Operative Orthopadie Und Traumatologie, Aug 1, 2022
Die proximale femorale Varisationsosteotomie (PVO) ist eine chirurgische Technik zur Rezentrierun... more Die proximale femorale Varisationsosteotomie (PVO) ist eine chirurgische Technik zur Rezentrierung des Hüftkopfes, sofern es bspw. im Rahmen der ablaufenden Legg-Calvé-Perthes(LCPD)-Krankheit zur Subluxation gekommen ist. Indikationen: Bis anhin existieren keine einheitlichen Indikationskriterien für die Containment-Therapie bei LCPD-Patienten. Einzelne, für die Deformitätsentwicklung prädiktive radiologische Faktoren, Alter bei Diagnosestellung oder Symptombeginn und Klassifikationen, welche die Pathomorphologie des Femurkopfes bezogen auf die Nekrose beschreiben, können die Indikationsstellung erleichtern. Kontraindikationen: Die absolute Kontraindikation stellt die Entwicklung eines Scharniergelenkes dar (Hinge-Abduktion). Bleibt der Femurkopf in einer Abduktionsröntgenaufnahme von 20°auch in Abwesenheit einer Hinge-Abduktion dezentriert oder besteht ein Total-Kopf-Befall, ergibt sich ebenfalls eine Kontraindikation. Relativ kontraindiziert ist die PVO bei Kindern mit Beginn der Erkrankung < 6 Jahren, in der Lateral-Pillar-Klassifikation Gruppe A soiwe bei I und II nach Catterall. Operationstechnik: Lateraler Standardzugang zum proximalen Femur. Platzieren des Anteversions-K-Drahtes ventral des Schenkelhalses. Weitere K-Drähte werden parallel mithilfe von Positionierinstrumenten in den Schenkelhals eingebracht. Der optimale Bereich für die Osteotomie wird aufgesucht. Für die Vereinfachung der Manipulation des distalen Fragments und als Referenz für die Derotation werden am Femurschaft weitere K-Drähte eingebracht. Nach Femurosteotomie erfolgt proximales Fixieren der Platte durch sukzessives Auswechseln der K-Drähte gegen winkelstabile Schrauben. Die interfragmentäre Kompression erzeugt eine exzentrisch positionierte Kortikalisschraube im mittleren distalen Plattenloch. Die weitere distale Fixation der Platte erfolgt mit winkelstabilen Schrauben. Auswechseln der Kortikalisschraube gegen eine weitere winkelstabile Schraube. Alternativ zur hier beschriebenen winkelstabilen Technik wurde früher meist mittels Winkelplatte korrigiert. Weiterbehandlung: Mobilisation unter Abrollbelastung an 2 Gehstöcken über 6 Wochen. Röntgenkontrolle und bei genügender Knochenkonsolidation Steigerung der Belastung. Implantatentfernung nach 9 bis 12 Monaten. Rückkehr zum Sport ab 3 Monaten. Ergebnisse: Die PVO ist eine in der Behandlung von LCPD nahezu seit 60 Jahren angewendete und weltweit etablierte chirurgische Technik. Durch ein stetig wachsendes Verständnis der Grunderkrankung wird einerseits die Indikationsstellung für operative Interventionen optimiert. Andererseits tragen neue Implantate zur Verbesserung der klinisch-radiologischen Resultate und Verringerung von Komplikationen während und nach Operation bei.
Zusammenfassung Operationsziel Die proximale femorale Varisationsosteotomie (PVO) ist eine chirur... more Zusammenfassung Operationsziel Die proximale femorale Varisationsosteotomie (PVO) ist eine chirurgische Technik zur Rezentrierung des Hüftkopfes, sofern es bspw. im Rahmen der ablaufenden Legg-Calvé-Perthes(LCPD)-Krankheit zur Subluxation gekommen ist. Indikationen Bis anhin existieren keine einheitlichen Indikationskriterien für die Containment-Therapie bei LCPD-Patienten. Einzelne, für die Deformitätsentwicklung prädiktive radiologische Faktoren, Alter bei Diagnosestellung oder Symptombeginn und Klassifikationen, welche die Pathomorphologie des Femurkopfes bezogen auf die Nekrose beschreiben, können die Indikationsstellung erleichtern. Kontraindikationen Die absolute Kontraindikation stellt die Entwicklung eines Scharniergelenkes dar (Hinge-Abduktion). Bleibt der Femurkopf in einer Abduktionsröntgenaufnahme von 20° auch in Abwesenheit einer Hinge-Abduktion dezentriert oder besteht ein Total-Kopf-Befall, ergibt sich ebenfalls eine Kontraindikation. Relativ kontraindiziert ist die P...
