R. von Eisenhart-Rothe

Fußtumoren: Diagnostik und Therapie

Despite the compact anatomy with thin soft tissue coverage, diagnosis of both benign and malignant tumors of the foot is often delayed. Diagnostic errors are more common than in other body regions, as neoplasias are rarely considered. Barring a few exceptions the foot is not a typical predilection site for malignant musculoskeletal tumors, although, basically any tumor entity of the musculoskeletal system can affect the foot. Delays in specific diagnostic and therapeutic procedures of these lesions can entail serious consequences for patients as tumor size is a major prognostic factor for recurrence-free survival. In cases of an indistinct persistent swelling or bone lesion a tumorous process should always be considered to ensure early diagnosis and therapy of foot tumors.ZusammenfassungTrotz der kompakten Anatomie und geringen Weichteildeckung erfolgt die Diagnose sowohl gut- als auch bösartiger Neubildungen des Fußes häufig verzögert. Diagnosefehler treten hier häufiger auf als bei anderen Körperregionen. Bis auf wenige Ausnahmen gehört der Fuß nicht zu den typischen Prädilektionsstellen maligner muskuloskelettaler Tumoren. Aggressive Neubildungen werden daher meist nicht in Betracht gezogen, obwohl prinzipiell jede Tumorentität des Bewegungsapparats auch am Fuß zu finden ist. Eine Verzögerung in der spezifischen Diagnostik und Therapie dieser Läsionen kann folgenschwere Konsequenzen nach sich ziehen, da die Größe des Tumors einen prognostisch wichtigen Faktor für das rezidivfreie Überleben darstellt. Bei Vorliegen einer unklaren, persistierenden Schwellung oder Knochenläsion sollte daher auch immer ein Tumor in Betracht gezogen werden, um nach entsprechender Abklärung eine frühzeitige, korrekte Diagnose und Therapie von Fußtumoren zu gewährleisten.AbstractDespite the compact anatomy with thin soft tissue coverage, diagnosis of both benign and malignant tumors of the foot is often delayed. Diagnostic errors are more common than in other body regions, as neoplasias are rarely considered. Barring a few exceptions the foot is not a typical predilection site for malignant musculoskeletal tumors, although, basically any tumor entity of the musculoskeletal system can affect the foot. Delays in specific diagnostic and therapeutic procedures of these lesions can entail serious consequences for patients as tumor size is a major prognostic factor for recurrence-free survival. In cases of an indistinct persistent swelling or bone lesion a tumorous process should always be considered to ensure early diagnosis and therapy of foot tumors.

Gluteale Insuffizienz: Pathogenese, Diagnostik und Therapie

INTRODUCTION Gluteal insufficiency is a common and challenging complaint. New concepts in pathobiomechanics and improved clinical understanding of chronic gluteal dysfunction have unmasked gluteus medius (GMed) tears as an underlying cause of enhanced trochanteric pain syndrome (GTPS). These tears are often missed or misdiagnosed as bursitis, but lead to prolonged chronic peritrochanteric pain. Clinic: The clinical signs are often dull pain on the lateral hip aspect, reduced hip abduction strength with positive Trendelenburg testing and a tendency for the leg to external rotation, as the internal rotation strength is reduced. IMAGING Radiography and ultrasound may be used to confirm the diagnosis, whereas MRI is the modality of choice for imaging. Compensatory hypertrophy of the tensor fascia latae muscle (TFL) and fatty involution (especially of the GMed) are also seen. THERAPY Conservative treatment regimens for partial thickness tears involve hip joint centering and strengthening of abductor muscles, sparing TFL. Failed conservative treatment and full thickness tears are treated surgically. Partial tears can be addressed endoscopically with suture anchors for tendon footprint reconstruction. Larger tears involving the anterior and/or lateral facets of the tendon or failed conservative treatment are repaired with minimally invasive open reduction techniques. Double row suture anchor techniques provide anatomical tendon footprint reconstruction. Postoperative rehabilitation is prolonged, due to high acting forces in the peritrochanteric region, and needs to be carried out under professional surveillance. CONCLUSION Reconstruction of gluteal tendon tears is often the only solution in the treatment of chronic hip pain due to gluteal insufficiency. Available data suggest that reduction in pain and restoration of abduction power can be achieved in mid-term follow-up.

