Abstract

Aims

Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

Aim

The aim of this study was to investigate the metabolomic profile of synovial fluid in periprosthetic joint infection (PJI) cases regarding a possible diagnostic approach. Also, further information about the metabolic composition of synovial fluid in PJI may point to future diagnostic and therapeutic approaches.

Aim

To improve the challenging treatment of periprosthetic joint infections (PJI), researchers are constantly developing new handling methods and strategies. In patients with PJI after total knee arthroplasty (TKA) and severe local or systemic comorbidities, a two-stage exchange using a temporary antibiotic loaded PMMA-spacer is considered gold standard. This method has undisputed advantages, however, the increased risk of biofilm formation on the spacer surface, bone defects and soft tissue contractions after a six-week spacer interval are severe limitations. Our hypothesis is that a vacuum sealed foam in combination with constant instillation of an antiseptic fluid can address these drawbacks due to a significantly reduced spacer interval.

Aims

This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton.

Aim

In the diagnosis of prosthetic joint infection (PJI), many biomarkers have shown a sound performance in terms of accuracy, sensitivity and specificity. In this study we aimed to test the frequently used serum biomarkers C-reactive Protein (CRP), Fibrinogen, Leukocytes, Interleukin-6 (IL-6), Interferon alpha (IF-alpha) and Procalcitonin (PCT) regarding these qualities. Following that, the optimal multi-biomarker combination was calculated to further improve the diagnostic performance.

Aim

Bone loss is a severe problem in septic revision total knee arthroplasty (RTKA). The use of porous coated metaphyseal sleeves is a promising treatment option for extended bone defects. The currently published mid-term results remain limited and no study has been focused exclusively on septic cases. Our aim was to determine the implant survivorship (with special focus on osseointegration) and the clinical and radiological mid-term outcome of metaphyseal sleeve fixation in septic RTKA surgery (minimum follow-up of 2 years).

Aim

One of the most challenging problems in total knee arthroplasty (TKA) is periprosthetic infection. A major problem that arises in septic revision TKA (RTKA) are extended bone defects. In case of extended bone defects revision prostheses with metaphyseal sleeves are used. Only a few studies have been published on the use of metaphyseal sleeves in RTKA - none were septic exclusive. The aim of our study was to determine the implant survival, achieved osseointegration as well as the radiological mid-term outcomes of metaphyseal sleeve fixation in septic two-stage knee revision surgery.

The use of antibiotic-loaded cement has become a well-accepted method to develop high local antibiotic concentrations in orthopedic surgery. A new surgical technique has been established in our department in order to further increase the local antibiotic concentration, when implanting a prosthesis during revision surgery. By additional superficial vancomycin coating of the bone cement, high local antibiotic concentrations are generated. They should reach inhibiting and bactericidal concentrations of the respective pathogen during the first days after surgery.

The aim of this study was to state the safety of this method by analyzing postoperative serum and drain vancomycin concentrations. Attention was focused on possible systemic side effects. To determine nephrotoxicity, creatinine levels were also measured.

In total 32 revision operations (hip n=10, knee n=22) with additional superficial vancomycin coating were performed between 05/2013 and 04/2015. Procedures with removal of the prosthesis following temporary spacer implantation were excluded. In nine cases a one-stage procedure was performed, while in the others an arthroplasty or arthrodesis was performed after temporary spacer explantation. Vancomycin powder (2 grams) was added superficially to the surface of the bone cement and pressed onto manually before curing. Postoperative Vancomycin levels were measured in serum and the drain on day 1 to 5 or until the drain has been removed. In total 90 blood serum samples and 100 drain fluid samples were obtained.

The highest median vancomycin level from the drain was documented on postoperative day 1 with a value of 555.3 μg/mL (range 66.1 – 1081.8), continually decreasing until postoperative day 4. The highest value was documented on the second postoperative day with 2170.0 μg/mL. On the first postoperative day, a median serum vancomycin level of 3.35 μg/mL was present (range <2.0 – 8.5), while from postoperative day 2 to 5 a median level less than 2.0 μg/mL (range <2.0 – 7.2) was documented.

Anaphylactic reaction, red man syndrome or fever and chills were not observed after the surgical procedure. Furthermore, no subjective hearing loss was reported. Only in one case, a creatinine increase of 0.5 mg/dL from baseline value was detected. In this case the patient suffered preoperatively from a chronic kidney insufficiency.