Background: Acute hematogenous osteomyelitis (OM) and septic arthritis require immediate diagnosi... more Background: Acute hematogenous osteomyelitis (OM) and septic arthritis require immediate diagnosis and treatment by an interdisciplinary team of pediatric infectious disease specialists and pediatric orthopedic surgeons. Adverse outcomes such as growth disturbance, bone deformity, and chronic infections have been described in older studies. However, there is only little known about long-term follow-up of patients of the last two decades. Therefore, we aimed to evaluate subjective and objective long-term outcomes of these children with osteoarticular infections treated in the millennial years.Methods: Cross-sectional study performed in two pediatric centers including patients admitted for OM and/or SA between 2005 and 2014 and follow-up consultations in 2019. Patients with symptoms of ≤2 weeks duration at initial presentation were contacted. Subjective outcomes were assessed by standardized interview, objective outcomes by clinical examination. Medical charts were used to extract dat...
ObjectiveTo report on a CT scan virtual periacetabular osteotomy (PAO) process to evaluate the po... more ObjectiveTo report on a CT scan virtual periacetabular osteotomy (PAO) process to evaluate the potential risk of different PAO cutting planes.MethodsA total of 123 patients (64 men and 59 women) underwent virtual PAO. We defined two retroacetabular cutting (RC) planes: the RC plane and the RC+ plane (10 mm posteriorly as compared to the RC plane). Subsequently, we measured the anatomical minimum distance between the acetabulum and the sciatic notch, the minimum distance between the acetabulum and the retroacetabular cutting plane (osteotomy of the posterior column), and the osteotomy length in the cranio‐caudal direction.ResultsThe mean (standard deviation [SD]) minimum distance between the acetabulum and the sciatic notch was 25.82 ± 3.52 mm (95% confidence intervals [CI], 25.36–26.25 mm). In men, the mean (SD) minimum distance between the acetabulum and sciatic notch (27.18 ± 3.47 mm; 95% CI, 26.56–27.78 mm) was significantly (3 mm) larger than in women (24.34 ± 2.92 mm; 95% CI, 2...
Aims The severe form of coxa vara, the ‘shepherd's crook deformity’, is always a consequence ... more Aims The severe form of coxa vara, the ‘shepherd's crook deformity’, is always a consequence of a locally extensive form of polyostotic fibrous dysplasia (or McCune-Albright syndrome). Treatment of this deformity is a challenge. The soft bone does not tolerate any implant that depends on the stability of the cortical bone (like plates or external fixators). Intramedullary nails are the most appropriate implants for stabilisation, but if they are inserted from the greater trochanter, they cannot correct the varus deformity enough. Patients and Methods We have developed a special intramedullary nail that can be inserted from the osteotomy site and can be driven retrograde into the femoral neck in an appropriate valgus position. We have operated 15 legs in 13 patients. The average age at surgery was 14 years and 5 months (6 to 28.9). In all, 11 femora had been operated before (unsuccessfully) with various implants. Results The average follow-up was 54.2 months (7 to 132). The avera...
Purpose The eight-plate system for angular deformity correction is well known, reliable and effec... more Purpose The eight-plate system for angular deformity correction is well known, reliable and effective at any age during growth. Due to high implant costs, we sought to evaluate the effectiveness and safety of a less expensive alternative. Methods Between 2006 and 2011, 41 children with angular deformities were managed using a two-hole one-third tubular plate in cases where an eight plate would normally be indicated. Inclusion criteria in this retrospective study were: genu valgum and genu varum. X-ray documentation was performed before and after surgery and patients were followed clinically every 3 months after surgery. The cost per implant was 361.40 Sfr (Swiss Francs) compared to the eight plate at 737 Sfr. Results Mean time for correction was 13 months. A mean LDFA/MPTA after correction of 89.9°/86.8° was recorded, as well as a mean correction angle of 6.8°/6.6°. The complication rate was 6.6 % (one superficial wound infection and one insufficient correction in an older child). T...
