Peter Michael Prodinger

Nontraumatic Subluxation of the Atlanto-Axial Joint as Rare Form of Aquired Torticollis: Diagnosis and Clinical Features of the Griselʼs Syndrome

Study Design. Case report and review of the literature. Objective. We report a case of Grisels syndrom with a delayed diagnosis. The patients first presentation in our pediatric orthopedics department was 2 month after surgery (cochlea implantation) with a persistent torticollis. Radiographs revealed a subluxated atlantoaxial joint. We treated our patient with manual repositioning and calculated antibiotics, which lead to a restitutio ad integrum within a short time. Summary of Background Data. Grisels syndrome is synonymous with rare nontraumatic, rotational subluxation of the atlantoaxial joint (C1–C2). All formerly reported cases showed a clear association to infection or were related to head and neck surgery. Still, there is a lack of understanding about pathogenetic features and causative agents. In 1977 Fielding proposed a classification of the atlantoaxial subluxation and stage-related therapy was recommended. Methods. Our patient was a 11-year-old girl with a torticollis after insertion of a cochlea implant. After surgery, physiotherapy was performed because of her wryneck. As the symptoms did not improve, she was presented in our clinic. Our radiographs revealed a subluxated atlantoaxial joint. Results. In general anesthesia we performed a manual repositioning and she was temporarily immobilized with a cervical collar for 2 weeks. In addition, we administered calculated antibiotics, although CRP and leukocytes were not elevated. The follow up showed a good repositioning within a short time. Conclusion. At least in this case, our treatment led to shorter recovery and avoidance of halo fixation. Our new therapeutic approach to patients with Grisels syndrome might lead to a shorter recovery.

Can Bone Tissue Engineering Contribute to Therapy Concepts after Resection of Musculoskeletal Sarcoma

Resection of musculoskeletal sarcoma can result in large bone defects where regeneration is needed in a quantity far beyond the normal potential of self-healing. In many cases, these defects exhibit a limited intrinsic regenerative potential due to an adjuvant therapeutic regimen, seroma, or infection. Therefore, reconstruction of these defects is still one of the most demanding procedures in orthopaedic surgery. The constraints of common treatment strategies have triggered a need for new therapeutic concepts to design and engineer unparalleled structural and functioning bone grafts. To satisfy the need for long-term repair and good clinical outcome, a paradigm shift is needed from methods to replace tissues with inert medical devices to more biological approaches that focus on the repair and reconstruction of tissue structure and function. It is within this context that the field of bone tissue engineering can offer solutions to be implemented into surgical therapy concepts after resection of bone and soft tissue sarcoma. In this paper we will discuss the implementation of tissue engineering concepts into the clinical field of orthopaedic oncology.

Diagnostik und Therapie von Wirbelsäulenmetastasen

Out of all skeletal metastases 30% are located in the spine as are 10% of primary bone tumors, whereby 52% of metastases occur in the lumbar region, 36% in the thoracic spine and 12% in the cervical spine. Patients suffer from local pain caused by irritation of the periosteum due to rapid growth of the tumor or subsequent pathologic fractures which may lead to compression and neurological impairment with paresthesia, paresis and paraplegia. If the diagnosis cannot be confirmed exactly by radiological imaging and laboratory tests, a biopsy should be performed. A precise diagnosis of the tumor entity as well as an estimation of the prognosis provides an important basis for further decision-making. The aim of therapy is pain relief and stabilization by operative and non-operative measures. Therapy is palliative with the aim of pain relief and preservation of mobility. In cases of solitary metastasis a curative operative treatment should be performed.

Diagnostics and therapy of spinal metastases

Out of all skeletal metastases 30% are located in the spine as are 10% of primary bone tumors, whereby 52% of metastases occur in the lumbar region, 36% in the thoracic spine and 12% in the cervical spine. Patients suffer from local pain caused by irritation of the periosteum due to rapid growth of the tumor or subsequent pathologic fractures which may lead to compression and neurological impairment with paresthesia, paresis and paraplegia. If the diagnosis cannot be confirmed exactly by radiological imaging and laboratory tests, a biopsy should be performed. A precise diagnosis of the tumor entity as well as an estimation of the prognosis provides an important basis for further decision-making. The aim of therapy is pain relief and stabilization by operative and non-operative measures. Therapy is palliative with the aim of pain relief and preservation of mobility. In cases of solitary metastasis a curative operative treatment should be performed.

Total hip replacement in developmental dysplasia using an oval-shaped cementless press-fit cup

PurposeAcetabular roof deficiency due to subluxation of the femoral head (Hartofilakidis type II) increases the complexity of total hip arthroplasty. In these cases some form of support is usually required, to reach stable fixation of the acetabular component. Pursuing this aim, the oval-shaped cementless cranial socket could be an alternative to conventional treatment options.MethodsBetween 1998 and 2008, 37 patients (40 hips) underwent primary total hip arthroplasty using the cranial socket (mean follow-up 5.6 years, range 26 to 133 months). In a retrospective study we compared these clinical and radiological results with the results of a matched control group consisting of 35 patients (40 hips) treated with a standard cementless hemispherical cup in combination with bulk femoral autografting (mean follow-up 6.9 years, range 30 to 151 months).ResultsThere were no statistically significant differences in the HHS (p = 0.205) or the SF-36 (p = 0.26) between both groups. There was no prosthesis failure due to septic or aseptic loosening. Time of surgery was significantly shorter in the cranial socket group (p < 0.001). The acetabular component could be placed in the ideal rotational hip centre in 24 (60%) hips in the cranial socket group and 32 (80%) hips in the control group, respectively.ConclusionsOur study indicates, that the cranial socket can be an alternative treatment option for the reconstruction of acetabular deficiency in osteoarthritis secondary to developmental dysplasia.

