Klemens Trieb

Prevalence of aneurysmal and solitary bone cysts in young patients.

Aneurysmal and solitary bone cysts develop most commonly during skeletal growth. The objective of our epidemiologic study was to evaluate the prevalence, recurrence rate, and probability of recurrence-free survival for aneurysmal and solitary bone cysts in young patients. We did a population-based analysis of 141 histologically confirmed cases. Seventy-three patients with aneurysmal bone cysts and 68 patients with solitary bone cysts were registered. The annual prevalence was 0.32 per 100,000 individuals (range, 0-1.238) for aneurysmal cysts, with a 1.8:1 male to female ratio and a median age of the patients of 11.1 years (range, 1-19.7 years). For solitary bone cysts, the calculated annual prevalence was 0.30 (range, 0-0.963) with a median age of the patients of 1.1 years (range, 0.5-19.9) and a 1.96:1 male to female ratio. Recurrent lesions occurred frequently in young males. Secondary aneurysmal bone cysts were observed only in females. During skeletal growth, aneurysmal and juvenile bone cysts more often occur in males with a peak prevalence at approximately 11 years of age. A greater prevalence of aneurysmal bone cysts in young individuals is associated with skeletal growth and immaturity. Young age and male gender are associated with an increased risk of local recurrence.

What affects the recurrence and clinical outcome of pigmented villonodular synovitis

Studies investigating the outcome of pigmented villonodular synovitis have been restricted to certain locations or types of the disease and have not provided adequate documentation of followup. We asked the following questions: What were the recurrence rates especially when considering location and type of pigmented villonodular synovitis?; What was the long-term clinical outcome?; and Was MR imaging essential for the correct diagnosis? We retrospectively reviewed 42 of 53 consecutive patients primarily treated at our institution (19 diffuse lesions and 23 nodular lesions in 19 large joints and 23 digits of the hands or feet). Ten patients had recurrences after an average followup of 80 months (range, 26-293.8 months). Recurrences were more frequent for the diffuse type than the nodular type and in large joints rather than in digits. The average Enneking score was 92% of normal limb function indicating that surgical treatment led to good functional results. Preoperative magnetic resonance imaging results corresponded well with histologic diagnoses and intraoperative findings.Level of Evidence: Therapeutic Level IV. See the Guidelines for Authors for a complete description of levels of evidence.

Reconstructing the extensor apparatus with a new polyester ligament

We analyzed the clinical outcome of patients who had reconstruction of the extensor apparatus with a new polyester ligament after extensive resection of malignant tumors around the knee. Twenty-two patients were included; 19 were evaluated after a mean followup of 44 months (range, 8-67 months) to assess active and passive knee range of motion, walking ability, need for revision, and TESS and Enneking scores. The patients were divided into two groups; patients in Group A had a weakened extensor mechanism and patients in Group B had a completely dissected extensor mechanism. Seven patients had excellent knee function with an extension lag less than 5°. Five patients had an extension deficit less than 20°, three patients had a deficit less than 40°, and four patients could not extend their limb against gravity. However, all patients were able to walk without walking aids. They had a mean Enneking score of 83 points and a mean TESS score of 82 points. Patients who had distal femur resections had worse results than patients who had proximal tibia resections. The LARS® ligament proved promising for augmentation and complete reconstruction of the extensor apparatus of the knee after extensive tumor resection, with excellent and good results in 59% of patients.Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Evaluation of HLA-DR expression and T-lymphocyte infiltration in osteosarcoma.

