[Sport and rheumatoid arthritis]. / Sport und rheumatoide Arthritis.

BACKGROUND: Sport is becoming increasingly more important in our society. Due to the changing age spectrum with a greater number of elderly and substantially more active people, an increasing number of people with underlying orthopedic diseases are becoming interested in participating in sport. MATERIAL AND METHODS: This article deals with the possibilities and effects of sporting activities for people with rheumatoid arthritis within the framework of a conservative therapy. A literature search was carried out using medical search engines, in particular PubMed, and also via the recommendations of specialist societies and patient help groups. RESULTS: The quality of life of patients with rheumatoid arthritis consists of physical, mental and social components. Sport as a means of rehabilitation influences all of these components. Sport should be comprehended as a form of therapy and be adapted to the needs of the individual patient. The willingness to actively participate in sport should always be highly rated and encouraged. Sport is therefore an important pillar of therapy in a conservative total concept. The main aspects of sport therapeutic activities are functional, pedagogical and experience-oriented aspects. The clinical symptoms, extent of damage and physical impairment must, however, be evaluated and taken into consideration for the therapeutic concept. CONCLUSION: The amount of data on the complex topic of sport and rheumatoid arthritis is low and is mainly dealt with as retrospective reviews. A prospective randomized study basis is lacking. The aim must therefore be to confirm the currently available recommendations for various types of sport in controlled studies.

Radiofrequency ablation in experimental bone metastases using a controlled and navigated ablation device.

BACKGROUND: Radiofrequency ablation is a minimal invasive therapy in the treatment of bone metastases. In this study we present a new ablation system enabling an ablation in multiple directions and with an adaptable size and shape. MATERIAL AND METHODS: VX-2 tumor was used for the induction of experimental bone metastases in the femur of six New Zealand white rabbits. X-ray imaging as well as CT and MRI scans before and after treatment was carried out. After detecting bone tumor, radiofrequency ablation was performed. The ablation instrument contained a 10 g bipolar, articulated extendable electrode and a proprietary generator with an impedance controlled algorithm. All bones and the soft tissue were examined histologically. RESULTS: All animals developed local bone tumor. Mean duration until first osteolytic lesions on CT-scans was 48±14 days. The mean lesion area was 26 mm(2). No systemic tumor spread was seen. 6 radiofrequency procedures were carried out with a mean application time of 6 min±2:30 and an average temperature in the region of effect of 55 °C±4. MRI imaging demonstrated an ablation zone of 23±6 mm around the electrode. Histopathology showed an extensive heat necrosis with no remaining tumor cells in the ablation area. CONCLUSION: Radiofrequency ablation is a quickly developing treatment option on the field of minimal invasive bone tumor therapy. The electrode enables an ablation adapted to size and shape of the metastases. Further clinical studies are necessary to test and enhance this radiofrequency system.

The quality of applied bone cement depends on the chemical composition of the application system.

UNLABELLED: The exothermal reaction of polymethylmethacrylate leads to an extensive interaction between bone cement and the synthetic material of the application system. This chemical reaction changes the structure of the cement and might generate air inclusions. METHODS AND MATERIALS: Two application systems for bone cement made of polycarbonate (PC) and polypropylene (PP) were evaluated. The application systems were mounted in a testing unit. The testing device injects a defined amount of bone cement with a certain pressure. After the injection procedure a microscopic examination was carried out. RESULTS: There were no differences in the size and the design of the used syringes. Forty procedures were carried out. The time frame for application of the cement was 5 min in the PC group and 9 min in the PP group. There was a remarkable interaction between the plastics and the cement with the appearance of numerous air inclusions in the PC group. Barely any interaction was found in the PP group. CONCLUSION: Application systems made of PP enable a prolonged application time and a reduced number of air inclusions. Further research, especially on a molecular level as well as material tests on the quality of the applied bone cement, should be carried out.

Direct implantation of VX-2 carcinoma: a new rabbit bone model using a three-dimensional matrix as a carrier for the tumor cells.

BACKGROUND: Animal bone models are inevitable for musculoskeletal research. The induction of a local bone tumor is complex and time consuming. In this study a new model is presented using a direct implantation of tumor cells into the bone without a preliminary passaging of the cells. METHODS: A three-dimensional matrix consisting of alginate spheroids and carrying the VX-2 tumor suspension was used for implantation into the bone of 6 female New Zealand white rabbits. X-ray imaging, CT and MRI scans as well as a histological examination were carried out. RESULTS: All rabbits developed local bone tumor in the metaphysis of the femoral leg. Bone tumor was identifiable on average 6.2 weeks after implantation. Fluoroscopy, CT and MRI scans showed a cortical reaction but no destruction of the compact bone together with a mean tumor size of 14 mm. Histological examination revealed a tumor infiltration with an activation of osteoclasts and an osteoclastic resorption. CONCLUSION: The direct implantation of a VX-2 tumor suspension into the rabbit bone using alginate spheroids is an effective and reproducible way to successfully induce bone tumor. This new animal model allows further examination of surgical and minimal invasive therapy in musculoskeletal research.

