[Total endoprosthetic replacement of femur, humerus and tibia]. / Endoprothetischer Totalersatz von Femur, Humerus und Tibia.

Improvements in diagnostics and effectiveness of chemotherapy have resulted in most patients with primary malignant bone tumours being candidates for limb salvage surgery. Herewith, the use of modern modular tumour endoprostheses allows for the replacement of all big joints and even entire long bones such as the femur, humerus and tibia. In this article, we focus on individual prerequisites for and challenges with performing a total endoprosthetic reconstruction of the above-mentioned anatomic structures. Additionally, data from the literature with regards to functional outcome, problems and complications are presented.

A new technique for correction of leg length discrepancies in combination with complex axis deformities of the lower limb using a lengthening nail and a locking plate.

PURPOSE: Intramedullary lengthening nails are an accepted alternative to external fixators but are limited by anatomical preconditions. Therefore, to date the use of external fixators is sometimes inevitable. We report on a new technique for correction of combined limb length discrepancies and complex axis deformities using solely internal devices - a lengthening nail and a locking plate. METHODS: Between October 2008 and November 2011 five patients (two femora, three tibias) with a mean leg length discrepancy of 36 mm (25 to 50) and a complex angular deformity were treated with a fully implantable motorized lengthening nail (Fitbone) and a locking plate. All patients were evaluated with regards to the pre- and postoperative leg length as well as axis alignment, functional outcome, lengthening indices and complications. RESULTS: A successful leg length equalization was achieved in all cases and physiological joint orientation angles in all but one case. The mean distraction index was 1.2 mm/day, the maturation index 24 days/cm and the consolidation index 35 days/cm. The functional outcome was very encouraging in all cases with bilateral free range of movement. In total, two complications were observed, one nonunion and one loss of leg length after an early locking bolt removal in a peripheral hospital. CONCLUSION: The combination of a fully implantable motorized lengthening nail and a locking plate is a valuable alternative option for treating selected cases with limb length discrepancies in combination with a complex deformity of the lower leg. However, the reported technique puts high demands on the preoperative planning, operative technique as well as surgeon's skills. LEVEL OF EVIDENCE: IV (retrospective series).

[Autologous fibula transplantation for reconstruction of bone defects]. / Die autologe Fibulatransplantation zur Rekonstruktion knöcherner Defekte.

The reconstruction of large bone defects following tumor resection, trauma or infection is difficult and subject to individual preferences of each surgeon. Free autologous fibula grafts are a reliable biological treatment method, whereas both a vascularised and a non-vascularised transplantation is possible. The use of either treatment option - vascularised or non-vascularised - is accompanied by individual advantages and/or disadvantages that should be taken into consideration during the preoperative planning process. Vascularised fibula transplants should be used especially for the reconstruction of large segmental defects and in patients, in whom adjuvant chemo- and/or radiation therapy is to be administered. Non-vascularised fibula grafts - which offer the advantage of a certain regeneration potential at the donor site as well as a shorter operation time - might be beneficial for bridging hemicortical defects and segmental defects with good soft tissue coverage.

Intramedullary lengthening nails: can we also correct deformities?

Unlike external fixators, the use of solid intramedullary lengthening nails is restricted to defined anatomical preconditions, such as an adequate bone length. Furthermore, all deformity corrections except the lengthening procedure have to be implemented intraoperatively and cannot be adjusted postoperatively. Conversely, even complex deformity corrections can be performed using intramedullary devices after a thorough preoperative planning. For preparation of the intramedullary cavity as well as positioning of the lengthening nail according to the preoperative planning, reaming the medullary canal with rigid reamers which don't follow the line of least resistance is inevitable. However, the application of solid lengthening nails might be limited, especially in children with ongoing epiphyseal growth, although a central perforation of the growth plate was shown to have no adverse effects on the growth potential. In cases with complex or multilevel deformities, an additional osteotomy and locking plate fixation could sometimes be a valuable solution in order to avoid external fixation. The low complication rate as well as the reduced compromising of soft tissues and periosteum render intramedullary lengthening nails the state-of-the-art procedure for limb lengthening in combination with deformity correction in patients who meet the anatomical preconditions.

[Pathological Fractures of the Humerus: Experience with 76 Cases in a Musculoskeletal Oncology Centre]. / Pathologische Frakturen des Humerus: Erfahrungen an 76 Fällen eines muskuloskeletalen Tumorzentrums.

BACKGROUND: Pathological fractures can be caused by numerous local and systemic processes. The humerus is one of the commonest sites of pathological, tumour-associated fractures. PATIENTS AND METHODS: In a retrospective study, 76 cases of pathological fractures of the humerus were analysed; 57 (75 %) were caused by a malignant disease, 19 fractures were associated with benign musculoskeletal disorders (25 %). The grade of the tumour, treatment strategy, intra- and postoperative complications, and survival rates in malignant tumours were documented. RESULTS: Two thirds of fractures were localised in the proximal third of the humerus. In 59 % of patients, malignant lesions were metastases (mainly renal cell, breast, lung and prostate cancer), followed by haemato-oncological diseases and primary sarcomas. Most benign tumours were simple bone cysts and enchondromas. A total of 70 patients were treated surgically and only 6 conservatively. Most malignant tumours were treated with compound osteosynthesis and tumour prostheses. Complications in both groups were rare. CONCLUSION: The demographic transition - with an increasing number of malignancies on the one hand and improved life expectancy under modern, adjuvant therapies on the other - will become a challenge in the treatment of pathological fractures of the humerus for a variety of disciplines.