Heterotope Ossifikationen im Rahmen der Hüftendoprothetik

Heterotopic ossification (HO) is a frequent and occasionally severe complication after total hip arthroplasty. Clinical symptoms of this benign abnormal bone formation are loss of mobility and local pain. The etiology and pathomechanisms are not yet completely understood. Overexpression of bone morphogenetic proteins and dysregulation of prostaglandin metabolism seem to be relevant. Medication with non-steroidal anti-inflammatory drugs (NSAIDs) and perioperative single dose radiotherapy are used for prophylaxis, whereby radiotherapy should only be performed in patients with a history of HO or additionally after resection of HO. From currently available data selective cyclooxygenase-2 inhibitors seem to have a preventive efficacy equal to the classical NSAIDs diclofenac and indometacin. This work discusses current knowledge about the pathophysiology, risk factors and the clinical approach for prevention and treatment of HO.ZusammenfassungHeterotope Ossifikationen (HO) stellen eine häufige und bisweilen schwerwiegende Komplikation nach Hüfttotalendoprothesenimplantation dar. Klinisch bewirkt diese gutartige Knochenneubildung Bewegungseinschränkungen und lokale Schmerzen. Ätiologie und Pathomechanismus sind bislang nicht vollständig geklärt, eine Überexpression von „bone morphogenetic proteins“ und eine Dysregulation des Prostaglandinstoffwechsels erscheinen bedeutsam. Zur Prophylaxe von HO nach Hüfttotalendoprothesenimplantation stehen eine Medikation mit nichtsteroidalen Antirheumatika (NSAR) sowie eine perioperative einmalige lokale Strahlentherapie zur Verfügung, wobei letztere nur bei Patienten mit HO in der Vorgeschichte und additiv nach einer HO-Resektion angewendet werden sollte. Selektive Cyclooxygenase-2-Inhibitoren erscheinen nach bisher vorliegenden Daten eine gegenüber den klassischen NSAR Diclofenac und Indometacin vergleichbare prophylaktische Wirkung zu haben. Die vorliegende Arbeit diskutiert die bisherigen Kenntnisse bzgl. Pathophysiologie und Risikofaktoren sowie die klinischen Empfehlungen zur Prophylaxe und Therapie von HO.AbstractHeterotopic ossification (HO) is a frequent and occasionally severe complication after total hip arthroplasty. Clinical symptoms of this benign abnormal bone formation are loss of mobility and local pain. The etiology and pathomechanisms are not yet completely understood. Overexpression of bone morphogenetic proteins and dysregulation of prostaglandin metabolism seem to be relevant. Medication with non-steroidal anti-inflammatory drugs (NSAIDs) and perioperative single dose radiotherapy are used for prophylaxis, whereby radiotherapy should only be performed in patients with a history of HO or additionally after resection of HO. From currently available data selective cyclooxygenase-2 inhibitors seem to have a preventive efficacy equal to the classical NSAIDs diclofenac and indometacin. This work discusses current knowledge about the pathophysiology, risk factors and the clinical approach for prevention and treatment of HO.

Analyse und Vergleich 2-D- vs. 3-D-Glenoidversion bei a-/traumatischer Schulterinstabilität – ist eine 3-D-Analyse notwendig?