In total two reinfections occurred, one after explanting a spacer with subsequent hip total endoprosthesis, the other one after a one-stage hip revision.

Superficial Vancomycin Coating of bone cement in orthopedic revision surgery represents a safe method to increase local inhibiting vancomycin concentrations.

In two-stage revision surgery of infected joint prosthesis, temporary bone cement spacers have been used for several years. By adding antibiotics to the cement, high local antibiotic concentrations that exceed the minimum inhibiting and bactericidal concentration of the respective pathogen during the first days after surgery, are achieved. Currently, aminoglycosides (e.g. gentamicin and tobramycin), as well as glycopetides (e.g vancomycin) are used as antibiotic agents and mixed into the acrylic cement. In order to increase the quantity of active antibiotic substances, we established a novel surgical technique of additional superficial vancomycin coating (SVC) of temporary bone cement spacer. The aim of this study was to analyze the safety of this method by measuring postoperative joint and serum vancomycin concentrations, as well as the creatinine levels.

We reviewed prospectively collected data on all patients, which were treated by explanting the prosthetic components, following temporary spacer implantation and SVC between 05/2013 and 04/2015 at the Department of Orthopedic Surgery, Medical University of Graz. In total 13 patients were treated by addition SVC during the study period. Before hardening, vancomycin powder (2 grams) was pressed manually onto the surface of the bone cement. Vancomycin levels were obtained from drains and blood samples on postoperative days 1 to 5. Forty-six blood serum samples and 52 drain fluid samples were available for further

On postoperative day one to five, a median serum vancomycin level of < 2.0 μg/mL was present (range <2.0 – 3.9). The highest median vancomycin level from the drain was documented on postoperative day 1 with a value of 388.0 μg/mL (range 44.4–1650.0), continually decreasing until postoperative day 4. After SVC, neither an anaphylactic reaction nor side effects such as a red man syndrome, fever and chills were observed. Furthermore, no patient complained about subjective hearing loss. No serum creatinine increase of 0.5 mg/dL from creatinine baseline value or a ≥50% increase from baseline was detected. After a median of 64 days (range 18–82), the temporary cement spacer was explanted followed by prosthesis implantation. During this time no reinfection occurred. One patient suffered from a dislocation of the spacer with a distal femur fracture and was therefore re-operated after 18 days.

Powdered vancomycin as an additional superficial coating of bone cement spacer results in much higher local antibiotic concentrations than in conventional spacers. The newly introduced method is feasible, safe and promising to enhance local inhibiting concentrations of vancomycin.

Introduction

Insufficient arthroscopic cuff tear reconstruction leading to massive osteoarthritis and irreparable rotator cuff tears might be salvaged by implantation of an inverted total shoulder prosthesis Delta in the elderly. However, despite the generally high success rate and satisfying clinical results of inverted total shoulder arthroplasty, this treatment option has potential complications. Therefore, the objective of this study was a prospective evaluation of the clinical and radiological outcome after a minimum of 2 years follow-up of patients undergoing inverted shoulder replacement with or without prior rotator cuff repair.

The rising incidence of atraumatic fractures in patients either with Ewing's sarcoma or osteosarcoma years after chemotherapy revealed a growing population of childhood cancer survivors with a decreased bone mineral density (BMD) possibly due to a long-term effect of the chemotherapy. Therefore we started to screen our patients below 50y of age who were treated for bone malignancies between 1994 and 2009.

The first series of measurements included 15 patients – eight Ewing's sarcoma, three female and five male, with a mean age of 18y (±13SD), and seven osteosarcoma, two female and five male, with a mean age of 19y(±9SD). We screened the patients for deficits in their bone status using DEXA (dual-energy-x-ray-absorptiometry) to gain the T-and Z-Scores of the proximal femur and the lumbal spine. Additionally we took blood samples for endocrinological analysis and utilised a questionnaire to scan the patient's liefestyle. The mean time between diagnosis and investigation was 95months (±79SD) in Ewing's sarcoma and 105months (±54 SD) in osteosarcoma.

The results of the age and gender matched lumbal measurement (Z-Score) of the Ewing's sarcoma patients showed a reduction of the BMD in six cases (6/8), including three times osteopenia (3/8) and two times osteoporosis (2/8). The osteosarcoma patients presented a BMD-decline in four cases (4/7) with two times osteopenia (2/7) and one osteoporosis (1/7).