[Biopsies from bone and soft tissue sarcoma : a nationwide survey in Germany]. / Biopsie von Knochen- und Weichteilsarkomen : Eine deutschlandweite Umfrage.

AIM OF THE STUDY: A biopsy is an essential step in the diagnostic cascade of malignant bone and soft tissue tumors. The objective is always the extraction of a representative tissue specimen in line with the approach for the definitive operation. The aim of this study therefore was to assess the diagnostic approaches regarding the biopsy of tumors in orthopedic centers in Germany. MATERIAL AND METHODS: In total 60 hospitals with an orthopedic focus on tumors were contacted and provided with a newly developed questionnaire with 13 items regarding biopsy technique, indication criteria, execution, supportive imaging and histopathological results. Evaluation of the responses was performed by means of binary systems and proportional consent to every answer possibility was calculated. RESULTS: The results of the questionnaire showed that open biopsies are performed in all centers and in 72 % of the hospitals percutaneous techniques are additionally applied. The most important criterion for an open or percutaneous procedure was the tumor location (80 %). The indications for either technique are assessed by a tumor orthopedic consultant in 68 % of the centers and special imaging is applied in 36 % of the institutions. The approach for the biopsy is defined by the orthopedic surgeon in 88 %. Percutanous biopsies are carried out by interventional radiologists in 60 % of the centers. Open biopsies are performed by residents under supervision by a tumor orthopedic consultant in 88 %. The histopathological results are discussed in 88 % of the hospitals in an interdisciplinary tumor board and in 64 % patients are informed about the diagnosis in an outpatient clinic. CONCLUSIONS: Overall, biopsy of musculoskeletal tumors is performed according to the guidelines in most institutions. Only small differences were identified regarding the definition of the surgical approach and the application of imaging techniques during biopsy.

[The role of psycho-oncology in orthopedic tumor centers]. / Stellenwert der Psychoonkologie und ihre Versorgungslage an Zentren für Tumororthopädie.

INTRODUCTION: Psychosocial screening has not been implemented into diagnosis-related guidelines for the treatment of orthopedic tumor patients. The aim of the study was to evaluate the significance of psycho-oncology in orthopedic institutions specialized in musculoskeletal tumors as well as the opinion and clinical experience of the treating physicians. METHODS: In total 60 orthopedic institutions were recruited. Data were assessed and analyzed by a newly developed, standardized questionnaire. To detect specific, demographic differences results were additionally analyzed according to gender, age and professional experience. RESULTS: A total of 118 physicians from 47 institutions participated. Significant differences between professional experience groups were obtained regarding the wish for psychosocial treatment in cases of own illness (p=0.032) and the difficulty of addressing patient feelings (p=0.05). CONCLUSIONS: The majority of orthopedic physicians deemed psycho-oncology important. To ensure a holistic approach to the treatment of orthopedic tumor patients, psycho-oncological aspects should be implemented in diagnosis-related guidelines.

[Tumors of the foot: diagnostics and therapy]. / Fußtumoren: Diagnostik und Therapie.

Despite the compact anatomy with thin soft tissue coverage, diagnosis of both benign and malignant tumors of the foot is often delayed. Diagnostic errors are more common than in other body regions, as neoplasias are rarely considered. Barring a few exceptions the foot is not a typical predilection site for malignant musculoskeletal tumors, although, basically any tumor entity of the musculoskeletal system can affect the foot. Delays in specific diagnostic and therapeutic procedures of these lesions can entail serious consequences for patients as tumor size is a major prognostic factor for recurrence-free survival. In cases of an indistinct persistent swelling or bone lesion a tumorous process should always be considered to ensure early diagnosis and therapy of foot tumors.

[Diagnosis of malignant bone and soft tissue tumors]. / Diagnostik von malignen Knochen- und Weichteiltumoren.

Primary sarcoma of bone is a rare entity but nevertheless a significant cause of mortality in children and adolescents. The focus of the preoperative evaluation is to set up a histological diagnosis, define local tumor extent and develop a therapy regimen. In addition to patient history and clinical findings a radiograph in two orthogonal planes is still of great importance. MRI plays a major role in the further clarification of the diagnosis, while CT is valuable in the diagnosis of tumors of the axial skeleton as well as in systemic staging. A PET-CT can be performed to obtain an overview of further tumor sites. Open bone biopsy is the final diagnostic step and should be carried out at the institution where the definitive treatment will be performed. Complications such as fracture, neural lesions and spread of tumor cells are relatively rare if the biopsy is performed appropriately; however, patients should be instructed to strictly avoid weight-bearing on the affected extremity.

