Repeat two-stage exchange arthroplasty for recurrent periprosthetic hip or knee infection: what are the chances for success?

INTRODUCTION

Two-stage revision is a frequently chosen approach to treat chronic periprosthetic joint infection (PJI). However, management of recurrent infection after a two-stage exchange remains debated and the outcome of a repeat two-stage procedure is unclear. This study investigates the success rates of repeat two-stage exchange arthroplasty and analyzes possible risk factors for failure.

MATERIALS AND METHODS

We retrospectively identified 55 patients (23 hips, 32 knees) who were treated with repeat resection arthroplasty and planned delayed reimplantation for recurrent periprosthetic joint infection between 2010 and 2019 after a prior two-stage revision at the same institution. The minimum follow-up was 12 months with a median follow-up time of 34 months (IQR 22-51). The infection-free survival, associated revision surgeries, and potential risk factors for further revision were analyzed using Kaplan-Meier survival curves and comparative non-parametric testing.

RESULTS

78% (43/55) underwent reimplantation after a repeat implant removal. Of those who completed the second-stage surgery, 37% (16/43) underwent additional revision for infection and 14% (6/55) underwent amputation. The reinfection-free implant survivorship amounted to 77% (95% CI 64-89%) after 1 year and 38% (95% CI 18-57%) after 5 years. Patients with a higher comorbidity score were less likely to undergo second-stage reimplantation (median 5 vs. 3, p = 0.034). Furthermore, obese patients (p = 0.026, Fisher's exact test) and diabetics (p < 0.001, log-rank test) had a higher risk for further infection. Most commonly cultures yielded polymicrobial growth at the repeat two-stage exchange (27%, 15/55) and at re-reinfection (32%, 9/28). Pathogen persistence was observed in 21% (6/28) of re-reinfected patients.

CONCLUSION

The success rates after repeat two-stage exchange arthroplasty are low. Patients must be counseled accordingly and different modes of treatment should be considered.

Promising functional outcomes following anterior cruciate ligament repair with suture augmentation

PURPOSE

There has been a renewed interest in the repair of the torn anterior cruciate ligament (ACL). Purpose of this study was to evaluate the functional outcome of arthroscopic ACL repair with additional suture augmentation (SA), hypothesizing that isolated ACL ruptures would yield superior patient-reported outcome measures (PROMs) compared to those with concomitant meniscal and/or ligamentous injuries.

METHODS

This is a retrospective analysis of 93 consecutive patients (67 female, median age 42 years) who underwent arthroscopic ACL repair with SA between January 2017 and March 2019 for an acute traumatic ACL tear confirmed by magnetic resonance imaging (MRI). Patients with pre- or intraoperative mid-substance or distal ACL tears and/or poor tissue quality of the ACL remnant were not considered for ACL repair but were scheduled for an ACL reconstruction with a tendon autograft. In patients who underwent ACL repair with SA, the SA construct was proximally stabilized with a flip-button and distally with a suture anchor. Surgery was preferably performed on the day of injury and all surgeries were performed by the same surgeon. Postoperative rehabilitation included partial weight-bearing (20 kg) for 6 weeks and immobilization in a brace limited at 90-degrees of knee flexion for 4 weeks. Patient-reported outcome measures (PROMs) were determined using International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm Score (LS), Tegner Activity Score (TS) and Forgotten Joint Score (FJS). Knee-laxity was assessed using the KT-1000 arthrometer (Med Metrics Corp. Inc., San Diego, USA).

RESULTS

Nine patients underwent revision surgery for a traumatic re-tear (four patients) and chronic instability (five patients) and were excluded from further functional analysis. Functional results of 77 patients (54 female) with a median age of 44 years (IQR 33-51) on the day of surgery were available for follow-up after a median time of 35 months (IQR 33-44). Concomitant injuries were observed in 66 Patients (86%), meniscal injuries in 43 patients (55%) and ligamentous injuries in 50 patients (65%). Median interval from injury to surgery was 1 day (IQR 0-1) with 81% (62/77) of patients being treated within 24 h of injury. The median IKDC was 92 (IQR 86-99), the median LS was 95 (IQR 86-100), the median pre-traumatic TS was 7 (IQR 6-7), the median post-traumatic TS was 6 (IQR 5-7) with a non-significant median difference (TS_Diff) of 0 (IQR 0-1). The median FJS was 95 (IQR 78-98). KT-1000 measurements were available in 34 of 77 patients with a median postoperative laxity compared to the uninjured side of 1 mm (IQR 0-2). Interval from injury to surgery, patients' age, body mass index (BMI), knee laxity and concomitant ligamentous or meniscal injuries had no statistically significant impact on postoperative PROMs (n.s.).

CONCLUSION

Following arthroscopic ACL repair with SA good-to-excellent functional results were observed. However, a failure rate of 10% cannot be neglected and warrants further attention. Concomitant injuries to the meniscus and/or collateral ligaments do not seem to be associated with inferior PROMs.

LEVEL OF EVIDENCE

Level IV.

[Growth modulation through hemiepiphysiodesis : Novel surgical techniques: risks and progress]

The correction of angular deformities of the lower limb is a key task in paediatric orthopaedic surgery. The growth potential of the physis can be employed for the correction of these malalignments in childhood and adolescence. Hemiepiphysiodesis (HED) is a surgical technique used for growth modulation by permanent or temporary asymmetrical arrest of the growth plate. In permanent HED, exact timing of the procedure is mandatory to achieve optimal correction. Temporary HED through tension band devices such as two-hole-plates or flexible staples has been established as the treatment of choice for growth guidance with excellent results. Implant-associated complications have been significantly reduced through implant modifications. Several experimental procedures have the potential to achieve growth modulation even without the requirement of surgical intervention.

Assessing the spreading potential of an undetected case of COVID-19 in orthopaedic surgery

BACKGROUND

With the novel coronavirus-induced disease (COVID-19), there is the fear of nosocomial infections and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmissions to healthcare workers (HCW). We report the case of a 64-year-old male patient who underwent explantation of a shoulder prosthesis due to a periprosthetic infection. He was tested SARS-CoV-2 positive 7 days after admission to the orthopaedic department following strict infection control measures, routinely including screening all patients for multi-drug-resistant organism (MDRO) colonization upon admission. Aim of our study is to report on the spreading potential of SARS-CoV-2 in a healthcare setting if standard contact precautions and infection control measures have been established.

METHODS

All HCW with exposure to the patient from day of admission until confirmed diagnosis of COVID-19 were identified and underwent oropharyngeal swab testing for SARS-CoV-2 by real-time RT-PCR.

RESULTS

Sixty-six HCW were identified: nine orthopaedic surgeons, four anaesthesiologists, 25 orthopaedic nurses, five nurse anesthetists, eight scrub nurses, five nursing students, two medical assistants and seven service employees. Fourteen HCW (21%) showed clinical symptoms compatible with a SARS-CoV-2 infection: cough (n = 4), sore throat (n = 3), nasal congestion (n = 3), dyspnea (n = 2), fever (n = 1), headache and myalgia (n = 1). SARS-CoV-2 was not detected in any of the 66 HCW.