In the proximal femur six Ewing's sarcoma (6/8) and six osteosarcoma patients (6/7) showed a BMD-decrease including three osteopenic (3/8) and one osteoporotic (1/8) Ewing's sarcoma and four osteopenic osteosarcoma (4/7). We found two cases of pathologic fractures (2/15), one Ewing's sarcoma 29 months after diagnosis with a fracture of the distal femur and the proximal Tibia (1/8) and one osteosarcoma with a fractured distal femur after 72 months (1/7).

As presented in our case series osteoporosis after chemotherapy is an underestimated long-term effect of the chemotherapeutic treatment. In our series BMD-reduction seems to be independent of tumour-type and chemotherapeutic agent like MTX.

Aim

Accurate and reliable patient information plays a crucial role in the multidisciplinary treatment of malignancies helping to ensure compliance of the patients and their relatives with often long-lasting and stressful treatment. The English version of the online encyclopaedia Wikipedia has been recently reported to be the prominent source of online health information. However, there is little information concerning the quality of information found in Wikipedia.

Objective: Metastases in the spinal column are a common manifestation of advanced cancer disease. Severe pain, pathologic fracture and neurologic deficit due to spinal metastases need adequate treatment. Considering oncologic aspects as well as quality of life, treatment decision should also include prediction of the survival period. In this study we analysed the scoring systems of Bauer, Bauer modified, Tokuhashi, Tokuhashi revised, Tomita, van der Linden and Sioutos, as well as the parameters they consist of, for their predictive value.

Methods: Two-hundred and fifty four patients with confirmed spinal metastases were investigated retrospectively (treatment 1998–2006; 62 received surgery, 189 only conservative therapy). The following factors were analysed: primary tumor, general condition (Kar-nofsky Performance Scale), neurological deficit, number of spinal and extraspinal bone metastases, visceral metastases, pathologic fracture. Survival period was calculated from date of diagnosis of the spinal metastases until date of death or last follow up (minimum follow-up: 12 months). For statistical analysis univariate and stepwise multivariate Cox regression analyses were performed.

Results: Median overall survival for all patients was 10.6 months. The following factors showed significant influence on survival in multivariate analysis: primary tumor (p< 0.0001), status of visceral metastases (p< 0.0001), and systemic therapy (p< 0.0001). Cox regression proved all scores significant in metric analysis. Distinguishing between the prognostic subgroups, only Bauer and Bauer modified showed significant results for this classification into good, moderate and poor prognosis. The other systems failed to distinguish significantly between good and moderate prognosis.

Conclusion: In our collective, Bauer and Bauer modified score prove to be the most reliable systems for predicting survival. We therefore want to propose the Bauer modified score (consisting of only four positive prognostic factors, excluding pathologic fracture) as valid for predicting survival and practicable for clinical use.

Introduction: Giant cell tumor of bone is a semimaligne tumor which locally recurs very often but rarely metastasises. En bloc resection of the distal radius with reconstruction using a homologeous allograft, curettage with PMMA blomb, and allograft arthrodesis are established methods. The aim of the study was to evaluate the functional outcome of our patients with the DASH-Score and the Mayo Wrist Score

Materials and Methods: In the last 7 years six patients were treated at our clinic due to a giant cell tumor of the distal radius. Two patients were primary treated with an en bloc resection. The other four were primary treated with curettage and filled up with PMMA cement plomb (Phenol was used in every case). In two of these cases a secondary en bloc resection was performed for local recurrence. For evaluation of function in daily live we used the DASH Score and the MAYO wrist score.

Results: The mean bone resection length was 5,25cm (5–6 cm).

All four patients treated with en bloc resection (primary or secondary) had no recurrence but in two out of that cases a re-operation was necessary because of non union.

At a mean follow up from 27 months (4–95) there were no recurrences or metastases at all

The flexion/extension of the wrist in currettaged radius was 60° and 80° compared with 38° and 68° in reconstructed radius. The pronation/suppination was 90°/90° in the currettaged ones versus 77°/77° in the allograft replaced ones.

The functional outcome evaluated with Mayo Wrist Score and DASH score showed an exellent outcome for both groups (84/7,7 Allograft < -> 85/10 Currettage)

Discussion: Functional outcome of distal radius resection reconstruction using an allograft is highly satisfactory compared with the literature, however we experienced a high risk for pseudoarthrosis. For prevention of non union simultan bone grafting at the index operation could be advisable.