Sclerosing epithelioid fibrosarcoma of the bone: a case report of high resistance to chemotherapy and a survey of the literature.

Sclerosing epithelioid fibrosarcoma (SEF) is a rare soft tissue sarcoma mostly occurring in extraosseous sites. SEF represents a clinically challenging entity especially because no standardized treatment regimens are available. Intraosseous localization is an additional challenge with respect to the therapeutical approach. We report on a 16-year-old patient with SEF of the right proximal tibia. The patient underwent standardized neoadjuvant chemotherapy analogous to the EURAMOS-1 protocol for the treatment of osteosarcoma followed by tumor resection and endoprosthetic reconstruction. Histopathological analysis of the resected tumor showed >90% vital tumor cells suggesting no response to chemotherapy. Therefore, therapy was reassigned to the CWS 2002 High-Risk protocol for the treatment of soft tissue sarcoma. To date (22 months after diagnosis), there is no evidence of relapse or metastasis. Our data suggest that SEF may be resistant to a chemotherapy regimen containing Cisplatin, Doxorubicin, and Methotrexate, which should be considered in planning treatment for patients with SEF.

Periprothetische Frakturen bei Hüftendoprothese

The number of periprosthetic fractures following hip replacement is increasing due to longer life expectancy and the rising number of joint replacements. The main causes of periprosthetic fractures include trauma, implant specific factors or loosening of the endoprosthesis. When planning therapy, surgeons should consider specific and general implant- and patient-related risk factors to ensure the best possible treatment. Established classification systems can facilitate preoperative planning. At present, the Vancouver classification system probably comes closest to the ideal, as it considers fracture configuration, stability of the implant and quality of the bone stock. Depending on these factors, therapeutic options include conservative treatment, fracture stabilisation or replacement of the endoprosthesis. The problems associated with periprosthetic fractures of varying etiology and the available treatment options are discussed against the background of the established classification systems.ZusammenfassungDie Inzidenz periprothetischer Frakturen nach Hüftgelenkendoprothetik nimmt aufgrund erhöhter Lebenserwartung und steigender Implantationszahlen kontinuierlich zu. Ursächlich können reine Traumen, implantatspezifische Faktoren und Prothesenlockerungen sein. Bei der Therapieplanung müssen zudem spezifische Patientenparameter sowie allgemeine Risikofaktoren bedacht werden, um eine bestmögliche Versorgung zu gewährleisten. Im Rahmen der präoperativen Diagnostik können etablierte Klassifikationssysteme hilfreich sein. Zurzeit wird die Vancouver-Klassifikation am häufigsten verwendet, da sie die Lokalisation der Fraktur, die Stabilität des Implantats und die Knochenqualität berücksichtigt. Abhängig von diesen Faktoren reichen die Therapieoptionen vom konservativen Vorgehen über die operative Frakturstabilisierung bis hin zum Prothesenwechsel. Unter Berücksichtigung etablierter Klassifikationssysteme werden die Probleme der periprothetischen Frakturen verschiedener Ausgangssituationen dargestellt und die verfügbaren Versorgungsmöglichkeiten diskutiert.AbstractThe number of periprosthetic fractures following hip replacement is increasing due to longer life expectancy and the rising number of joint replacements. The main causes of periprosthetic fractures include trauma, implant specific factors or loosening of the endoprosthesis. When planning therapy, surgeons should consider specific and general implant- and patient-related risk factors to ensure the best possible treatment. Established classification systems can facilitate preoperative planning. At present, the Vancouver classification system probably comes closest to the ideal, as it considers fracture configuration, stability of the implant and quality of the bone stock. Depending on these factors, therapeutic options include conservative treatment, fracture stabilisation or replacement of the endoprosthesis. The problems associated with periprosthetic fractures of varying etiology and the available treatment options are discussed against the background of the established classification systems.