The Journal of Bone and Joint Surgery. British volume, 2009
Polyethylene wear of acetabular components is a key factor in the development of periprosthetic o... more Polyethylene wear of acetabular components is a key factor in the development of periprosthetic osteolysis and wear at the articular surface has been well documented and quantified, but fewer data are available about changes which occur at the backside of the liner. At revision surgery for loosening of the femoral component we retrieved 35 conventional modular acetabular liners of the same design. Linear and volumetric articular wear, backside volumetric change and the volume of the screw-head indentations were quantified. These volumes, clinical data and the results from radiological Ein Bild Röntgen Analyse migration analysis were used to identify potential factors influencing the volumetric articular wear and backside volumetric change. The rate of backside volumetric change was found to be 2.8% of the rate of volumetric articular wear and decreased with increasing liner size. Migrated acetabular components showed significantly higher rates of backside volumetric change plus scre...
Management of minimally displaced femoral neck fractures in paediatric patients with autosomal do... more Management of minimally displaced femoral neck fractures in paediatric patients with autosomal dominant osteopetrosis (ADO) remains unclear as only small numbers have been reported. There are no detailed reports on successful conservative treatment. Common causes of failure in this particular area include non-union and development of coxa vara. Although there are no quantitative studies, case reports have inXuenced most authors to recommend operative treatment. It is well recognised that operative treatment of osteopetrotic bone is challenging. Problems arise intraoperatively due to the bone hardness, and postoperatively due to altered biomechanics and defective remodelling. This case of a child with ADO who suVered two asynchronous compression-side stress fractures in the femoral neck demonstrates that non-operative management can be satisfactory. After 8 weeks with partial weight-bearing the fractures were stable. At the latest follow-up 2.5 and 4 years after the fractures the patient presented with an excellent clinical and radiological outcome. There was no development of coxa vara.
Synovial sarcoma is a rare and highly malignant soft tissue sarcoma. The inconspicuous and divers... more Synovial sarcoma is a rare and highly malignant soft tissue sarcoma. The inconspicuous and diversity of its early symptoms make it a highly misdiagnosed disease. The management of synovial sarcomas is challenging as they are rare and have a poor prognosis. Early and correct diagnosis and treatment are critical for clinical outcomes. Misdiagnosis or delayed diagnosis can have devastating consequences for the patient. The detection of SS18 gene rearrangement is considered a powerful tool in establishing the diagnosis of synovial sarcomas. Biopsies and testing for gene rearrangements are recommended for all patients in whom SS cannot be excluded. • Surgery is the mainstay of treatment for synovial sarcomas. Neoadjuvant/adjuvant radiotherapy is recommended for patients with big tumors (>5 cm) or positive resection margins, and neoadjuvant/adjuvant chemotherapy is recommended for patients with high-risk tumors or advanced diseases. • This article reviews synovial sarcomas from the perspectives of clinical and radiological presentation, histological and cytogenetic analysis, differential diagnosis, treatment, and prognosis.
Non-ossifying fibroma (NOF) is considered the most common benign and self-limiting lesion of the ... more Non-ossifying fibroma (NOF) is considered the most common benign and self-limiting lesion of the growing skeleton which occasionally results in pathologic fracture. In a sequencing analysis we have identified hotspot KRAS, FGFR1 and NF1 mutations in 48 of 59 patients (81.4%) with NOF harbouring allelic frequencies ranging from 0.04 to 0.61. Our findings thus define NOF as a genetically-driven neoplasm caused by activated MAP-kinase signalling in the majority of cases. Interestingly, this driving force either diminishes over time or at least is not sufficient to prevent autonomous regression and resolution. Beyond its contribution to a better understanding of the molecular pathogenesis underlying NOF, the data presented here add another benign lesion to the spectrum of KRAS-and MAP-kinase signalling-driven tumours.
Leg lengthening by external fixation is associated with various difficulties. We evaluated eight ... more Leg lengthening by external fixation is associated with various difficulties. We evaluated eight adolescent patients who underwent leg lengthening with a motorized intramedullary lengthening device. We asked whether this method could reduce the time of hospitalization and rehabilitation and whether the incidence of complications commonly associated with external fixators could be reduced. We compared our preliminary results with those from other reports, with a focus on leg length achieved, time of rehabilitation, and rate of complications. The average leg-length discrepancy was 3.8 cm (range, 3-5 cm). The average lengthening distance was 3.8 cm (range, 2.9-4.7 cm). In six patients, leg lengthening was combined with successful correction of the mechanical axis alignment. The consolidation index averaged 26 days/cm (range, 19-41 days/cm). The average hospital stay was 9.6 days. No bone or soft tissue infections were observed. In comparison to other studies (1.0-2.8 complications/ patient), our results suggest that the difficulties commonly associated with external fixators can be reduced with this method. It also allows good angular correction in patients with mechanical axis deviation. These features combined with a short time of hospitalization and rehabilitation make it a promising procedure for limb lengthening. Level of Evidence: Level IV Therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. Each author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained.