Although in recent years the outcome of patients with osteosarcoma has considerably been improved by combining neoadjuvant chemotherapy with radical surgery, there still remains the problem of nonresponse to chemotherapy. T-lymphocytes play a critical role in tumor immunology, and MHC molecules are of central importance in the regulation of the immune response. It is the aim of this study to investigate whether T-lymphocyte infiltration of osteosarcomas and HLA-DR expression on tumor cells and infiltrating immune cells are of predictive or diagnostic value. Expression of CD3, CD8 and HLA-II was evaluated immunohistochemically on paraffin-embedded sections of 35 patients with high-grade osteosarcoma at the time of biopsy before chemotherapy and correlated with histologic response to chemotherapy, tumor size, age, alkaline-phosphatase serum levels and duration of symptoms. Thirty-four patients with osteoblastoma (n = 7), osteoid osteoma (n = 7) or fibrous dysplasia (n = 20) served as controls. Osteosarcomas were infiltrated by CD3+ (33/35, 95%) and CD8+ T-lymphocytes (24/35, 68%), non malignant bone tumors by CD3+ in 91% (31/34) and CD8+ T-lymphocytes in 74% (25/34), respectively. T-lymphocytes were positive for HLA-DR expression in 29% (10/35) in osteosarcomas and in 11% (4/34) in non-malignant controls. Osteosarcoma cells were positive for HLA-DR in 11/35 (31%) and non-malignant tumor cells in only 9% (3/34). Therefore, HLA-DR is overexpressed in osteosarcoma (p < 0.05). HLA-DR expression on osteosarcoma cells showed a positive correlation with HLA-DR expression on lymphocytes (p < 0.001) as well as with duration of symptoms and age (p < 0.05). Response to preoperative chemotherapy, gender, tumor size and serum alkaline-phosphatase levels did not correlate with the expression of the molecules tested. Our results show that HLA-DR is overexpressed in osteosarcoma cells compared to non-malignant bone-tumors. This overexpression, however, fails to serve as a predictive marker for response to neoadjuvant chemotherapy. The same is also true for tumor-infiltrating lymphocytes expressing CD3, CD8 and HLA-DR. Increased HLA-DR expression in osteosarcoma is most likely due to the immune response against the tumor.

Microarray analysis identifies distinct gene expression profiles associated with histological subtype in human osteosarcoma

Osteosarcoma is the most common primary malignant bone tumour. Currently osteosarcoma classification is based on histological appearance. It was the aim of this study to use a more systematic approach to osteosarcoma classification based on gene expression analysis and to identify subtype specific differentially expressed genes. We analysed the global gene expression profiles of ten osteosarcoma samples using Affymetrix U133A arrays (five osteoblastic and five non-osteoblastic osteosarcoma patients). Differential gene expression analysis yielded 75 genes up-regulated and 97 genes down-regulated in osteoblastic versus non-osteoblastic osteosarcoma samples, respectively. These included genes involved in cell growth, chemotherapy resistance, angiogenesis, steroid- and neuropeptide hormone receptor activity, acute-phase response and serotonin receptor activity and members of the Wnt/ß-catenin pathway and many others. Furthermore, we validated the highly differential expression of six genes including angiopoietin 1, IGFBP3, ferredoxin 1, BMP, decorin, and fibulin 1 in osteoblastic osteosarcoma relative to non-osteoblastic osteosarcoma. Our results show the utility of gene expression analysis to study osteosarcoma subtypes, and we identified several genes that may play a role as potential therapeutic targets in the future.

Outcome of Total Knee Arthroplasty in Hemophilic Arthropathy

The clinical histories of 45 consecutively performed TKAs in 32 patients with hereditary bleeding disorders were reviewed retrospectively. The mean follow up was 88.7 (range, 24-232) months. The cumulative probability of infection free-survival was 87.8% after 180 months. When removal of component was defined as endpoint, the survival probability was 86.4% after 180 months. In regression analysis no significant independent risk factors for infection or aseptic loosening were identified. The HSS score improved significantly from 45 to 85 points. Hemophilic patients can be considered to be at high risk for prosthetic failure, our study has demonstrated favorable functional results of total knee arthroplasty in hemophilic patients.

Location modalities for focused extracorporeal shock wave application in the treatment of chronic plantar fasciitis.

Background: Focused extracorporeal shock waves (ESWT) has been used in the treatment of plantar fasciitis with heel spurs. The optimal location for administering treatment, however, has not been determined. The purpose of this study was to determine whether fluoroscopy-guided location of a heel spur or patient location of the maximal point of tenderness is more effective in administering ESWT. Methods: In a prospective, examiner-blinded trial, 41 patients were randomized into two groups for treatment by ESWT: group 1, location of the heel spur for ESWT by fluoroscopy, and group 2, patient location for ESWT by maximal point of tenderness. Each group had three session of ESWT at 1-week intervals. The success rates between the two groups were assessed at 6 and 12 weeks. Results: No significant differences were noted between the groups. Conclusions: Despite the small number of patients in the study, patient location for positioning the focus in ESWT in treatment of plantar fasciitis with a heel spur is recommended.