CONCLUSION

Hygienic measures and contact precautions, aimed at preventing the spread of MRDO, may have helped to prevent a SARS-CoV-2 transmission to HCW-despite high-risk exposure during intubation, surgical treatment and general care.

LEVEL OF EVIDENCE

IV, case series.

Do Positive Cultures at Second Stage Re-Implantation Increase the Risk for Reinfection in Two-Stage Exchange for Periprosthetic Joint Infection?

BACKGROUND

Intraoperative cultures are important in the diagnosis and targeted treatment of periprosthetic joint infection (PJI). Positive cultures at reimplantation during a two-stage exchange are discussed as a risk factor for reinfection. The aim of this study is the investigation of the incidence and risk factors for positive cultures during reimplantation.

METHODS

We retrospectively identified 204 patients (111 knees, 93 hips) who were treated between 2012 and 2016 for PJI using a two-stage exchange protocol at a median follow-up of 42 months. PJI was diagnosed using the criteria of the musculoskeletal infection society (MSIS) of 2011. All cultural findings from first and second stage surgery were recorded. The primary endpoint was revision for infection. Risk factors for positive cultures and reinfection were analyzed.

RESULTS

During reimplantation 25% (51/204) of patients had at least one positive culture, in 19.1% (39/204) only a single culture. Patients with culture-negative infections had a higher risk for positive cultures at reimplantation (HR 2.946 (95% CI 1.247-6.961), P = .014) and patients with infected total hip arthroplasty (THA) (HR 3.547 (95% CI 1.7-7.4), P = .001). Patients with positive cultures during reimplantation had a higher risk for reinfection (HR 2.27 (95% CI 1.181-4.363), P = .014) as well as patients with a single positive culture (HR 2.421 (95% CI 1.139-5.143), P = .021).

CONCLUSION

As positive cultures are common and increase reinfection risk irrespective of their numbers, longer antibiotic therapy following reimplantation can be an option. Single positive cultures in reimplantation surgery should not be considered contamination.

What is the Likelihood That Tumor Endoprostheses Will Experience a Second Complication After First Revision in Patients With Primary Malignant Bone Tumors And What Are Potential Risk Factors?

BACKGROUND

Endoprosthetic reconstruction of massive bone defects has become the reconstruction method of choice after limb-sparing resection of primary malignant tumors of the long bones. Given the improved survival rates of patients with extremity bone sarcomas, an increasing number of patients survive but have prosthetic complications over time. Several studies have reported on the outcome of first endoprosthetic complications. However, no comprehensive data, to our knowledge, are available on the likelihood of an additional complication and the associated risk factors, despite the impact of this issue on the affected patients.

QUESTIONS/PURPOSES

(1) What are the types and timing of complications and the implant survivorship free from revision after the first complication? (2) Does survivorship free from repeat revision for a second complication differ by anatomic sites? (3) Is the type of first complication associated with the risk or the type of a second complication? (4) Are patient-, tumor-, and treatment-related factors associated with a higher likelihood of repeat revision?

METHODS

Between 1993 and 2015, 817 patients underwent megaprosthetic reconstruction after resection of a tumor in the long bones with a single design of a megaprosthetic system. No other prosthetic system was used during the study period. Of those, 75% (616 of 817) had a bone sarcoma. Seventeen patients (3%) had a follow-up of less than 6 months, 4.5% (27 of 599) died with the implant intact before 6 months and 43% (260 of 599 patients) underwent revision. Forty-three percent of patients (260 of 599) experienced a first prosthetic complication during the follow-up period. Ten percent of patients (26 of 260) underwent amputation after the first complication and were excluded from further analysis. Second complications were classified using the classification of Henderson et al. to categorize surgical results. Briefly, this system categorizes complications as wound dehiscence (Type 1); aseptic loosening (Type 2); implant fractures or breakage and periprosthetic fracture (Type 3); infection (Type 4); and tumor progression (Type 5). Implant survival curves were calculated with the Kaplan-Meier method and compared using the log-rank test. Hazard ratios (HR) were estimated with their respective 95% CIs in multivariate Cox regression models.

RESULTS

A second complication occurred in 49% of patients (115 of 234) after a median of 17 months (interquartile range [IQR] 5 to 48) after the surgery for the first complication. The time to complication did not differ between the first (median 16 months; IQR 5 to 57) and second complication (median 17 months; IQR 5 to 48; p = 0.976). The implant survivorship free from revision surgery for a second complication was 69% (95% CI 63 to 76) at 2 years and 46% (95% CI 38 to 53) at 5 years. The most common mode of second complication was infection 39% (45 of 115), followed by structural complications with 35% (40 of 115). Total bone and total knee reconstructions had a reduced survivorship free from revision surgery for a second complication at 5 years (HR 2.072 [95% CI 1.066 to 3.856]; p = 0.031) compared with single joint replacements. With the numbers we had, we could not show a difference between the survivorship free of revision for a second complication based on the type of the first complication (HR 0.74 [95% CI 0.215 to 2.546]; p = 0.535). We did not detect an association between total reconstruction length, patient BMI, and patient age and survivorship free from revision for a second complication. Patients had a higher risk of second complications after postoperative radiotherapy (HR 1.849 [95% CI 1.092 to 3.132]; p = 0.022) but not after preoperative radiotherapy (HR 1.174 [95% CI 0.505 to 2.728]; p = 0.709). Patients with diabetes at the time of initial surgery had a reduced survivorship free from revision for a second complication (HR 4.868 [95% CI 1.497 to 15.823]; p = 0.009).

CONCLUSIONS

Patients who undergo revision to treat a first megaprosthetic complication must be counseled regarding the high risk of future complications. With second complications occurring relatively soon after the first revision, regular orthopaedic follow-up visits are advised. Preoperative rather than postoperative radiotherapy should be performed when possible. Future studies should evaluate the effectiveness of different approaches in treating complications considering implant survivorship free of revision for a second complication.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Application of motorized intramedullary lengthening nails in skeletally immature patients : Indications and limitations]

BACKGROUND

Limb lengthening and deformity correction with motorized intramedullary lengthening nails is a more comfortable and equally safe procedure than the use of external fixators. While this treatment is a well-established method in adults, intramedullary nailing for skeletally immature patients remains a challenge and is the focus of current clinical investigations.

OBJECTIVE

Elucidation of the indications for the application of femoral and tibial lengthening nails in skeletally immature patients, presentation of essential characteristics and limitations of the treatment.

MATERIAL AND METHODS

Treatment of skeletally immature patients up to 16 years old who had a lengthening nail inserted was retrospectively clinically and radiologically evaluated (2016-2018).

RESULTS

A total of 60 procedures were performed on 54 patients. Mean age at the time of surgery was 13.6 years and the mean follow-up time was 10 months. Different nailing approaches were used: antegrade femoral (n = 42), retrograde femoral (n = 10) and antegrade tibial (n = 8). The average amount of lengthening was 45 mm. In 58 of the 60 cases (96.7%) the desired amount of lengthening was achieved, while 2 patients experienced complications that required interruption of the treatment. None of the patients developed growth disorders associated with the nailing approach.