Background and purpose: The retrograde femoral approach is an established technique for implantat... more Background and purpose: The retrograde femoral approach is an established technique for implantation of nails for leg lengthening and correction and in cases of distal femoral fractures. The purpose of this study was to determine the 10-year outcome of this technique by analyzing the clinical long-term effects and radiological status of the knee after leg lengthening via a retrograde femoral approach.Patients and methods: This retrospective single-center study included 13 patients (median age at surgery 17 [range 15–20] years) who underwent unilateral, retrograde, femoral lengthening with a motorized nail. Outcome measurements were graded variables of the SF-36, ISKD score, and Lysholm score. MRI of both knees was performed in all patients. MRI was evaluated for the presence of degenerative changes and compared with the healthy contralateral knee. Cartilage condition was graded according to the International Cartilage Repair Society (ICRS) scoring system.Results: All patients were p...
Osteosarcomas are aggressive primary tumors of bone that are typically detected in locally advanc... more Osteosarcomas are aggressive primary tumors of bone that are typically detected in locally advanced stages; however, which genetic mutations drive the cancer before its clinical detection remain unknown. To identify these events, we performed longitudinal genome‐sequencing analysis of 12 patients with metastatic or refractory osteosarcoma. Phylogenetic and molecular clock analyses were carried out next to identify actionable mutations, and these were validated by integrating data from additional 153 osteosarcomas and pre‐existing functional evidence from mouse PDX models. We found that the earliest and thus clinically most promising mutations affect the cell cycle G1 transition, which is guarded by cyclins D3, E1, and cyclin‐dependent kinases 2, 4, and 6. Cell cycle G1 alterations originate no more than a year before the primary tumor is clinically detected and occur in >90% and 50% of patients of the discovery and validation cohorts, respectively. In comparison, other cancer dri...
Background Tumor-associated fibroblast growth factor 23 (FGF-23)-induced hypophosphatemic rickets... more Background Tumor-associated fibroblast growth factor 23 (FGF-23)-induced hypophosphatemic rickets is a rare but known pediatric entity first described in 1959. It results from local production of phosphatonins by benign and malignant mesenchymal tumors. Case-Diagnosis/Treatment We report an 8-year-old boy with tumor-associated hypophosphatemic rickets due to paraneoplastic FGF-23 secretion from a benign mesenchymal pelvic-bone tumor. Excessive FGF-23 production was visualized by immunohistochemistry in the resected tumor. Phosphate wasting stopped immediately after tumor resection. We reviewed 26 reports of pediatric patients with tumorinduced hypophosphatemic rickets; paraneoplastic FGF-23 secretion was documented in only three of them. All tumors developed inside bone, were benign in 21/26 cases, and were localized in femur/tibia (13/26), radius/ulna/humerus (7/26), pelvis (4/26), rib (1/26), and craniofacial (1/26) bones. Mean interval between onset of signs and/or symptoms and diagnosis was 34 months. Conclusions In patients with hypophosphatemic rickets acquired beyond infancy, radiologic investigations for bone tumors need to be performed rapidly. In contrast to biochemical screening for increased circulating FGF-23 levels, immunohistochemical confirmation of FGF-23 production in resected tumor tissue can be regarded as being well established.
Clinical Orthopaedics & Related Research, 2008
Leg lengthening by external fixation is associated with various difficulties. We evaluated eight ... more Leg lengthening by external fixation is associated with various difficulties. We evaluated eight adolescent patients who underwent leg lengthening with a motorized intramedullary lengthening device. We asked whether this method could reduce the time of hospitalization and rehabilitation and whether the incidence of complications commonly associated with external fixators could be reduced. We compared our preliminary results with those from other reports, with a focus on leg length achieved, time of rehabilitation, and rate of complications. The average leg-length discrepancy was 3.8 cm (range, 3-5 cm). The average lengthening distance was 3.8 cm (range, 2.9-4.7 cm). In six patients, leg lengthening was combined with successful correction of the mechanical axis alignment. The consolidation index averaged 26 days/cm (range, 19-41 days/cm). The average hospital stay was 9.6 days. No bone or soft tissue infections were observed. In comparison to other studies (1.0-2.8 complications/ patient), our results suggest that the difficulties commonly associated with external fixators can be reduced with this method. It also allows good angular correction in patients with mechanical axis deviation. These features combined with a short time of hospitalization and rehabilitation make it a promising procedure for limb lengthening. Level of Evidence: Level IV Therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. Each author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained.