Functional results after giant cell tumor operation near knee joint and the cement radiolucent zone as indicator of recurrence.

BACKGROUND: Giant cell tumor of bone near the knee joints is a dilemma for the operating surgeon. Curettage and bone grafting have a high recurrence, whereas wide resection has a reduced recurrence rate with the compromise of limb function. MATERIALS AND METHODS: Thirty-eight patients with histologically proven giant cell tumor near the knee joint were treated. All patients were reviewed with regard to the operative method, recurrence rate, postoperative arthritis and functional results of the joint. In cases of cement filling, the radiolucent zone and the sclerotic rim were assessed as possible markers for recurrence. RESULTS: 14 male and 24 female patients were included in this study (mean age 28 years, range 13-56 years). All patients underwent surgery, 21 patients were treated with a bone cement filling and additional osteosynthesis after curettage. Seventeen patients were filled with cancellous bone or curettage alone. In the group with bone cement filling after curettage, the recurrence rate was 23.8%, whereas a recurrence rate of 52.9% was detected in the group with cancellous bone filling or curettage alone. The average time to recurrence was two years (5 months to 6 years). An increase of the radiolucent zone was seen in 80% of all patients with a recurrence. CONCLUSION: Cement filling after extensive curettage does not increase the recurrence rate and does not induce osteoarthritis, as long as the continuity of articular cartilage is maintained. Patients with giant cell tumor of bone near the knee joint can be treated satisfactorily with intralesional resection and bone cement packing. The extension of the radiolucent zone after bone cement filling is a reliable indicator for a possible local recurrence.

Radiofrequency ablation of experimental bone metastases in nude rats.

PURPOSE: Animal models are indispensable to investigate bone metastasis and to test different preclinical therapy options. Radiofrequency ablation is an upcoming technique for palliating pain from bone metastases. The aim of this study was to generate osteolytic lesions and to enable a technique to achieve access to the bone to successfully carry out radiofrequency ablation. MATERIALS AND METHODS: Human breast cancer cell line MDA-MB-231 (10(5) tumor cells) was implanted into the femur of 10 nude rats using a drill hole after arthrotomy of the knee joint and opening of the femur through the notch. Weekly CT- and MRI-scans were performed to document number and size of bone metastases. Radiofrequency ablation (22G bipolar and impedance-controlled RF-applicator, 2-4 Watt, 3 min application time) was carried out. One week after RFA, the animals were sacrificed and macroscopic and histological examination followed. For statistical analysis, paired comparison procedures were used. RESULTS: Inoculation of the tumor cells was well tolerated. The mean time of the surgical procedure was 6 minutes. All animals developped local bone metastases. Mean time to metastasis was 8 weeks (range 7-10 weeks) after tumor cell implantation. No leakage of tumor cells and no soft part metastases occurred. Radiofrequency ablation was performed without complications. Imaging showed a complete ablation of the bone tumor in all rats. Histological findings confirmed a circular necrosis with an extensive destruction of tumor cells leaving a necrosis cavity. CONCLUSION: The experimental model presented here describes the first time the ability to carry out radiofrequency ablation in nude rats with intrafemoral induced osteolytic metastases of human breast cancer. RFA in human breast cancer cell line in nude rats is a feasible and useful possibility to evaluate and to test different RF-procedures. Additional treatment options like local chemotherapy or chemoembolization can be performed.

Monostotic fibrous dysplasia of the spine: report of a case involving a cervical vertebra.

Monostotic fibrous dysplasia of the spine is a rare entity. Only 26 cases, of which 11 were located in the cervical spine, are to be found in the literature. We report a 56-year-old male patient with cervicobrachialgia of half year's duration. Radiographs showed a diffuse destruction of the vertebral body and the spinous process of C4. A biopsy of the spinous process confirmed histopathologically a fibrous dysplasia. Due to minor symptoms, no surgical treatment was performed or is planned unless in case of increasing pain, an acute instability or neurological symptoms.

False aneurysm of the left femoral artery and thrombosis of the left femoral vein after total hip arthroplasty.

We report a 75-year-old male patient with an aneurysm of the left femoral artery after cemented total hip arthroplasty. Two months after the operation, the patient showed a spherical resistance and pain in the left groin. Examination showed a big false aneurysm of the left femoral artery. After resection of the aneurysm, an endovascular stent graft vessel prosthesis was implanted. The aneurysm originated from a punctual lesion of the artery caused by a screw. Since the first description of vessel lesions in orthopaedic surgery in 1964, a total of 24 cases of aneurysm in hip surgery have been described. Therefore, a review of literature tries to explain causes and mechanisms of vessel injuries in hip surgery and the possibilities of repair.

[Contrast-enhanced diagnostics in orthopaedics]. / Kontrastmittelgestützte Diagnostik in der Orthopädie.

The diagnostic competence of the orthopaedist not only allows him to perform adequate therapy concepts, but also to meet the current structural challenges, both social and health related. In addition to clinical diagnosis, machine-aided diagnosis is becoming more important due to technical advances. In this context, contrast-enhanced examination has a special place, as it has an important diagnostic advantage in difficult or unclear cases. Current improvements in the areas of phlebography, myelography, arthrography and angiography are reviewed. Indications, risks and complications as well as the technical procedure are critically discussed.