CONCLUSION

Different approaches for intramedullary lengthening nails can be used in children and adolescents to correct leg length discrepancy with or without concomitant deformities. The treatment is limited by the size of the available nails, the residual growth and extent of the deformity. Larger trials will be needed to further validate the application of lengthening nails in skeletally immature patients.

Fungal prosthetic joint infection in total hip or knee arthroplasty

Aims

Fungal prosthetic joint infections (PJIs) are rare and account for about 1% of total PJIs. Our aim was to present clinical and microbiological results in treating these patients with a two-stage approach and antifungal spacers.

Patients and Methods

We retrospectively reviewed our institutional database and identified 26 patients with positive fungal cultures and positive Musculoskeletal Infection Society (MSIS) criteria for PJI who were treated between 2009 and 2017. We identified 18 patients with total hip arthroplasty (THA) and eight patients with total knee arthroplasty (TKA). The surgical and antifungal treatment, clinical and demographic patient data, complications, relapses, and survival were recorded and analyzed.

Results

The median follow-up was 33 months. The success rate was 38.5% (10/26). Fluconazole resistance was found in 15%. Bacterial co-infection was common in 44% of patients for THA and 66% of patients with TKA. Mortality, reoperations, and treatment failure were common complications.

Conclusion

Treatment with a two-stage exchange is a possible option for treatment, although fungal infections have a high failure rate. Therapeutic factors for treatment success remain unclear. Cite this article: Bone Joint J 2019;101-B:589–595.

Ultra-short stem anchorage in the proximal tibial epiphysis after intercalary tumor resections: analysis of reconstruction survival in four patients at a mean follow-up of 56 months

INTRODUCTION

Tumors localized in the proximal tibial meta-diaphysis often lead to osteoarticular resections.

MATERIALS AND METHODS

In this study, we retrospectively reviewed four patients who underwent intercalary tumor resection and reconstruction using an ultra-short stem in the proximal tibial epiphysis, a procedure that to our knowledge has not been reported in literature so far.

RESULTS

At the time of operation, the mean patient age was 26.2 years. Three patients were male and one was female. Patients were diagnosed with osteosarcoma in two cases, Ewing's sarcoma and malignant fibrous histiocytoma of bone in one case each. In all cases, wide tumor resections were achieved (osteotomy 3-3.5 cm below the tibia plateau joint surface, mean resection length of tibial bone 18 cm) at a mean time of operation of 198.8 min. Two superficial wound-healing disorders occurred, leading to one surgical revision in each case. One local tumor recurrence occurred 12 months after operation in a patient who discontinued his adjuvant chemotherapy. This patient died of disease, 31 months after operation. Three patients are alive with no evidence of disease at a mean follow-up of 56 months. Walking is not impaired and light sports activities have been reported in all cases. The mean MSTS score is 28/30.

CONCLUSIONS

Therefore, we report this reconstruction technique to be considered for special indications where the functional outcome can be improved by preservation of the knee joint in tumors of the proximal meta-diaphyseal tibial region.

Evaluation of the SMALL nail: Drive technology and behavior in situ

Although clear advances have been made during the last 5 years, practical difficulties persist for patients and surgeons in procedures for intramedullary lengthening of long bones. In particular, precise adjustment of the desired amount of lengthening and technically reliable checking of the length actually achieved are problematic. An intramedullary nail with a new type of drive that exploits the shape memory effect has been constructed. The drive technology and the behavior of the intramedullary nail in situ were evaluated in a cadaver experiment. Three shape memory alloy limb lengthening (SMALL) nails were implanted in a body donor. The SMALL nail contains a spring coupled to a shape memory element consisting of a nickel-titanium alloy. This shape memory element "remembers" its initial state before the lengthening through the spring and can return to it when it is warmed. A cartridge heater inside the lengthening nail is warmed using transcutaneous induction with high-frequency energy via a subcutaneously implanted coil. For evaluation, two SMALL nails were implanted into the femora (antegrade on the left and retrograde on the right) and one SMALL nail was implanted into the left tibia. Lengthening by 50mm was attempted using repeated activation of the drive mechanism. At the same time, test parameters for temperature increases and cooling periods were continually monitored and the data were subsequently analyzed. The nail's mechanism worked in principle, but was inadequate in view of success rates (number of lengthening steps attempted versus number of lengthening steps achieved) of 21% for the SMALL nail in the tibia and left femur and 14% for the nail in the right femur. The temperature values measured during the distraction experiments show that high-frequency energy induction in the SMALL nail gives no cause for concern for patients.

[PASTA-lesions--debridement versus repair]

BACKGROUND

Partial articular supraspinatus tendon avulsions (PASTA) lesions remain challenging with regard to diagnosis and treatment.

DIAGNOSTICS

For the diagnosis of PASTA lesions, arthroscopic evaluation of the supraspinatus tendon is key. Preoperative imaging alone is usually not sufficient to make the treatment decision.

OPERATIVE TECHNIQUE

For non-significant partial tears of less than 50 % of the tendon thickness a simple debridement is indicated. Two basic repair techniques, a transtendon repair technique and a repair after tear completion, can be distinguished. In PASTA lesions, a repair is generally preferred to debridement.

RESULTS

Results in the literature do not favor one repair technique over the other. Prospective randomized trials comparing debridement with repair are lacking in the literature. From a technical standpoint tear completion and repair seem to be a bit more reproducible.

Selective arterial Embolisation of Aneurysmal Bone Cysts of the Sacrum: a promising Alternative to Surgery

PURPOSE

The sacrum is a rare but unfavourable location for Aneurysmal Bone Cysts (ABCs), surgical procedures aiming to achieve local tumour control can be mutilating. Aim of this study was to evaluate whether selective arterial embolisation (AE) of ABC of the sacrum is an effective treatment and might be an alternative to surgical treatment options.

MATERIALS AND METHODS

Between 2007 and 2011 six patients (mean age 13.7 years, range 8 - 18 years) with an ABC of the sacrum were treated by AE. Follow-up was performed by MRI-scans as well as clinical examination (mean 36.5 months, range 14 - 56 months).

RESULTS

No treatment related complications have been observed. AE resulted in devascularisation of ABC and led to local tumour control in all patients. A partial consolidation was noticed in three patients. Pain relief was achieved in five of six patients, neurological deficits dissolved. In two patients more than one embolization was necessary. In one of these patients due to exacerbation of pain a surgical decompression was performed.

CONCLUSION

AE of sacral ABCs can serve as an effective and safe treatment option. Thus it might be an alternative to potentially harmful surgical procedures. In case of ongoing tumour growth or pain recurrence AE can be repeated. In case of treatment failure surgical interventions are still possible.

KEY POINTS

• transarterial embolisation enables local tumour control in sacral ABCs. • transarterial embolisation of sacral ABCs is a safe procedure. • in case of tumour progression repetitive embolisations are possible and effective.

[Benign cartilage tumors. What should I do with incidental findings?]

BACKGROUND

The majority of benign bone tumors are cartilage tumors. Most common are enchondroma and osteochondroma. Often they represent incidental findings in radiological diagnostics. Thus, the incidence of cartilage tumors is unknown, as most of them are never diagnosed due to the absence of any symptoms.