Charakteristika von 200 Patienten mit Verdacht auf Implantatallergie im Vergleich zu 100 beschwerdefreien Endoprothesenträgern

BACKGROUND Data on implant allergies are incomplete; therefore, we compared the data on allergy history, patch test (PT) and lymphocyte transformation test (LTT) results in a patient series from the Munich implant allergy outpatient department with symptom-free arthroplasty patients. PATIENTS AND METHODS In this study 200 arthroplasty patients with complaints involving the prosthesis (130 female, 187 knee and 13 hip prostheses) and in parallel 100 symptom-free patients (75 female, 47 knee and 53 hip prostheses) were investigated. A questionnaire-aided history including implant type, cementing, intolerance of dental materials, atopy, cutaneous metal intolerance (CMI) and PT, including a standard series with Ni, Co, Cr, seven bone cement components, including gentamicin and benzoyl peroxide and LTT for Ni, Co and Cr. RESULTS In the knee arthroplasty patients with complaints 9.1% showed dental material intolerance, 23.5% atopy, 25.7% CMI, 18.2% metal allergies, 7.4% gentamicin allergy and 27.8% positive metal LTT (mostly to Ni). In symptom-free patients 0% showed dental material intolerance, 19.1% atopy, 12.8% CMI, 12.8% metal allergy, 0% gentamicin allergy and 17% positive metal LTT. CONCLUSIONS Characteristics of the patients with complaints were increased intolerance of dental materials, higher rates of atopy, CMI, metal and gentamicin allergy and LTT reactivity.

Periprosthetic fractures after total hip arthroplasty. Classification, diagnosis and therapy strategies

The number of periprosthetic fractures following hip replacement is increasing due to longer life expectancy and the rising number of joint replacements. The main causes of periprosthetic fractures include trauma, implant specific factors or loosening of the endoprosthesis. When planning therapy, surgeons should consider specific and general implant- and patient-related risk factors to ensure the best possible treatment. Established classification systems can facilitate preoperative planning. At present, the Vancouver classification system probably comes closest to the ideal, as it considers fracture configuration, stability of the implant and quality of the bone stock. Depending on these factors, therapeutic options include conservative treatment, fracture stabilisation or replacement of the endoprosthesis. The problems associated with periprosthetic fractures of varying etiology and the available treatment options are discussed against the background of the established classification systems.ZusammenfassungDie Inzidenz periprothetischer Frakturen nach Hüftgelenkendoprothetik nimmt aufgrund erhöhter Lebenserwartung und steigender Implantationszahlen kontinuierlich zu. Ursächlich können reine Traumen, implantatspezifische Faktoren und Prothesenlockerungen sein. Bei der Therapieplanung müssen zudem spezifische Patientenparameter sowie allgemeine Risikofaktoren bedacht werden, um eine bestmögliche Versorgung zu gewährleisten. Im Rahmen der präoperativen Diagnostik können etablierte Klassifikationssysteme hilfreich sein. Zurzeit wird die Vancouver-Klassifikation am häufigsten verwendet, da sie die Lokalisation der Fraktur, die Stabilität des Implantats und die Knochenqualität berücksichtigt. Abhängig von diesen Faktoren reichen die Therapieoptionen vom konservativen Vorgehen über die operative Frakturstabilisierung bis hin zum Prothesenwechsel. Unter Berücksichtigung etablierter Klassifikationssysteme werden die Probleme der periprothetischen Frakturen verschiedener Ausgangssituationen dargestellt und die verfügbaren Versorgungsmöglichkeiten diskutiert.AbstractThe number of periprosthetic fractures following hip replacement is increasing due to longer life expectancy and the rising number of joint replacements. The main causes of periprosthetic fractures include trauma, implant specific factors or loosening of the endoprosthesis. When planning therapy, surgeons should consider specific and general implant- and patient-related risk factors to ensure the best possible treatment. Established classification systems can facilitate preoperative planning. At present, the Vancouver classification system probably comes closest to the ideal, as it considers fracture configuration, stability of the implant and quality of the bone stock. Depending on these factors, therapeutic options include conservative treatment, fracture stabilisation or replacement of the endoprosthesis. The problems associated with periprosthetic fractures of varying etiology and the available treatment options are discussed against the background of the established classification systems.

[Characteristics of 200 patients with suspected implant allergy compared to 100 symptom-free arthroplasty patients].

BACKGROUND Data on implant allergies are incomplete; therefore, we compared the data on allergy history, patch test (PT) and lymphocyte transformation test (LTT) results in a patient series from the Munich implant allergy outpatient department with symptom-free arthroplasty patients. PATIENTS AND METHODS In this study 200 arthroplasty patients with complaints involving the prosthesis (130 female, 187 knee and 13 hip prostheses) and in parallel 100 symptom-free patients (75 female, 47 knee and 53 hip prostheses) were investigated. A questionnaire-aided history including implant type, cementing, intolerance of dental materials, atopy, cutaneous metal intolerance (CMI) and PT, including a standard series with Ni, Co, Cr, seven bone cement components, including gentamicin and benzoyl peroxide and LTT for Ni, Co and Cr. RESULTS In the knee arthroplasty patients with complaints 9.1% showed dental material intolerance, 23.5% atopy, 25.7% CMI, 18.2% metal allergies, 7.4% gentamicin allergy and 27.8% positive metal LTT (mostly to Ni). In symptom-free patients 0% showed dental material intolerance, 19.1% atopy, 12.8% CMI, 12.8% metal allergy, 0% gentamicin allergy and 17% positive metal LTT. CONCLUSIONS Characteristics of the patients with complaints were increased intolerance of dental materials, higher rates of atopy, CMI, metal and gentamicin allergy and LTT reactivity.