The functional outcome proof no disadvantages in daily life and daily work compared to curettage. Thus allograft reconstruction of the distal radius represents a valuable alternative to arthrodesis.

Introduction: Despite advances in radiotherapy and chemotherapy, metastatic disease of the spine remains a challenging situation for spinal surgeons. An individual therapy should be chosen to provide the maximum palliative effect (reduction of pain, restoration of stability and function) with a minimum of operative morbidity and mortality. Predicting prognosis is the key factor in selecting the proper treatment. Therefore, various assessment systems have been designed in order to provide a basis for deciding the course of treatment. Such systems have been proposed by Tokuhashi, Sioutos, Tomita, Van der Linden, and Bauer. The scores differ greatly in the kind of parameters assessed. The aim of this study was to evaluate the prognostic value of each score.

Patients and Methods: Eight parameters were assessed for 69 patients (37 male, 32 female): location, general condition, number of extraspinal bone metastases, number of spinal metastases, visceral metastases, primary tumour, severity of spinal cord palsy, and pathological fracture. Scores according to Tokuhashi (original and revised), Sioutos, Tomita, Van der Linden, and Bauer were assessed as well as a modified Bauer score without scoring for pathologic fracture.

Results: Nineteen patients were still alive as of September 2006 with a minimum follow-up of 12 months. All other patients died after a mean period of 17 months after operation. The mean overall survival period was only 3 months for lung cancer, followed by prostate (7 months), kidney (23 months), breast (35 months), and multiple myeloma (51 months). At univariate survival analysis, primary tumour and visceral metastases were significant parameters, while Karnofsky score was only significant in the group including myeloma patients. In multivariate analysis of all seven parameters assessed, primary tumour and visceral metastases were the only significant parameters. Of all seven scoring systems, the original Bauer score and a Bauer score without scoring for pathologic fracture had the best association with survival (P < 0.001).

Conclusion: The data of the present study emphasize that the original Bauer score and a modified Bauer score without scoring for pathologic fracture seem to be practicable and highly predictive preoperative scoring systems for patients with spinal metastases. However, decision for or against surgery should never be based alone on a prognostic score but should take symptoms like pain or neurological compromise into account.

Background: Desmoplastic fibroma (DF) of bone is a very infrequent non-metastasizing osseous tumour with local aggressive appearance. The tendency of local recurrence in published cases is high.

Case reports: We present the clinical and radiological data of a male (35 years) and a female (37years) patient suffering from desmoplastic fibroma. Although in literature spinal lesions are severity rare, in our database two lesions located in the spine (C6 and L4) were identified. The first disturbances have been variable: The lesion in C6 was an accidental finding due to a control examination of a thyroid-ca, whereas the relapse-tumour of the L4 induced lumbago and hypaesthesia of the left heel.

Due to the importance of the thyroid treatment it was decided to control the lesion in C6 in close intervals. The lumbar tumour was initially treated outside and the first relapse was marginal resected at our department 11 years after the first diagnosis. The bone alterations appeared radiographically lytic and cystic.

Discussion: The spine is an unusual location of desmoplastic fibroma which arises in 56% at the long tubular bones followed by the mandible. To our knowledge only a few cases are reported to be located in the spine. DF located spinal, is a very untypical tumour and initial symptoms can be very unequal. Due to this dissimilar symptoms and variable histological appearance the diagnosis can be tricky. At least marginal resection should be achieved because intraleasional resected lesions show a local recurrence of 43%.

Based on paleopathological findings there is evidence that primary malignant bone und probably soft tissue tumours accompanied mankind from the very beginning. Impressive findings of osteosarcomas have been reported from ancient Peru and medieval Hungary. Astonishingly a report exists on a 3rd century AD amputation of a leg affected by “cancer” and, even more amazing, on the successful reconstruction using a homologous limb transplant.

This “miracle” has been attributed to Saints Cosmas and Damian. According to the legenda aurea of Jacobo da Varragine the miraculous treatment of took place in 3rd century Rome. The saints amputated the leg of the Deacon Justinian and successfully transplanted the leg of a black African, who had died some hours ago. According to the legend the deacon was able to walk again and glorify his doctors. This legend inspired artists throughout the centuries as can be seen in a famous 16th century oil painting in Stuttgart’s Landesmuseum Württemberg. The twin saints Cosmas and Damian have been praised before for the first homoplastic limb transplant. The cause for amputation, however, was reported to be a “gangrenous leg” or a “diseased leg”. Looking at the original text of the legenda aurea, a different picture emerges, the cause for surgery being “cancer” of the leg – “…cui cancer unum crus totum còsumpserat”.

