Christoph Böhler

Rheumatoid arthritis and falls: the influence of disease activity

OBJECTIVE To examine the correlation between disease activity of RA and the risk of falling. METHODS Seventy-eight patients were tested. Disease activity was measured with acute-phase reactants, autoantibodies, swollen and tender joint count (SJC28, TJC28), pain on a visual analogue scale (VAS pain), patient and evaluator global assessment of disease activity (PGA, EGA), HAQ disability index (HAQ-DI), 28-joint DAS (DAS-28) and the clinical and simple disease activity indexes (CDAI, SDAI). The risk of falling was evaluated by a fall assessment consisting of Tinetti test (TIT), timed get up and go test (TUG), chair-rising test (CRT), tandem walk and tandem stand test. RESULTS During the last 12 months, 26.9% of the participants reported a fall and 46.2% mentioned the fear of falling. The most evident link [Spearmans correlation (r(s))] with the results of the fall assessment was found in HAQ-DI (CRT: r(s) = 0.523, TUG: r(s) = 0.620, TIT: r(s) = -0.676), CDAI (CRT: r(s) = 0.460, TUG: r(s) = 0.504, TIT: r(s) = -0.472), VAS pain (CRT: r(s) = 0.441, TUG: r(s) = 0.616, TIT: r(s) = -0.548) PGA (CRT: r(s) = 0.473, TUG: r(s) = 0.577, TIT: r(s) = -0.520) and TJC (CRT: r(s) = 0.488, TUG: r(s) = 0.394, TIT: r(s) = -0.385). Patients with higher disease activity achieved poorer results in the fall assessment. CONCLUSION The strongest correlation with falls was evident for patient-reported outcomes. Pain seems to be the common ground of these parameters. At the same time, disease activity influences pain. The results suggest an increased attention towards the risk of falling with patients of higher levels of disease activity or pain, and physio- or ergotherapeutical interventions as needed.

Qualitative α-defensin test (Synovasure) for the diagnosis of periprosthetic infection in revision total joint arthroplasty

Aims The diagnosis of periprosthetic joint infection (PJI) remains demanding due to limitations of all the available diagnostic tests. The synovial fluid marker, &agr;‐defensin, is a promising adjunct for the assessment of potential PJI. The purpose of this study was to investigate the qualitative assessment of &agr;‐defensin, using Synovasure to detect or exclude periprosthetic infection in total joint arthroplasty. Patients and Methods We studied 50 patients (28 women, 22 men, mean age 65 years; 20 to 89) with a clinical indication for revision arthroplasty who met the inclusion criteria of this prospective diagnostic study. The presence of &agr;‐defensin was determined using the qualitative Synovasure test and compared with standard diagnostic methods for PJI. Based on modified Musculoskeletal Infection Society (MSIS) criteria, 13 cases were categorised as septic and 36 as aseptic revisions. One test was inconclusive. Results The Synovasure test achieved a sensitivity of 69% and a specificity of 94%. The positive and negative likelihood ratios were 12.46 and 0.33, respectively. A good diagnostic accuracy for PJI, with an area under the curve of 0.82, was demonstrated. Adjusted p‐values using the method of Hochberg showed that Synovasure is as good at diagnosing PJI as histology (p = 0.0042) and bacteriology with one positive culture (p = 0.0327). Conclusion With its ease of use and rapid results after approximately ten minutes, Synovasure may be a useful adjunct in the diagnosis of PJI.

Serological changes in the course of traditional and biological disease modifying therapy of rheumatoid arthritis

Objective To investigate changes of rheumatoid factor (RF) and antibodies against citrullinated peptides (ACPA) during therapy with disease modifying antirheumatic drugs. Methods We obtained clinical and serological data of patients from the treatment start and after 6 months of therapy. With non-parametric tests, we analysed changes of ACPA and RF levels between the two visits and the influence of treatment response. Furthermore, we analysed potential influential factors as disease chronicity, different therapeutics and the trend over 18 months. Results 143 ACPA and RF positive patients were included. The median (25th/75th percentile) relative changes after 6 months were −35.6% (−63.3; −8.3) for RF and −15.2% (−40.0; 10.0) for ACPA (p<0.001 for both). Changes of RF levels were significantly greater than those seen for ACPA (p<0.001). The decrease of ACPA and RF was significantly higher in treatment responders (p=0.034 and p=0.01, respectively). Aside from changes in disease activity, only a short disease duration showed an independent effect on changes of RF levels (p=0.087). Conclusions ACPA and RF levels decreased significantly after 6 months of therapy. Reductions of both autoantibodies were closely linked to a reduction of disease activity. RF declined faster, to a larger extent and in greater numbers of patients than ACPA.