[Intramedullary motorized nail for equalization of posttraumatic leg length discrepancies]. / Ausgleich posttraumatischer Beinverkürzungen mit einem motorisierten intramedullären Nagel.

BACKGROUND: Fractures in childhood may result in a significant leg length discrepancy (LLD). The common correction method of LLD and deformities is callotasis with external fixation. This is often associated with pain, pin site infection, muscle tethering and reduced range of movement (ROM). PATIENTS AND METHODS: Between 2006 and 2008 a total of 11 cases of posttraumatic LLD (range 2.4-4.3 cm) were treated with a fully implanted motorized lengthening device (Fitbone®). Hospitalization time, leg equalization, rehabilitation time and complications compared to external fixation were recorded. RESULTS: Leg lengthening was successfully performed in all cases, in five combined with angular and/or rotatory corrections. The mean distraction index was 1.03 mm/day (range 0.6-1.2 mm/day) and the mean consolidation index was 40 days/cm (range 25.2-50.9 days/cm). The average hospital stay was 9.8 days (range 8-20 days). Bone or soft tissue infections were not observed, nor were the complications commonly associated with external fixation. Functional results were excellent as the preoperative knee ROM was regained in all cases and with improved ROM in three cases. CONCLUSION: The Fitbone® nail is a valuable alternative to conventional methods which reduces complications commonly associated with external fixation.

The outcome of pelvic reconstruction with non-vascularised fibular grafts after resection of bone tumours.

We retrospectively evaluated 18 patients with a mean age of 37.3 years (14 to 72) who had undergone pelvic reconstruction stabilised with a non-vascularised fibular graft after resection of a primary bone tumour. The mean follow-up was 10.14 years (2.4 to 15.7). The mean Musculoskeletal Tumor Society Score was 76.5% (50% to 100%). Primary union was achieved in the majority of reconstructions within a mean of 22.9 weeks (7 to 60.6). The three patients with delayed or nonunion all received additional therapy (chemotherapy/radiation) (p = 0.0162). The complication rate was comparable to that of other techniques described in the literature. Non-vascularised fibular transfer to the pelvis is a simpler, cheaper and quicker procedure than other currently described techniques. It is a biological reconstruction with good results and a relatively low donor site complication rate. However, adjuvant therapy can negatively affect the outcome of such grafts.

Ilizarov hip reconstruction without external fixation: a new technique.

PURPOSE: The Ilizarov hip reconstruction is a well accepted but complication-prone operative salvage procedure in chronically dislocated hips, not least due to the long-term application of external fixation. Although the advantages of fully implantable devices are well known in limb lengthening and are described consistently, until now, external fixation has been used exclusively to perform the Ilizarov hip reconstruction procedure. We present a new technique of Ilizarov hip reconstruction with purely internal implants. METHODS: A 14-year-old girl with a history of spina bifida presented with a 4-cm-short right leg, a Trendelenburg gait and a complex neurological disease expression. Because of refusal of external fixation by the patient and significantly lower complication rates, an Ilizarov hip reconstruction without external fixation was performed. A locking compression plate was applied to fix the proximal femoral valgus-extension osteotomy and a motorised intramedullary distraction nail was used for the distal, lengthening-varisation osteotomy. RESULTS: A healing index of 33 days/cm and full weight bearing after 6 months were noted. At the 1 year follow-up, the patient showed an improvement of the Trendelenburg gait, as well as successful leg equalisation. Satisfaction to a high degree was additionally noted by factors such as reduced pain, the ability to wear workaday clothes and cosmetically appealing scars. No complications were recorded. CONCLUSION: The exclusive use of internal implants for Ilizarov hip reconstruction is a feasible and patient-friendly alternative to traditional methods. Their use, however, may be restricted by geometric preconditions.

[Additional oral therapy of atopic dermatitis with unsaturated fatty acids]. / Additive orale Therapie der atopischen Dermatitis mit ungesättigten Fettsäuren.

The effects of unsaturated fatty acids were examined in a double-blind study on 34 patients suffering from atopic dermatitis. In comparison to the placebo group a clinical improvement (24%) was seen after a three month period during which patients had received linoleic acid and gamma-linolenic acid.

[On myositis ossificans localisata and its operative treatment (author's transl)]. / Zur Myositis ossificans localisata und ihrer operativen Therapie

We observed 52 patients with myositis ossificans localisata partly of a traumatic, neurogenic or morbid (inflammable) origin. The fact that preferably young men are concerned in cases of traumatic and neurogenic myositis ossificans localisata is certainly not only caused by their increased exposition to trauma, but also by disposition. For indication and operative treatment it is necessary to classify as well as radiologically III different stages of development as respective groups of muscles. In posttraumatic and neurogenic cases relapses post operationem may probably be avoided in case, there is a radiological stage III (total development of muscle ossification).