OBJECTIVES

This article describes the diagnostic and therapeutic approach of benign cartilage tumors, focusing on incidental findings.

METHODS

The current knowledge and our own experience in the diagnostics and treatment of benign condroid tumors are presented.

RESULTS

As enchondroma represent most often the classic incidental finding without any symptoms or clinical findings, osteochondroma are often diagnosed in young patients by clinical examination showing a painless swelling that can increase in size according to skeletal growth. Most of these asymptomatic enchondroma and osteochondroma are so called "leave me alone lesions" and do not need any treatment, while other benign tumors (e.g., atypical cartilage tumors, chondroblastoma, chondromyxoidfibroma or osteochondroma with a cartilage cap of over 2 cm) need surgical treatment. These active or local aggressive tumors must be differentiated from the "leave me alone lesions". Additionally, patients with syndromes like Ollier disease (enchondromatosis), Maffucci syndrome or hereditary multiple exostosis must be examined and checked carefully as malignant degradation is possible.

CONCLUSION

As most cartilage tumors are benign and remain benign, inappropriate diagnostics or operative treatment just to provide security is obsolete. Plain X-ray is often enough for follow-up and other modalities only become necessary when symptoms occur.

Development of curative therapies for Ewing sarcomas by interdisciplinary cooperative groups in Europe

Curative therapies for Ewing sarcoma have been developed within cooperative groups. Consecutive clinical trials have systematically assessed the impact and timing of local therapy and the activity of cytotoxic drugs and their combinations. They have led to an increase of long-term disease-free survival to around 70% in patients with localized disease. Translational research in ES remains an area in which interdisciplinary and international cooperation is essential for future progress. This article reviews current state-of-the art therapy, with a focus on trials performed in Europe, and summarizes novel strategies to further advance both the cure rates and quality of survival.

[Interdisciplinary diagnostic and treatment of bone sarcomas of the extremities and trunk]

Contrary to the relatively common benign bone tumours and tumour-like lesions, bone sarcomas are rare malignancies with an incidence of 0.8 new cases per 100 000 persons per year. The most common primary malignant bone tumour is osteosarcoma, followed by chondrosarcoma and Ewing sarcoma. Osteosarcomas and Ewing sarcomas occur predominantly in children, adolescents and young adults, while chondrosarcomas primarily affect older patients. Most of the tumours are located in the extremities and the pelvis and in about 90% of the cases the surgical treatment can be performed by means of a limb-sparing wide resection. An endoprosthetic or biological reconstruction of the resulting defect, depending on several patient- und tumour-related factors, is usually necessary. Apart from the surgical treatment, patients with osteosarcoma and Ewing sarcoma require a pre- and postoperative chemotherapy, while Ewing sarcoma patients often undergo radiation therapy as well. Regular follow-up examinations are required after the completion of treatment for the early detection and management of local and/or systemic recurrences as well as treatment-related complications. An extensive experience in the clinical and imaging features as well as the interdisciplinary treatment of these tumours is necessary for optimal patient care. Without it mistakes are often made, which can have grave consequences on the patients' prognosis and functional outcome. The centralised treatment of these patients in specialised sarcoma centres is therefore recommended.

Interleukin-6 in two-stage revision arthroplasty

The purpose of this study was to evaluate whether the serum level of interleukin 6 (IL-6) could be used to identify the persistence of infection after the first stage of a two-stage revision for periprosthetic joint infection.

Between 2010 and 2011, we prospectively studied 55 patients (23 men, 32 women; mean age 69.5 years; 36 to 86) with a periprosthetic joint infection. Bacteria were identified in two intra-operative tissue samples during re-implantation in 16 patients. These cases were classified as representing persistent infection.

To calculate a precise cut-off value which could be used in everyday clinical practice, a 3 x 2 contingency table was constructed and manually defined.

We found that a serum IL-6 ≥ 13 pg/mL can be regarded as indicating infection: its positive-predictive value is 90.9%. A serum IL-6 ≤ 8 pg/mL can be regarded as indicating an absence of infection: its negative predictive value is 92.1%.

The serum IL-6 level seems to be a reasonable marker for identifying persistent infection after the first stage of a revision joint arthroplasty and before attempting re-implantation.

Cite this article: Bone Joint J 2015;97-B:71–5.

Prognostic relevance of the mitotic count and the amount of viable tumour after neoadjuvant chemotherapy for primary, localised, high-grade soft tissue sarcoma

Background:

We sought to examine whether mitotic count (MC) and the amount of viable tumour (VT) following neoadjuvant systemic chemotherapy (SC) for primary, localised, high-grade soft tissue sarcoma (STS) correlate with prognosis.

Methods:

Retrospective analysis of 57 patients who underwent SC involving a combination of an anthracycline and an alkylating agent, followed by surgical resection between 2001 and 2011.

Results:

The amount of VT after chemotherapy was significantly associated with disease-specific survival (DSS) and event-free survival (EFS). Patients with <10% VT had a DSS of 94% at 5 years, compared with 61% for patients with ⩾10% VT (P=0.033); EFS was 75%, compared with 48% (P=0.030). Patients with an MC of ⩾20/10 high power fields (HPF) after chemotherapy had a significantly lower DSS (33% vs 84% at 5 years, P<0.001) and EFS (40% vs 63% at 5 years, P=0.019) than patients with an MC of <20/10 HPF.

Conclusions:

The MC and the amount of VT after neoadjuvant therapy for primary, localised, high-grade STS appear to correlate with prognosis. If these results are validated prospectively, then they could provide a rational for the design of neoadjuvant treatment modification/escalation studies, analogue to the EURAMOS-1 trial for bone sarcomas.

EURAMOS-1, an international randomised study for osteosarcoma: results from pre-randomisation treatment

BACKGROUND

Four international study groups undertook a large study in resectable osteosarcoma, which included two randomised controlled trials, to determine the effect on survival of changing post-operative chemotherapy based on histological response.

PATIENTS AND METHODS

Patients with resectable osteosarcoma aged ≤40 years were treated with the MAP regimen, comprising pre-operatively of two 5-week cycles of cisplatin 120 mg/m(2), doxorubicin 75 mg/m(2), methotrexate 12 g/m(2) × 2 (MAP) and post-operatively two further cycles of MAP and two cycles of just MA. Patients were randomised after surgery. Those with ≥10% viable tumour in the resected specimen received MAP or MAP with ifosfamide and etoposide. Those with <10% viable tumour were allocated to MAP or MAP followed by pegylated interferon. Longitudinal evaluation of quality of life was undertaken.

RESULTS

Recruitment was completed to the largest osteosarcoma study to date in 75 months. Commencing March 2005, 2260 patients were registered from 326 centres across 17 countries. About 1334 of 2260 registered patients (59%) were randomised. Pre-operative chemotherapy was completed according to protocol in 94%. Grade 3-4 neutropenia affected 83% of cycles and 59% were complicated by infection. There were three (0.13%) deaths related to pre-operative chemotherapy. At definitive surgery, 50% of patients had at least 90% necrosis in the resected specimen.