Outcome after Reconstruction of the Proximal Tibia--Complications and Competing Risk Analysis.

Background and Objectives The proximal tibia (pT) is a common site for bone tumors. Improvements in imaging, chemotherapy and surgical technique made limb salvage surgery the treatment of choice. Yet, reconstructions of the pT have been associated with less favorable outcome compared to other parts of the extremities. The aim of this study was to evaluate the outcome of patients with a modular endoprosthetic reconstruction of the pT. Methods Eighty-one consecutive patients with an average age of 29 years underwent endoprosthetic reconstruction of the pT. Postoperative complications were categorized according to the ISOLS classification, and revision-free survival until first complication (any Type 1–5), soft tissue failure (Type 1), aseptic loosening (Type 2), structural failure (Type 3), infection (Type 4), and local tumor progression (Type 5) was estimated by using a Fine-Gray model for competing risk analyses for univariate and multivariable regression with Firth’s bias correction. Results A total of 45 patients (56%) had at least one complication. Cumulative incidence for complication Types 1 to 5 at 5 years with death and amputation as competing events revealed a risk of 41% for the first complication, 14% for Type 1, 16% for Type 2, 11% for Type 3, 17% for Type 4, and 1% for Type 5. Conclusion Despite inclusion of amputation and death as strong competing events, pT replacements are still associated with a high risk of postoperative failures. The results suggest that infection and soft tissue failures (Type 1 and 5) seem to depend from each other. Sufficient soft tissue reconstruction and closure allow better function and reduce the risk of infection as the most prominent complication. The use of a rotating hinge design has significantly reduced structural failures over time.

Oncological and surgical outcome after treatment of pelvic sarcomas

Background and objectives Treatment of pelvic tumors remains challenging due to complex anatomy, poor oncological outcome and high complication rates. We sought to investigate the long-term oncological and surgical outcome of these patients. Methods Between 1980 and 2012, 147 patients underwent surgical treatment for pelvic sarcoma. Histological diagnosis was Chondrosarcoma in 54, Ewing’s Sarcoma/PNET in 37, Osterosarcoma in 32 and others in 24 patients. Statistical analysis for the evaluation of oncological and surgical outcome was performed by applying Cox proportional hazards regression and Fine-Gray regression models for competing risk (CR) endpoints. Results The estimated overall survival (OS) to death was 80%, 45% and 37% at 1, 5 and 10 years, respectively. Univariate analyses revealed a statistically significant unadjusted influence of age age (p = 0.038; HR = 1.01), margin (p = 0.043; HR = 0.51) and grade (p = 0.001; HR = 2.27) on OS. Considering the multivariable model, grade (p = 0.005; HR = 3.04) and tumor volume (p = 0.014; HR = 1.18) presented themselves as independent prognostic factors on OS. CR analysis showed a cumulative incidence for major complication of 31% at 5 years. Endoprosthetic reconstruction had a higher risk for experiencing a major complication (p<0.0001) and infection (p = 0.001). Conclusions Pelvic resections are still associated with a high incidence of complications. Patients with pelvic reconstruction and high volume tumors are especially at risk. Consequently, a cautious decision-making process is necessary when indicating pelvic reconstruction, although a restrictive approach to pelvic reconstruction is not necessarily reasonable when the other option is major amputation.

Sonication culture improves microbiological diagnosis of modular megaprostheses.

Modular megaprostheses are known for high infection rates followed by high rates of revisions. Microbial biofilms growing adherently on prosthetic surfaces may inhibit the detection of the pathogens causing prosthetic joint infections. We sought to answer the following questions: Does sonication culture (SC) improve the microbiological diagnosis of periprosthetic infections of megaprostheses compared to conventional tissue culture (TC)? Which pathogens were detected on the surface of megaprostheses with either SC or TC and do the findings help to identify low‐grade infections? Included were 31 patients with modular megaprostheses, whose implant had been explanted due to suspected joint infection or revision surgery. SCs were performed according to the protocol by Trampuz et al. The diagnosis of infection was evaluated according to the definition of the Musculoskeletal Infection Society. The sensitivity of SC was 91.3% compared to 52.2% for TC and the specificity was 100% for SC and TC (p = 0.004). Under preoperative antibiotic therapy, the sensitivity of SC was 83.3% while the sensitivity of TC was 50%. Without preoperative antibiotic therapy the sensitivity of SC was 100% compared to 54.5% for TC. In nine cases, SCs detected microorganisms, while TC was negative. Detected bacteria were Staphylococcus epidermidis in four, Micrococcus species in one, Finegoldia magna in one, Brevibacterium casei in one, Pseudomonas fluorescens in one, and Enterococcus faecium in one. SC is a reliable method for dislodging pathogens from orthopedic implants. The SC of modular megaprostheses showed significantly higher pathogen detection than the periprosthetic TC, especially for low virulence pathogens.