[Magnetic resonance imaging in orthopaedic medicine]. / Die Magnetresonanztomografie in der Orthopädie.

Magnetic resonance imaging (MRI) is an established diagnostic tool in orthopaedics. Superior soft tissue contrast, lack of ionised radiation and free slice orientation are the key points for optimal evaluation of joint structures, muscles and ligaments. Application of contrast agents improves the detection of inflammation and tumour tissue. However, measuring and interpretation of magnetic resonance imaging is a challenge both for orthopaedists and radiologists. Basic requirements for good diagnosis are clinical findings, plain radiographs and a clear indication. This report provides information about the method of magnetic resonance imaging, artefacts, indications, risks and drawbacks as well as limitations of this method that necessitate alternative imaging modalities.

Percutaneous vertebroplasty in the therapy of osteoporotic vertebral compression fractures: a critical review.

Percutaneous vertebroplasty has become an efficient technique for the treatment of painful vertebral fractures. Osteoporotic vertebral compression fractures are characterized by severe back pain and immobilization causing other complications like thrombosis or pneumonia. Vertebral cement augmentation provides increased strength of the vertebral body and an obvious pain relief. Between 1989 and 2004, 30 studies and a total of 2,086 treated patients have been published in literature. A review of these studies has been performed. The number and age of the patients, number of treated vertebrae, pre- and postoperative outcome of pain and complications of the different studies were assessed and analyzed. Percutaneous vertebroplasty is an efficient technique with low complication rates and a significant reduction in pain. It rapidly improves the mobility and quality of life of patients with vertebral compression fractures. With an increasing number of treated patients, experience with this interventional technique has become excellent. But still there are no randomized controlled trials available, showing that percutaneous vertebroplasty has a significantly better outcome than other treatment options, especially after a long-term follow-up.

CT-guided percutaneous vertebroplasty in the therapy of vertebral compression fractures.

The purpose of this study was to determine the efficacy and safety of CT-guided percutaneous vertebroplasty in the treatment of vertebral compression fractures. The primary objectives were pain reduction and bone-cement leakage during a long-term follow-up in patients with osteoporotic vertebral compression fractures. CT-guided percutaneous vertebroplasty was carried out in 61 patients (mean age 71.4 years; range 42-83; female ratio: 73.8%) with vertebral compression fractures. Treatment was carried out on an outpatient basis. Pain, bone-cement leakage and complications were monitored and recorded. The mean follow-up time was 19.8 months (range 3-52). Paired comparison procedures were used for the analysis of the results, which showed that all patients had a significant reduction of pain. The mean visual-analogue scale (VAS) before treatment was 8.8 points (range 6.5-9.8 points). The mean VAS score after treatment was significantly reduced to 2.6 points (range 1.5-4.1 points; p<0.01). No clinical or neurological complications were documented. Minor and asymptomatic bone-cement leakage was observed in 54% of the cases. Percutaneous vertebroplasty is an efficient and safe interventional procedure which rapidly improves the mobility and quality of life of patients with vertebral compression fractures. CT-guidance is a reasonable upgrade in the treatment procedure which reduces the amount of bone-cement leakage.

Prospective pilot study of neoadjuvant chemotherapy with 5-fluorouracil, folinic acid and oxaliplatin in resectable liver metastases of colorectal cancer. Analysis of 42 neoadjuvant chemotherapies.

PURPOSE: Since there are currently no data available from a prospective trial, the primary objective of this prospective study was to investigate whether the rate of R0-liver resections without morbidity would be at least 50 % in patients with neoadjuvant chemotherapy for colorectal liver metastases. PATIENTS AND METHODS: 42 patients were treated with a biweekly FOLFOX regimen. Chemotherapy consisted of a 2-hour infusion of folinic acid (FOL) 500 mg/m2, followed by a 24-hour infusion of 5- fluorouracil (F) 2000 mg/m2 daily for two days. Oxaliplatin (OX) 85 mg/m 2 was given simultaneously with FOL. Treatment allocation was randomized with either 3 or 6 cycles for the final 30 patients. A liver resection was performed 2 to 5 weeks after the final infusion. RESULTS: An objective response was observed in 20 of 42 patients (response rate was 27 % higher after 6 cycles). Liver resection (R0) could be performed in 34 patients. Postoperative complications were reported in 14 patients (13 occurring within 30 days after resection) and severe complications in 5 cases (including two deaths after extended resection). Liver failure and persistent biliary fistula were the most frequently documented complications. There was no relevant difference in safety criteria between 3 and 6 applications. CONCLUSION: The use of neoadjuvant chemotherapy in resectable liver metastases induced significant remissions without increasing morbidity. The rate of severe complications and cases of no R0-resection in this study was 31 % and was with that significantly lower than 50 % (95 % CI 17.6 %-47.1 %). The risk to the patient is therefore acceptable when undergoing neoadjuvant treatment in a prospective intergroup trial.