CONCLUSIONS

New models of collaboration are required to successfully conduct trials to improve outcomes of patients with rare cancers; EURAMOS-1 demonstrates achievability. Considerable regulatory, financial and operational challenges must be overcome to develop similar studies in the future. The trial is registered as NCT00134030 and ISRCTN 67613327.

[New surgical treatment options for bone tumors]

Primary bone neoplasms can be classified into benign, locally/aggressive and rarely metastasizing and malignant tumors. Patients with benign tumors usually undergo surgical treatment in cases of local symptoms, mainly consisting of pain or functional deficits due to compression of important anatomical structures, such as nerves or blood vessels. Locally/aggressive and rarely metastasizing tumors exhibit an infiltrative growth pattern, so that surgical treatment is necessary to prevent further destruction of bone leading to local instability. Finally, the surgical treatment of malignant tumors is, with few exceptions, considered to be a prerequisite for long-term survival, either alone or in combination with systemic chemotherapy. Whereas the main objective of surgery in the treatment of benign tumors is relief of local symptoms with a minimum amount of damage to healthy tissue and minimizing the risk of local recurrence while ensuring bone stability in locally aggressive and rarely metastasizing tumors, the primary goal in the operative treatment of bone sarcomas is the resection of the tumor with clear surgical margins followed by defect reconstruction and the preservation of function. This review examines the current developments in the surgical treatment of primary bone neoplasms with respect to the management of the tumors and novel reconstructive options.

[Shoulder injuries in golf]

BACKGROUND

Due to its growing popularity golf has now come into the focus of orthopedic sports medicine. With a wide range of age groups and playing levels, orthopedic surgeons will encounter a wide range of musculoskeletal problems which are usually the result of overuse rather than trauma.

ANATOMY

The shoulder joint plays an important role in the golf swing whereby not only the muscles around the glenohumeral joint but also the scapula stabilizing muscles are extremely important for an effective golf swing.

INJURY PATTERNS

Golf is strictly not considered to be an overhead sport; however, the extreme peak positions of the golf swing involve placing the shoulder joint in maximum abduction and adduction positions which can provoke impingement, lesions of the pulley system or even a special form of posterior shoulder instability.

PERSPECTIVES

Even after complex shoulder operations, such as rotator cuff repair or shoulder arthroplasty, a return to the golf course at nearly the same level of play can be expected.

Effects of an exercise intervention on bone mass in pediatric bone tumor patients

The aim was to evaluate the effects of additional exercises during inpatient stays on bone mass in pediatric bone tumor patients. 21 patients were non-randomly allocated either to the exercise group (n = 10) or the control group (n = 11). DXA of the lumbar spine, the non-affected femur and both calcanei was performed after completion of neoadjuvant chemotherapy (baseline), as well as 6 and 12 months after baseline. Bone mineral content (BMC), bone mineral density (BMD) and height-corrected lumbar spine Z-scores were determined. Group changes after 6 and 12 months were compared by covariance analyses. Additionally, daily physical activities (PA) were assessed by means of accelerometry. After adjusting for initial age, height and weight, mean reductions in lumbar spine and femoral BMC were lower in the exercise group (not significant). Effect sizes during the observational period for lumbar spine and femur BMC were generally small (partial η² = 0.03). The exercise group demonstrated substantially higher PA levels in terms of gait cycles per day, per hour and moderate PA (activities above 40 gait cycles per minute). Additional exercises for bone tumor patients are feasible during hospitalization. Though the intervention did not influence BMC, it appeared beneficial regarding PA promotion with respect to volume and intensity.

Endoprosthetic replacement after extra-articular resection of bone and soft-tissue tumours around the knee

We evaluated the clinical results and complications after extra-articular resection of the distal femur and/or proximal tibia and reconstruction with a tumour endoprosthesis (MUTARS) in 59 patients (mean age 33 years (11 to 74)) with malignant bone or soft-tissue tumours. According to a Kaplan-Meier analysis, limb survival was 76% (95% confidence interval (CI) 64.1 to 88.5) after a mean follow-up of 4.7 years (one month to 17 years). Peri-prosthetic infection was the most common indication for subsequent amputation (eight patients). Survival of the prosthesis without revision was 48% (95% CI 34.8 to 62.0) at two years and 25% (95% CI 11.1 to 39.9) at five years post-operatively. Failure of the prosthesis was due to deep infection in 22 patients (37%), aseptic loosening in ten patients (17%), and peri-prosthetic fracture in six patients (10%). Wear of the bearings made a minor revision necessary in 12 patients (20%). The mean Musculoskeletal Tumor Society score was 23 (10 to 29). An extensor lag > 10° was noted in ten patients (17%). These results suggest that limb salvage after extra-articular resection with a tumour prosthesis can achieve good functional results in most patients, although the rates of complications and subsequent amputation are higher than in patients treated with intra-articular resection.

Pelvic reconstruction with compound osteosynthesis following hemipelvectomy: A clinical study

To date, all surgical techniques used for reconstruction of the pelvic ring following supra-acetabular tumour resection produce high complication rates. We evaluated the clinical, oncological and functional outcomes of a cohort of 35 patients (15 men and 20 women), including 21 Ewing's sarcomas, six chondrosarcomas, three sarcomas not otherwise specified, one osteosarcoma, two osseous malignant fibrous histiocytomas, one synovial cell sarcoma and one metastasis. The mean age of the patients was 31 years (8 to 79) and the latest follow-up was carried out at a mean of 46 months (1.9 to 139.5) post-operatively. We undertook a functional reconstruction of the pelvic ring using polyaxial screws and titanium rods. In 31 patients (89%) the construct was encased in antibiotic-impregnated polymethylmethacrylate. Preservation of the extremities was possible for all patients. The survival rate at three years was 93.9% (95% confidence interval (CI) 77.9 to 98.4), at five years it was 82.4% (95% CI 57.6 to 93.4). For the 21 patients with Ewing's sarcoma it was 95.2% (95% CI 70.7 to 99.3) and 81.5% (95% CI 52.0 to 93.8), respectively. Wound healing problems were observed in eight patients, deep infection in five and clinically asymptomatic breakage of the screws in six. The five-year implant survival was 93.3% (95% CI 57.8 to 95.7). Patients were mobilised at a mean of 3.5 weeks (1 to 7) post-operatively. A post-operative neurological defect occurred in 12 patients. The mean Musculoskeletal Tumor Society score at last available follow-up was 21.2 (10 to 27). This reconstruction technique is characterised by simple and oncologically appropriate applicability, achieving high primary stability that allows early mobilisation, good functional results and relatively low complication rates.