Also astonishing, at their time and in ours, the saints treated patients without taking any payment. It is not surprising that they were the most renowned of all medically inclined saints and were soon regarded as patron saints of medicine. From today’s medical view, neither resection margins according to Enneking nor a follow-up period were provided by the legenda aurea. It therefore remains elusive whether a local or systemic recurrence occurred. Nevertheless, Saints Cosmas and Damian may well be regarded as Europe’s first orthopaedic oncologists.

Epimetaphyseal lesions may occur within congenital dysplasia or can be linked to metabolic, inflammatory and systemic diseases. They can also be caused by trauma or be due to malign or benign neoplasms.

Our case-report concerns a 4-year old boy who was x-rayed the day after falling from a chair and twisting his right ankle. X-ray showed an epimetaphyseal lesion of about 2 cm in diameter, located eccentrically in the lateral site of the distal tibia. A unilamellar periostal reaction could be detected in the lateral slices. On MRI, the lesion seemed to be of chondromatous origin and showed smooth borders with no evidence of surrounding oedema. The adjacent epiphyseal plate appeared as untypically fragmented. In CT-scans, the ventrolateral cortical bone was partially perforated and the lesion showed a tender sclerotic border. Due to the benign aspect, we agreed upon radiologic controls in order not to harm the epiphyseal plate by biopsy. MRI follow-ups revealed a slight but continuous growth. The lesion assumed an increasingly eccentric, tongue-shaped configuration with simultaneously increasing calcifications and mineralisations. After 5 years of radiological surveillance, the patient showed no evidence of growth-disturbance and did not report pain, but an increasing feeling of pressure when wearing boots.

Traumatic causes as well as metabolic, inflammatory and systemic diseases can, considering the patient’s history and clinical status, be put aside. The benign aspect combined with the long-term follow-up rules out malignancies. A chondroid matrix with increasing areas of mineralisation imply the diagnosis of a chondromatous tumour, although radiomorphology does not support this assumption; especially not, if age, clinical presentation, eccentric epimetaphyseal location and the involvement of the epiphyseal plate are taken into account. Among the entities left for differential-diagnosis, a dysplastic process e.g. Dysplasia hemimelica, must be considered, although doubts remain. For confirmation of diagnosis, further radiological and clinical surveillance will be conducted.

Introduction: Rotating hinge knee prostheses are designed to provide a stable knee reconstruction when the intrinsic soft-tissue stability of the knee had been lost as a result of tumor resection, multiple knee replacements, trauma or surgical reconstruction. Instability is the main risk factor for implant’s dislocation. We performed a biomechanical analysis to establish the association between design of the central rotational stem (length and taper) and the implant’s stability, using a self constructed biomechanical apparatus on a test bench in the laboratory.

Materials and Methods: The lengths and tapers of the central rotational stem of three different rotating hinge knee implants (LPS/M.B.T. (DePuy)-cylindrical, length: 46mm, taper: 0°; S-ROM Noiles (DePuy) -conical, length: 46mm, taper: 5°; GMRS (Howmedica) -cylindrical, length: 47mm, taper: 0°) were measured using a self-constructed biomechanical testing device. The degree of tilting of the central rotational stem within the vertical post-in channel by extending the distraction was measured as well the maximum amount of distraction before the stem’s dislocation.

Results: The GMRS implant design was superior to the LPS/M.B.T. and the S-ROM Noiles implant design concerning stability and maximum amount of distraction before dislocation (38 vs. 27 vs. 26 mm). The GMRS system had a steep rising distraction-angular displacement curve until the dislocation at 38mm occurred while the laxity curve of S-ROM Noiles showed a poor increasement. Besides early high laxity it required only 26mm of distraction to dislocate.

Conclusions: Our conclusion is that rotating hinge prostheses with a short and markedly tapered central rotational stem have the highest instability/angular laxity at any given amount of distraction. Such knee prostheses should be used with caution in patients after excessive soft tissue resection. A long and cylindrical central rotational stem seems to prevent early instability and implant’s dislocation.