Unlike external fixators, the use of solid intramedullary lengthening nails is restricted to defi... more Unlike external fixators, the use of solid intramedullary lengthening nails is restricted to defined anatomical preconditions, such as an adequate bone length. Furthermore, all deformity corrections except the lengthening procedure have to be implemented intraoperatively and cannot be adjusted postoperatively. Conversely, even complex deformity corrections can be performed using intramedullary devices after a thorough preoperative planning. For preparation of the intramedullary cavity as well as positioning of the lengthening nail according to the preoperative planning, reaming the medullary canal with rigid reamers which don't follow the line of least resistance is inevitable. However, the application of solid lengthening nails might be limited, especially in children with ongoing epiphyseal growth, although a central perforation of the growth plate was shown to have no adverse effects on the growth potential. In cases with complex or multilevel deformities, an additional osteo...
We analyze the delay in diagnosis and tumor size of malignant bone tumors of the foot in a retros... more We analyze the delay in diagnosis and tumor size of malignant bone tumors of the foot in a retrospective study. We compared the oncological and surgical long-term results with identical tumor at other anatomical sites in order to analyze the biological behavior of sarcomas that are found in the foot. Thirty-two patients with a histologically proven malignant bone tumor (fifteen chondrosarcomas, nine osteosarcomas, and eight Ewing sarcomas) between the years 1969 and 2008 were included. The median follow-up was 11.9 years. The overall median time gap between the beginning of symptoms and diagnosis in the study group was 10 months. Ewing sarcoma presented with the longest delay in diagnosis (median of 18 months), followed by osteosarcoma (median of 15 months) and chondrosarcoma (median of 7.5 months). The delay in diagnosis of these tumors was significantly longer than that of equivalent tumors at other skeletal sites, but the 5-and 10-year survival rates and the occurrence of distant metastases were comparable. In contrast, the average size of foot tumors was 5-to 30-fold less than that of tumors analyzed at other skeletal sites. This study indicates that sarcomas of the foot demonstrate a distinct biological behavior compared to the same tumor types at other skeletal sites.
Background and purpose In the last decade, intramedullary limb lengthening has become a viable al... more Background and purpose In the last decade, intramedullary limb lengthening has become a viable alternative to traditional external systems. We retrospectively analyzed the use of an intramedullary motorized nail (Fitbone) in a consecutive series of 32 patients. Patients and methods During the period September 2006 to December 2008, 32 consecutive patients with a median age of 17 (IQR: 15-19) years were treated with a fully implantable, motorized intramedullary lengthening device (Fitbone). The median leg length discrepancy was 35 (IQR: 30-44) mm at the femur (n = 21) and 28 (IQR: 25-30) mm at the tibia (n = 11). Results Leg lengthening was successful in 30 of 32 cases, with no residual relevant discrepancy (± 5 mm). No intraoperative complications were observed. The consolidation index was significantly different (p = 0.04) between femoral lengthening (mean 35 days/cm) and tibial lengthening (mean 48 days/cm) but did not depend on age older/younger than 16 or previous operations at the affected site. 3 problems, 3 obstacles, and 4 complications (3 minor, 1 major) were encountered in 8 patients, 5 of which were implant-associated. Interpretation This technique even allows correction in patients with multiplanar deformities. Compared to external devices, intramedullary systems provide comfort and reduce complication rates, give improved cosmetic results, and lead to fast rehabilitation since percutaneous, transmuscular fixation is prevented. This results in reasonable overall treatment costs despite the relatively high costs of implants.
Congenital pseudarthrosis of forearm fractures is rare and is strongly associated with neurofibro... more Congenital pseudarthrosis of forearm fractures is rare and is strongly associated with neurofibromatosis type 1 (NF1). Our case report illustrates the progression of a non-union of the ulna after minor trauma in a twelve-year-old boy, newly diagnosed with NF1, and presents the technique of microsurgical bone reconstruction, including the growth plate. More than seven years after the first operation, follow-up presents a favorable outcome with a pain-free patient and unrestricted function of the forearm after a secondary correction of the remaining radial bowing. This treatment is discussed with a comprehensive review of the current literature on ulnar congenital pseudarthrosis in PubMed and Google Scholar and free fibular growth plate transfer in PubMed and Google Scholar. Nine publications reporting on 20 cases of congenital ulnar non-unions were identified. With this reconstructive option, favorable outcomes were achieved in all cases with the union after primary surgery and compl...
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Papers by Andreas Krieg