[Diagnostics and therapy for periprosthetic joint infection in Germany - A survey of 450 hospitals and a comparison with the literature]

The diagnosis and treatment of periprosthetic joint infections is a difficult situation for the attending physician. From the extensive literature, algorithms for diagnosis and therapy can be created. The aim of this study was to collect a representative survey of current concepts in the Federal States of the former West Germany and to compare them with those in the current literature. In 2011 orthopaedic and trauma clinics were surveyed anonymously in western Germany about diagnosis and treatment of periprosthetic infections. 450 questionnaires could be evaluated. Septic hip arthroplasty revisions were performed on average 12 (± 20)/year, septic knee arthroplasty revisions were performed on average 9 (± 17)/year. On average 205 (± 178) primary hip and 167 (± 155) primary knee arthroplasties were implanted/year. The analysis of the collected parameters is summarised in three tables. In the field of diagnostics, parameters such as CRP are determined. The interpretation, however, differs in more than 50 % of the hospitals on the relevant literature. Some important diagnostic parameters are not used. Therapy concepts are largely consistent with the literature. To a non-negligible extent, the vacuum-assisted therapy (approximately 30 % of hospitals) is used. In the literature it is described only for early infection. But even for use in early infection, there are very few data available. A unified diagnostic algorithm would be desirable.

The treatment of locally recurrent chondrosarcoma

The aim of this study was to define the treatment criteria for patients with recurrent chondrosarcoma. We reviewed the data of 77 patients to examine the influence of factors such as the intention of treatment (curative/palliative), extent of surgery, resection margins, status of disease at the time of local recurrence and the grade of the tumour. A total of 70 patients underwent surgery for recurrent chondrosarcoma. In seven patients surgery was not a viable option. Metastatic disease occurred in 41 patients, appearing synchronously with the local recurrence in 56% of cases. For patients without metastasis at the time of local recurrence, the overall survival at a mean follow-up after recurrence of 67 months (0 to 289) was 74% (5 of 27) compared with 19% (13 of 50) for patients with metastasis at or before the development of the recurrence. Neither the type/extent of surgery, site of tumour, nor the resection margins for the recurrent tumour significantly influenced the overall survival.

With limited survival for patients with metastatic disease at the time of local recurrence (0% for patients with grade III and de-differentiated chondrosarcoma), palliative treatment, including local radiation therapy and debulking procedures, should be discussed with the patients to avoid long hospitalisation and functional deficits. For patients without metastasis at the time of local recurrence, the overall survival of 74% justifies an aggressive approach including wide resection margins and extensive reconstruction.

Intramedullary and total femur replacement in revision arthroplasty as a last limb-saving option

There has been a substantial increase in the number of hip and knee prostheses implanted in recent years, with a consequent increase in the number of revisions required. Total femur replacement (TFR) following destruction of the entire femur, usually after several previous revision operations, is a rare procedure but is the only way of avoiding amputation. Intramedullary femur replacement (IFR) with preservation of the femoral diaphysis is a modification of TFR. Between 1999 and 2010, 27 patients with non-oncological conditions underwent surgery in our department with either IFR (n = 15) or TFR (n = 12) and were included in this study retrospectively. The aim of the study was to assess the indications, complications and outcomes of IFR and TFR in revision cases. The mean follow-up period was 31.3 months (6 to 90). Complications developed in 37% of cases, 33% in the IFR group and 4% in the TFR group. Despite a trend towards a slightly better functional outcome compared with TFR, the indication for intramedullary femur replacement should be established on a very strict basis in view of the procedure’s much higher complication rate.

Expression of beta-catenin and p53 are prognostic factors in deep aggressive fibromatosis

AIMS

To determine the prognostic significance of beta-catenin in aggressive fibromatosis and to identify potential molecular markers for new targeted therapies.

METHODS AND RESULTS

A tissue microarray of 37 cases of deep aggressive fibromatosis was constructed and subjected to immunohistochemical analysis for beta-catenin, p53, smooth muscle actin (SMA), desmin, Ki67, c-erbB2, epidermal growth factor receptor (EGFR), c-kit, CD34 and S100. Complete clinical follow-up was available for 23 patients. Nuclear beta-catenin expression was associated with an increased rate of local tumour recurrence (60.0% 1-year and 0% 5-year event-free survival; P < 0.05). Furthermore, p53 expression was associated with an increased risk of tumour recurrence (50% 1-year event-free survival rate and 0% 5-years event-free survival rate, P < 0.05). The coexpression of p53 and beta-catenin was significantly correlated (P < 0.05). No statistically significant association was seen between MIB1 and p53 or beta-catenin expression, respectively. No expression of EGFR, c-erbB2 or c-kit was seen.

CONCLUSIONS

The overexpression of beta-catenin and p53 is associated with a decreased event-free survival in deep aggressive fibromatosis. Further studies are required to establish whether these findings can lead to an improvement in the treatment of this rare neoplasm.

The effect of rotationplasty on the ankle joint: long-term results

In patients with rotationplasty the biomechanical conditions in the ankle joint are altered dramatically. By displacement and reduction of the weight-bearing area of the joint, the stress affecting its cartilage is increased. The use of an exoprothesis results in skin and soft tissue irritation. Due to these biomechanical changes, a prearthrotic deformity or skin problems could be expected. The current study examines changes in 21 patients treated with rotationplasty (mean follow-up 13.5 years) because of a malignant bone tumour or a femoral segmental defect. Local tenderness, skin and soft tissue changes, problems with exoprostheses, and pain was assessed by clinical examination and documented. Osseous changes were evaluated by plain X-ray. A MRI-scan was also obtained in five patients. Hardened skin and blisters were located at the main loading areas of the rotated foot. These changes could be reduced by optimizing the exoprosthetic fit. Radiographically, a slight asymptomatic attenuation of the articular space was observed in four patients and a slight coexistent subchondral sclerosis with small osteophytes in one patient. No degenerative changes were observed on X-ray and no cartilaginous changes were observed on MRI. The results suggest that the foot is able to adapt to the load changes after this procedure and that rotationplasty does not cause an inevitable arthrosis in the ankle joint.

A particular solution in the treatment of primitive neoplasms of the distal third of the tibia. Presentation of a clinical case and review of the literature

Primitive malignant neoplasms affecting the distal third of the tibia are altogether rare, and their treatment is considerably controversial. The authors describe the diagnostic procedure and a particular surgical strategy of limb salvage in a case of malignant fibrous histiocytoma located at the distal third of the tibia, in particular pointing out the difficulties in restoring the continuity of the skeletal tissues and of the muscle, and with a review of the relevant literature.

[Cartilage tumours of the bone. Diagnosis and therapy]

Primary malignant bone tumours are rare. The annual incidence of these tumours is 10 per 1 million. Nearly 30% of the primary malignant bone tumours are malignant cartilage tumours. The frequency of benign cartilage tumours cannot be definitely estimated because these tumours are normally clinically inapparent and therefore often diagnosed as an incidental finding. The cartilage tumours appear as benign lesions (e.g. chondroma), as borderline tumours (proliferative chondroma vs grade I chondrosarcoma) or as highly malignant chondrosarcoma (e.g. dedifferentiated chondrosarcoma). Commensurate with the different clinical and oncological manifestations of the cartilage tumours, there are wide differences in the treatment and clinical course of the individual tumour. This article discusses the problems in the diagnosis and treatment of cartilage tumours from an orthopaedic point of view.

Free vascularized fibular grafting for reconstruction after tumor resection in the upper extremity

BACKGROUND

Limb salvage is viable in the majority of patients with malignant bone tumors, but especially in case of extensive tumors and bad soft tissue conditions, it is challenging in upper extremity.