AIM Changes in glenoid orientation as a primary cause of shoulder instability have been discussed controversially in the literature. The data of a physiological glenoid version vary widely among different authors and techniques. One reason may be that the previously used 2-D techniques suffer from a limited reproducibility and validity. The objective of this study was therefore to compare the 2-D and 3-D analyses of the glenoid version in patients with shoulder instability. METHOD The shoulders of 28 healthy volunteers and of 14 patients each with atraumatic/traumatic instability were examined in an open MR scanner (0.2 T). The 2-D glenoid version was determined using post-processing techniques according to the technique of Friedman et al. (1992). Afterwards, the 3-D glenoid version was analysed independently of the slice orientation and patient position. The coefficient of correlation (r) between the 2-D and 3-D glenoid versions was calculated using the correlation z test. RESULTS The 3-D post-processing technique showed a reproducibility with a coefficient of variation of 8.3 %. Patients with traumatic instability demonstrated no significant difference compared to the healthy control group (4.4 +/- 2.1 degrees vs. healthy: 3.9 +/- 1.3 degrees ). In atraumatic shoulder instability the glenoid retroversion was in the mean significantly increased (10.2 +/- 4.9 degrees ). The individual values ranged between 2.6 degrees and 16.6 degrees . Also for the contralateral, unaffected side a significantly increased retroversion (6.3 +/- 2.2 degrees ) was observed compared to healthy shoulders. There was a significant correlation (r: 0.84) between 2-D and 3-D retroversion. CONCLUSIONS The presented techniques allow for a reproducible assessment of glenoid version independent of the slice orientation and patient position. Our results demonstrate in the mean only a small difference of +/- 3 degrees between 2-D and 3-D glenoid versions. Therefore under standardised conditions the 2-D CT/MRI should be adequate for measuring the glenoid version except for borderline cases. No significant changes in glenoid version were found in patients with traumatic instability. In atraumatic, posterior instability, in the mean an increased retroversion was observed on both sides. However, the magnitude of these changes varied widely among individuals and should be identified to initiate a causal treatment.

OP-Technik: Rekonstruktion des defizitären Streckapparats des Kniegelenks – ein Case Report

Injuries to the extensor apparatus of the knee are a rare but in case of their occurrence a serious injury. In the following discussion, the focus is on treatment of chronic patellar tendon tears. The aim of surgical treatment is the recovery of the active extension and full weight-bearing ability of the leg. The video presentation shows the operative treatment of a patient with a chronic extensor mechanism deficiency of the knee after multiple revision of a total knee arthroplasty due to periprosthetic infection and three-times occurrence of a patella tendon tear. A frame-shaped reinforcement between patella and tibial tuberosity by FiberTape® combined with a medial gastrocnemius flap was performed. This type of surgery is indicated in cases of large defects of the patellar tendon that cannot be treated with end-to-end suture or simple augmentation with autologous tendons (e.g. semitendinosus). In addition to augmentation of the tendon defect, cutaneous soft tissue defects around the knee and proximal lower leg can be covered. In general, the best treatment option is chosen according to size of the defect, the quality of the tendon tissue and possible previous surgery on the knee joint. There are no reports of large series of chronic patella tendon tears, but only isolated cases using a variety of techniques. In addition with low level of evidence, there is currently no established gold standard in the surgical treatment of insufficiencies of the extensor apparatus of the knee.

Stellenwert der Psychoonkologie und ihre Versorgungslage an Zentren für Tumororthopädie

INTRODUCTION Psychosocial screening has not been implemented into diagnosis-related guidelines for the treatment of orthopedic tumor patients. The aim of the study was to evaluate the significance of psycho-oncology in orthopedic institutions specialized in musculoskeletal tumors as well as the opinion and clinical experience of the treating physicians. METHODS In total 60 orthopedic institutions were recruited. Data were assessed and analyzed by a newly developed, standardized questionnaire. To detect specific, demographic differences results were additionally analyzed according to gender, age and professional experience. RESULTS A total of 118 physicians from 47 institutions participated. Significant differences between professional experience groups were obtained regarding the wish for psychosocial treatment in cases of own illness (p=0.032) and the difficulty of addressing patient feelings (p=0.05). CONCLUSIONS The majority of orthopedic physicians deemed psycho-oncology important. To ensure a holistic approach to the treatment of orthopedic tumor patients, psycho-oncological aspects should be implemented in diagnosis-related guidelines.

„Nur“ Streßfraktur oder doch maligne?

Kommt ein Patient wegen Schienbeinschmerzen in die Praxis, kann oft bereits durch gezielte Anamnese und klinische Untersuchung eine Diagnose gestellt werden. Der radiologische Anfangsbefund kann allerdings Schwierigkeiten in der Differenzierung zu Knochentumoren darstellen. In unklaren Fällen ist die frühzeitige Kontaktaufnahme zu einem Tumorzentrum ratsam. Unsere Autoren stellen die Stressfraktur einer Tibia vor, die konservativ erfolgreich therapiert werden konnte.