Surgical treatment of the haemophilic pseudotumour: A single centre experience

PurposeHaemophilic pseudotumour was defined by Fernandez de Valderrama and Matthews as a progressive cystic swelling involving muscle, produced by recurrent haemorrhage into muscles adjacent to the bone. The pseudotumour mainly occurs in the long bones and the pelvis. The treatment of the haemophilic pseudotumour poses a challenge, and extensive clinical experience is essential to appropriately address this serious complication in patients with haemophilia. Consequently, the aim of this study is to present our own clinical experience and treatment results of the haemophilic pseudotumour.MethodsWe retrospectively reviewed the records of 87 patients with bleeding disorders treated between 1967 and 2011 for musculoskeletal complications of congenital bleeding disorders. We identified six patients with a haemophilic pseudotumour who were treated at our department.ResultsThe mean age at surgery was 45.9 (range, 40–61) years. The iliac bone was affected in three patients (one right, two left), the right tibia (distal diaphysis) in one, the right thigh in two and the right ulna (proximal part) in one patient. One patient had two pseudotumours. The perioperative course was easily controllable with adequate factor VIII substitution. At the latest follow-up after 8.4 (range, 4–24) years, normal healing with no recurrence was observed.ConclusionsThe haemophilic pseudotumour is a rare but severe complication of hereditary bleeding disorders. In the international literature the resection and postoperative course are described as challenging and difficult, requiring detailed preoperative planning. It is advisable to perform such operations in specialised centres with close co-operation between surgeons and haematologists.

The Weil osteotomy for correction of the severe rheumatoid forefoot

PurposeIn rheumatoid arthritis the metatarsophalangeal (MTP) joints are predominantly affected with resultant metatarsalgia and dislocation. Therapy options include many different surgical procedures with results that are not always satisfying. We present the oblique Weil metatarsal osteotomy as a treatment option for the rheumatic forefoot.MethodsA total of 216 osteotomies in 63 consecutive patients (72xa0feet) with a mean age at the time of surgery of 59.3xa0years and long-standing rheumatoid arthritis were observed prospectively for an average of 57.4xa0months (minimum 36xa0months). All patients received a Weil osteotomy of the lesser metatarsals with at least one additional procedure of the forefoot. Patients were evaluated prospectively for clinical outcome by the American Orthopaedic Foot and Ankle Society (AOFAS) lesser MTP-interphalangeal scale and subjective satisfaction. In the radiological evaluation weight-bearing X-rays were analysed for alignment, shortening and union.ResultsAmerican Orthopaedic Foot and Ankle Society score increased significantly from 21.9u2009±u20096.7 to 63.3u2009±u20099.8 (pu2009<u20090.05). The increase was significant for all subgroups regarding pain, function and alignment. All joints were dorsally dislocated preoperatively; a subluxation was present in 13.6xa0% at follow-up. There was a significant decrease of callositas in 82xa0%, a decrease in need for orthopaedic shoes in 61xa0%, a decrease of MTP joint stiffness in 96xa0% and a relief of severe pain in 97xa0% of all patients. No metatarsal head dislocation or necrosis, pseudoarthrosis or screw perforation was observed. Of 63 patients, 55 (88xa0%) subjectively reported excellent or good results.ConclusionsWe conclude that the Weil procedure for lesser metatarsals is a satisfactory method for correcting the rheumatic forefoot and can be recommended as an approach for the future.

Comparison of metal on metal versus polyethylene–ceramic bearing in uncemented total hip arthroplasty in patients with haemophilic arthropathy

PurposeWe report the results of a consecutive series of 12 cases with haemophilic hip arthropathy treated with uncemented total hip arthroplasty (THA). Our hypothesis was that THA results in the haemophilic group would be inferior to those in the nonhaemophilic group.MethodsThe clinical histories of 12 consecutive THAs in eight patients (all men) with hereditary bleeding disorders (haemophilia A and B and von Willebrand disease) were reviewed retrospectively. The results were compared with an age- and sex-matched control group without haemophilia, with special emphasis on bearing surfaces (Metasul metal-on-metal; polyethylene–ceramic articulation).ResultsThe mean follow-up of the control group was 9.7 (range five to 24) years and was similar to the haemophilia group, with 10.4. Survival in the Metasul haemophilic group was 22.2xa0% after 18xa0years, which significantly differed from the Metasul control group (100xa0% after 24xa0years). Survival of the polyethylene–ceramic haemophilic group was similar to the control group (100xa0% after seven years in both groups).ConclusionsThe metal-on-metal bearing surface in patients with haemophilia gave inferior results compared with nonhaemophilic patients. The use of metal-on-metal bearings in haemophilia is debatable.