OBJECTIVES/METHOD

The clinical and radiological results of 21 patients, who had free vascularized fibular grafts (VFG), for diaphyseal (14), and epipyseal (7) defect reconstruction of the upper extremity, are presented. The indications for VFG were resection after osteosarcoma (9 cases), Ewings sarcoma (9 cases), chondrosarcoma (1 case), rhabdomyosarcoma (1 case), and 1 case of fibrous dysplasia. The 20 malignant tumors were staged as follows: 2a (1), 2b (18), 3 (1). The mean follow-up was 43.6 months (min 6.0-max 131.9). Functional results were described and graded quantitatively according to the MSTS-score.

RESULTS

Results were satisfactory with regard to pain, emotional acceptance, manual dexterity, and function. Lifting ability was decreased in two patients. Hypertrophy index was 31% (min 13%-max 71%). Main complications were fracture (5), pseudoarthrosis (4), prolonged wound healing (4), temporary nerve irritation (2), and deep infection (1). Re-operation was required in eight patients (12 operations).

CONCLUSION

VFG offers a good possibility for biological reconstruction of large skeletal defects, with an acceptable complication and re-operation rate. When conservative treatment of complications was not successful, further surgery led to recovery in the majority of cases.

Characteristics and outcome of infections associated with tumor endoprostheses

INTRODUCTION

Infection associated with prosthesis used after tumor resection is a common and serious complication. The purpose of the current retrospective study was to describe the course of infection in patients with a tumor endoprosthesis and the determination of risk factors associated with failed limb salvage.

MATERIAL AND METHODS

30 patients with an infection associated with a tumor endoprosthesis were investigated with regard to treatment strategies, number and type of revision operations, duration of hospital stay, determination of risk factors associated with failed limb salvage and final outcome.

RESULTS

Limb salvage related to the complication infection was achieved in 19 patients (63.3%). Two-stage reimplantation of an endoprosthesis was successful in 14 patients but subsequently failed in one patient. Out of 11 patients where limb salvage failed, an amputation was performed in 6 patients, a rotationplasty in 4, and stump lengthening procedure in 1 patient. A poor soft tissue condition was a significant (P<0.05) risk factor for failed limb salvage. No patient receiving chemotherapy with a poor soft tissue condition had limb salvage surgery. The mean number of revision operations per patients was 2.6. The mean duration of hospital stay was 68 days.

CONCLUSION

Infection associated with prosthesis is a serious complication and is involved with long hospitalization. Limb salvage failed mostly in the case of a poor soft tissue condition. In these cases repeated revision surgery should be avoided and ablative surgery recommended at an early stage. Rotationplasty is an alternative to amputation in the case of an infection of the proximal or distal part of the femur.

Functional results and quality of life after treatment of pelvic sarcomas involving the acetabulum

BACKGROUND

Limb salvage after resection of a pelvic sarcoma that involves the acetabulum represents a surgical challenge. The ideal method of reconstruction after acetabular resection remains a subject of controversy, and the outcome in terms of the impact of therapy is still unknown. The purpose of this study was to determine the impact of surgery on health-related quality of life and function after acetabular resection.

METHODS

Eighty-one patients with a pelvic sarcoma underwent acetabular resection at a single institution. Functional evaluation and quality-of-life examination were performed in forty-five patients, and these patients comprised the study group. Quality of life was assessed with use of the European Organization for Research and Treatment of Cancer core quality-of-life questionnaire. Function was assessed with use of the Musculoskeletal Tumor Society system.

RESULTS

The median age of the patients was 30.4 years at the time of the acetabular resection and 35.7 years at the time of follow-up. The median time interval from the index operation to the latest follow-up was sixty-nine months. At the latest follow-up evaluation, the mean functional status score was 14.5 points of a maximum of 30 points. In a comparison of endoprosthetic replacement and hip transposition following resection, significantly better functional results (p = 0.017) and a lower number of complications were found in patients who had a hip transposition. Quality-of-life assessment results were also better in patients with a hip transposition, especially in role functioning (p = 0.043).

CONCLUSIONS

On the basis of the low complication rate and the good functional and quality-of-life results, hip transposition after acetabular resection seems to be the optimal technique for treating patients with a pelvic sarcoma involving the acetabulum.

Pitfalls in immunohistochemical assessment of EGFR expression in soft tissue sarcomas

BACKGROUND

New targeted cancer treatments acting against growth factor receptors such as the epidermal growth factor receptor (EGFR) necessitate selecting patients for treatment with these drugs. Besides carcinomas, soft tissue sarcomas (STS) express EGFR and might thereby be a promising target for this new therapeutic strategy.

OBJECTIVE

To test and compare different EGFR antibodies to determine the frequency of EGFR expression in STS.

METHODS

302 consecutive specimens of STS were examined using the tissue microarray technique. EGFR expression levels were assessed by immunohistochemistry using five different commercially available antibodies. Gene amplification status was measured by fluorescence in situ hybridisation (FISH). Immunoreactivity and amplification status were correlated with clinicopathological features and follow up data available in 163 cases.

RESULTS

EGFR expression frequency ranged between 0.3% and 52.9%, depending on the antibody and scoring method used. In all, 3.5% of the tumours showed egfr gene amplification by FISH, which correlated with EGFR expression for three antibodies. Only one antibody had independent prognostic value in multivariate analysis and correlated with an unfavourable outcome; egfr gene amplification status showed no correlation with clinical features.

CONCLUSIONS

Frequency of EGFR immunopositivity in STS strongly depends on the antibody used, and only one of five antibodies tested predicted an unfavourable clinical outcome. This indicates that choice of primary antibody and scoring system have a substantial impact on the determination of EGFR immunoreactivity.

Long-term results of the metal-cancellous cementless Lübeck total hip arthroplasty: a critical review at 12.8 years

INTRODUCTION

The influence of a spongy metal surface total hip arthroplasty (THA) (S&G, ESKA, Lübeck, Germany) on the clinical, psychometric, and radiograhic long-term results were examined.

MATERIAL AND METHODS

An amount of 137 THA with the cementless spongy metal Lübeck hip prosthesis were evaluated long-term, radiographically and clinically, with a mean follow-up time of 12.8 years (range 10.1-14.9 years). The MOS SF-36 was used to assess the health-related quality of life (HRQL).

RESULTS

Cumulative survival rates were 90% (+/-8%) for the cups and 86% (+/-5%) for the stems at 14.9 years. Four stems fractured at the middle part (3%) without major trauma. In the remaining patients the clinical results expressed as Harris Hip Score (HHS) averaged 88 (range 34-100). Patients above 60 years undergoing THA had no significant difference in HRQL (MOS SF-36) in comparison to the age-matched healthy population (P>0.05). Patients younger than 60 years had scores lower than normal in the physical function domains (P<0.01), but were comparable in the mental health domains (P>0.05). Radiolucent lines and bone atrophy related to stress shielding by distal fixation were found in the periprosthetic Gruen Zone I (19.8, 16.8%) and VII (10.3, 27.1%) of the proximal femur.

