrauma.

The haematological and immunological consequences of splenectomy have been the subject of increasingly intensive studies over the last few years. As a result there has been a significant change in the management of splenic trauma with the emphasis on organ preservation which has been associated with a possible reduction in postoperative infectious complications. The safety of splenic preservation (splenorrhaphy) has been demonstrated. There has also been a change in the increased use of non-surgical (conservative) management of injuries in adults, a policy which previously was reserved for children. There is no difference in the postoperative bleeding rate between patients with splenectomies or patients with splenorrhaphies. Non-surgical treatment is in adults not yet established. In our department splenic preservation gets an increasing weight in our treatment policy, even in patients with multiple injuries. Our treatment policy initially classifies the splenic injury into one of five groups and this determines the subsequent operative procedures. The crucial part of the surgical technique in splenic preservation involves the immediate dissection and delivery of the spleen from its subdiaphragmatic position, thus avoiding iatrogenic injuries which can readily occur in the emergency situation. The hilus is then clamped with a non-crushing vascular or intestinal clamp, which avoids blood loss during the repair. The methods used for the repair depend on the grade of the injury. Means to prevent sutures cutting through the tissue (resorbable collagen platelets, resorbable gauze, teflon stripes) and a variety of methods to achieve haemostasis (infra red photocoagulation, haemostatic material and supportive mesh) are used.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasound controlled aspiration cytology of liver, bile ducts and pancreas]. / Ultraschallgesteuerte Aspirationszytologie von Leber, Gallenwegen und Pankreas.

Aspiration cytology is an effective and safe method for diagnosis of intraabdominal malignancies. In a prospective study we analysed the cytology in 84 patients. The results showed a sensitivity of 95% with an accuracy of 96%. No false positive diagnosis was found where open biopsy was possible. The aspiration cytology is a good method to decide whether endoscopic stents or embolization of the liver can be used without explorative laparotomy.

[Results following sub-capital and Imhäuser-Weber osteotomy in femur head epiphyseolysis]. / Ergebnisse nach subkapitaler und Imhäuser-Weber Osteotomie bei Epiphyseolysis capitis femoris.

63 slipped capital femoral epiphysis were treated either by a femoral neck osteotomy or by an intertrochanteric osteotomy. In almost all cases a normal anatomical relationship of the proximal capital femoral epiphysis to the neck of the femur was achieved. At an average follow-up of 10 years (2 to 19 years) 90% were rated good to excellent clinically. In 33 hips with a follow-up period of more than 10 years mild degenerative arthritis was present in 36%. Slipping of 60 degrees or less is best treated by an intertrochanteric osteotomy to avoid the higher complication rate in the femoral neck osteotomy.