Midterm Results of a New Rotating Hinge Knee Implant: A 5-Year Follow-Up

Background In the current study, we investigated midterm results of a new rotating hinge total knee arthroplasty (EnduRo prosthesis), which uses a new bearing material (CFR PEEK). Methods We prospectively analysed data of 50 patients with a minimum follow-up of 5 years. In 24 (48%) patients, a primary implantation was performed and 26 (52%) were revision cases. Clinical and radiographic examinations were performed preoperatively as well as postoperatively after 3 and 12 months and annually thereafter. The Knee Society Score (KSS), WOMAC, Oxford Knee Score (OKS), and range of motion (ROM) were used for clinical assessment. Results KSS, WOMAC, OKS, and ROM significantly improved between the preoperative and the follow-up investigations. The overall survival rate with revision for any reason as an endpoint was 77.9% after five years. The number of complications was significantly higher in the revision group (p = 0.003). Conclusion The EnduRo prosthesis provides highly satisfying clinical and functional results in severe primary as well as in revision cases. Implant-associated complications were rare. However, in cases of revision surgery, the risk for complications was considerably high, mostly related to previous joint infections and poor soft tissue quality.

Surgical and Functional Outcome after Endoprosthetic Reconstruction in Patients with Osteosarcoma of the Humerus

Endoprosthetic reconstruction (EPR) is the most widely used reconstruction technique after humeral osteosarcoma (OSA). Complications are common and function is often compromised due to the premise of wide resection. In the current study we evaluated (1) the risk of complications after resection and EPR; (2) the functional outcome and how it is influenced by the preservation/resection of deltoid muscle (DM), rotator cuff (RC), axillary nerve or the type of resection (intra-/extraarticular) and (3) if the preservation/resection of DM, RC, axillary nerve or the type of resection has a negative influence on the oncological outcome. We retrospectively evaluated data of 49 patients with humeral OSA. All patients underwent resection and EPR. Complication-free survival according to the ISOLS classification was estimated by a competing risk model. Functional outcome was evaluated by range of motion (ROM) in abduction and the MSTS score. Eleven patients (22%) had at least one complication. The estimated cumulative incidence for the first complication was 18% at one year, 23% at five years, and 28% at ten years, respectively. Soft tissue failure was the most common complication. ROM and MSTS scores were significantly higher in patients where DM and RC (p = 0.043/p = 0.046) and axillary nerve (p = 0.014/p = 0.021) could be preserved. Preservation of these structures had no negative influence on the surgical margins. In conclusion, EPR is a good treatment method with an acceptable complication rate. Preservation of the abductor mechanism, when possible in the setting of obtaining negative margins, provides superior functional outcome.

Surgical treatment of shoulder infections: a comparison between arthroscopy and arthrotomy

BACKGROUND Management of bacterial shoulder infections includes antibiotic therapy and surgical joint decompression. Arthroscopy and open arthrotomy are recommended treatment options. Whether 1 of the 2 surgical options is superior remains unclear. The present study aimed (1) to compare the reinfection rates after arthroscopy and open arthrotomy and (2) to identify risk factors of reinfection after surgical intervention. MATERIALS AND METHODS The data of 59 consecutive patients were available for final analysis. All patients received arthroscopy or open arthrotomy at our institution between 2001 and 2015. The reinfection rates between the 2 distinct interventions were compared. We also evaluated the influence of potential confounders, such as age, sex, comorbidities, microbiological findings, duration of symptoms, osteoarthritis, Gächter score, and preoperative inflammatory parameters, on the recurrence of infections and compared the functional outcome between the 2 surgery groups. RESULTS From 59 included patients, 38 (64.4%) underwent open arthrotomy, and 21 (35.6%) were treated arthroscopically. Reinfection was documented in 18 patients (30.5%). The reinfection rate was significantly higher in arthroscopically treated patients (11 [52.4%]) than in patients who underwent open arthrotomy (7 [18.4%]; P = .007). An infection with Staphylococcus aureus negatively influenced the treatment success (P = .034). CONCLUSION According to our data, open arthrotomy is the more effective treatment method in septic arthritis of the shoulder, with lower reinfection rates and a comparable functional outcome. Furthermore, we could identify Staphylococcus aureus as an independent risk factor for the recurrence of infections.