DISCUSSION

Whereas the rate of aseptic cup failures of the cementless spongy metal Lübeck hip prosthesis is among the best, the failure rate of the stems is attributable to osteolysis of the proximal femur. The fractures of the stem may be attributed to the combination of the lack of proximal support, the fully porous stem made of a cast cobalt-chrome-molybdenum alloy, and the narrow dimension of the stem core. The long-term results of the spongy metal cup are good, whereas the high loosening and fracture rate of fully coated stem are a source of concern especially with regard to the difficult revision scenario with frequent massive bone loss.

The high tibial osteotomy, open versus closed wedge, a comparison of methods in 108 patients

INTRODUCTION

One hundred and eight patients with varus gonarthrosis were treated with high tibial osteotomy (HTO) in 2001. Fifty one patients received an open wedge osteotomy by using the 'Puddu' plate and 57 patients received a Coventry-type closing wedge osteotomy. For both groups the follow-up examination period was 22.5 months (253-1009 days).

MATERIAL AND METHODS

To evaluate the study, radiological and subjective criteria as well as the Lysholm and the Tegner Activity Score were used. Altogether 84 % of the patients were included in the follow-up examination study.

RESULTS

In both groups a significant improvement of both scores were achieved. Both methods obtained safe and reproducible results for the correction considering the different operation techniques. There were no differences in outcome between the two methods. Satisfactory results were also achieved for early arthrosis of the femoropatellar and the lateral compartment.

CONCLUSION

Open and closed wedge HTOs obtain significant improvement in patients with medial osteoarthritis of the knee. Using the right technique is very important for good results. For stabilization of the medial ligament we recommend the open wedge osteotomy. The patient should be informed about the routine removal of the metal plate.

Effectiveness of hydroxyapatite-vancomycin bone cement in the treatment of Staphylococcus aureus induced chronic osteomyelitis

In the field of local application of antimicrobials, a number of novel drugs and/or new drug delivery systems have been developed in recent years. The present study aimed to investigate hydroxyapatite cement (HAC) as a carrier for vancomycin in the treatment of chronic osteomyelitis due to Staphylococcus aureus strains with various mechanisms of resistance. The release of vancomycin from standard test cylinders was determined in vitro and the efficacy of the delivery system was measured in vivo using a rabbit model of chronic osteomyelitis. First, powdered HAC was mixed with vancomycin at 80, 160 and 240 mg/g. After hardening, formed cylinders were eluted in phosphate buffer and antibiotic release was measured by agar diffusion. High levels of release (1512+/-318 to 1937+/-336 microg/ml) were obtained for 12 to 20 days depending on the dosage of vancomycin. Additionally, bone infection was induced in the tibia of 30 New Zealand white rabbits by injecting either a methicillin-resistant S. aureus strain (MRSA) or a S. aureus strain with a small colony variant (SCV) phenotype. After 3 weeks (chronic infection), all animals were treated by debridement. Moreover, group 1 (challenged with SCVs) and group 2 (challenged with MRSA) were treated by filling the marrow with HAC alone, whereas in groups 3 (SCVs) and 4 (MRSA) the marrow was filled with HAC/vancomycin (160 mg/g). After 6 weeks all animals were sacrificed. At 3 weeks, pathogens were detected in 24 of 30 animals. All swabs of the control groups, positive for S. aureus on day 21, were also positive on day 42 and S. aureus strains recovered were shown to be clonal to the strains used for induction of osteomyelitis. By contrast, no growth was found in the treatment group following 7 days of incubation in BHI bouillon. HAC/vancomycin-treated animals showed no histological evidence of infection on day 42. In the other groups, different stages of chronic osteomyelitis were found histologically. No local or systemic side effects due to HAC or vancomycin were seen. HAC is an effective carrier material for antibiotic compounds even in refractory infections due to MRSA or S. aureus SCVs.

Continuous passive motion in the prevention of deep-vein thrombosis: a randomised comparison in trauma patients

There is a high risk of venous thromboembolism when patients are immobilised following trauma. The combination of low-molecular-weight heparin (LMWH) with graduated compression stockings is frequently used in orthopaedic surgery to try and prevent this, but a relatively high incidence of thromboembolic events remains. Mechanical devices which perform continuous passive motion imitate contractions and increase the volume and velocity of venous flow. In this study 227 trauma patients were randomised to receive either treatment with the Arthroflow device and LMWH or only with the latter. The Arthroflow device passively extends and plantarflexes the feet. Patients were assessed initially by venous-occlusion plethysmography, compression ultrasonography and continuous wave Doppler, which were repeated weekly without knowledge of the category of randomisation. Those who showed evidence of deep-vein thrombosis underwent venography for confirmation. The incidence of deep-vein thrombosis was 25% in the LMWH group compared with 3.6% in those who had additional treatment with the Arthroflow device (p < 0.001). There were no substantial complications or problems of non-compliance with the Arthroflow device. Logistic regression analysis of the risk factors of deep-vein thrombosis showed high odds ratios for operation (4.1), immobilisation (4.3), older than 40 years of age (2.8) and obesity (2.2).

Bone metastasis in hepatocellular carcinoma. A report of five cases and a review of the literature

Hepatocarcinoma occurs frequently throughout the world. Bone metastases are rare although incidence has increased because of progress in diagnosis and treatment. The authors report 5 cases of bone metastases and review the literature. The spine is the most frequent localization of bone metastases. Radiotherapy is the treatment of choice for this lesion. Surgery should be used to prevent and treat complications such as nerve compression and pathologic fracture, only if the coagulative pattern and the conditions of the patient allow it. The authors recommend the use of long intramedullary nailing when localization of the disease is in the femur, with prophylactic stabilization of the neck in diaphyseal metastasis.

Treatment of primary malignant bone tumours of the distal tibia

We treated 15 patients with primary malignant bone tumours of the distal tibia of which 14 were treated by limb salvage surgery. Reconstructions were done by allografts with or without microvascular fibula transfer, by bone transport, by fibula transfer alone or by endoprosthetic replacement. The most successful methods were bone transport and endoprosthetic replacement. However, serious complications with deep infections leading to secondary amputation occurred in four patients and in all reconstruction groups. After a mean follow up of 7 years, no local recurrence occurred, and all patients were alive and free of disease. After radical resection, bone transport in defects less than 15 cm is a viable option. In larger defects in children, allograft with vascularised fibula is an acceptable alternative, but amputation still has a role in this group. In adults, endoprosthetic replacement with proper soft tissue coverage is a viable option in cases with large bony defects.

Rotationplasty type BI versus type BIIIa in children under the age of ten years

Type BI rotationplasty is currently indicated for children with tumours of the proximal femur whereas type BIIIa rotationplasty is reserved for those in which the entire femur has to be removed. Our aim was to compare these two types of rotationplasty and determine whether the knee should be preserved in children with tumours of the proximal femur. We compared the post-operative complications, oncological outcome, range of movement, Enneking score and radiographs of six children, who had undergone type BI rotationplasty with those of 12 who had undergone type BIIIa rotationplasty.

Patients with type BI rotationplasty had a mean Enneking score of 21.6 compared with 24.4 in those with type BIIIa rotationplasty, and worse mean results in all of the parameters investigated. We conclude that type BI rotationplasty has a worse functional outcome and more complications than type BIIIa rotationplasty in children under the age of ten years.