The clinical, radiological, microbiological, and molecular profile of the skin-penetration site of transfemoral amputees treated with bone-anchored prostheses.

The breach of the skin barrier is a critical issue associated with the treatment of individuals with transfemoral amputation (TFA) using osseointegrated, percutaneous titanium implants. Thirty TFA patients scheduled for abutment exchange or removal were consecutively enrolled. The aims were to determine the macroscopic skin signs, the presence of bacteria and the gene expression in abutment-adherent cells and to conduct correlative and comparative analyses between the different parameters. Redness and a granulation ring were present in 47% of the patients. Bacteria were detected in 27/30 patients, commonly in the bone canal. Staphylococcus aureus, coagulase-negative staphylococci, streptococci, and Enterococcus faecalis were the most common. A positive correlation was found between TNF-α expression and the detection of S. aureus. Staphylococcus aureus together with other bacterial species revealed a positive relationship with MMP-8 expression. A negative correlation was demonstrated between the length of the residual femur bone and the detection of a granulation ring and E. faecalis. A positive correlation was revealed between fixture loosening and pain and the radiological detection of endosteal bone resorption. Fixture loosening was also correlated with the reduced expression of interleukin-10 and osteocalcin. It is concluded that several relationships exist between clinical, radiological, microbiological, and molecular assessments of the percutaneous area of TFAs. Further long term studies on larger patient cohorts are required to determine the precise cause-effect relationships and unravel the role of host-bacteria interactions in the skin, bone canal and on the abutment for the longevity of percutaneous implants as treatment of TFA. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 578-589, 2017

Översyn av Hallandsås nordsluttning: biologiskt värdefulla områden

Hallandsås nordsluttningar ligger i den allra sydligaste delen av Halland, och delas nära nog av E6:an mellan Hallands län (östra delen) och Skåne län (västra delen). Nordsluttningarna är kända för skogsområden med lövskogar på kalkrik mark, källor, bäckdalar och raviner. Många rödlistade arter och hotade eller sårbara biotoper finns i området. Sammantaget har de naturvärden som Hallandsåsen representerar få motsvarigheter och finns endast i en mycket begränsad del av landet. Orsakerna till den unika biologiska mångfalden består bl.a. i en kalkhaltig morän, fördelaktig hydrologi, lång kontinuitet av lövträd samt en topografisk hydrologi med t.ex. sprickdalar och raviner. Även för friluftsliv och kulturmiljövård är värdena mycket höga. HALLANDSÅS NORDSLUTTNING ÖSTER OM E6:AN (HALLANDS LÄN)Under 1999-2000 gjordes en översyn av Hallandsås nordsluttningar inom Hallands län. Huvudsyftet med översynen har varit att identifiera och avgränsa värdekärnor för biologisk mångfald, att använda som underlag för arbete med naturskydd. För att ge underlag till arbetet har kompletterande nyckelbiotopsinventeringar utförts till den nyckelbiotopsinventering som gjordes 1996 (Örjan Fritz på uppdrag av Skogsvårdsstyrelsen). I samband med inventeringsarbetena hittades många rödlistade arter från skilda organismgrupper, särskilt kärlväxter, svampar, mossor och landmollusker. Med inventeringsmaterialet som grund har totalt tre områden omfattande 437 hektar avgränsats som särskilt värdefulla ur biologisk synvinkel: Dömestorp 297 hektar, Hälleforsen 52 hektar och Vindrarp 87 hektar. När det gäller kulturmiljö och friluftsliv hyser särskilt Dömestorp betydande värden. Strövområdet i Dömestorp besöks redan idag i stor omfattning. Några tankar om friluftslivet inom denna värdekärna anges i rapporten.HALLANDSÅS NORDSLUTTNING VÄSTER OM E6:AN (SKÅNE LÄN)På Skåne-sidan täcker visserligen de två befintliga naturreservaten Hallandsås nordsluttning respektive Täppesås hela nordsluttningen. Naturreservaten har dock inte ändamålsenliga föreskrifter som skyddar biologisk mångfald. Reservaten måste därför omförhandlas med inköp/intrång av mark för att naturvärdena ska kunna bibehållas och utvecklas. För att klargöra naturvärdena inom naturreservaten på nordsluttningen väster om E6:an, inventerades skogsmarken på uppdrag av Bjäre Naturskyddsförening 1999. Med nyckelbiotopsinventeringen som underlag kan värdekärnan Petersberg, omfattande 117 hektar, avgränsas.Trots påverkan från bergtäkt och tunnelbygge (Skåne län), vattenuttag, almsjuka m.m. motiverar de särskilt höga värdena inom de i rapporten föreslagna värdekärnorna, sammantaget 554 hektar, ett varaktigt skydd.Regionala inventeringsrapporter import från MDP 2015-05</p

Implant survival, adverse events, and bone remodeling of osseointegrated percutaneous implants for transhumeral amputees.

BackgroundOsseointegrated percutaneous implants provide direct anchorage of the limb prosthesis to the residual limb. These implants have been used for the rehabilitation of transhumeral amputees in Sweden since 1995 using a two-stage surgical approach with a 6-month interval between the stages, but results on implant survival, adverse events, and radiologic signs of osseointegration and adaptive bone remodeling in transhumeral amputees treated with this method are still lacking.Questions/purposesThis study reports on 2- and 5-year implant survival, adverse events, and radiologic signs of osseointegration and bone remodeling in transhumeral amputees treated with osseointegrated prostheses.MethodsBetween 1995 and 2010, we performed 18 primary osseointegrated percutaneous implants and two implant revisions in 18 transhumeral amputees; of those, 16 patients were available for followup at a minimum of 2 years (median, 8 years; range, 2-19 years). These include all transhumeral amputees who have received osseointegrated prostheses and represented approximately 20% of the all transhumeral amputees we evaluated for potential osseointegration during that time; general indications for this approach included transhumeral amputation resulting from trauma or tumor, inability to wear or severe problems wearing a conventional socket prosthesis, eg, very short residual limb, and compliant patients. Medical charts and plain radiographs were retrospectively evaluated.ResultsThe 2- and 5-year implant survival rates were 83% and 80%, respectively. Two primary and one revised implant failed and were removed because of early loosening. A fourth implant was partially removed because of ipsilateral shoulder osteoarthritis and subsequent arthrodesis. The most common adverse event was superficial infection of the skin penetration site (15 infections in five patients) followed by skin reactions of the skin penetration site (eight), incomplete fracture at the first surgery (eight), defective bony canal at the second surgery (three), avascular skin flap necrosis (three), and one deep implant infection. The most common radiologic finding was proximal trabecular buttressing (10 of 20 implants) followed by endosteal bone resorption and cancellization (seven of 20), cortical thinning (five of 20), and distal bone resorption (three of 20).ConclusionsThe implant system presented a survivorship of 83% at 5 years and a 38% 5-year incidence of infectious complications related to the skin penetration site that were easily managed with nonoperative treatment, which make it a potentially attractive alternative to conventional socket arm prostheses. Osseointegrated arm prostheses have so far only been used in transhumeral amputations resulting from either trauma or tumor. Their use has not been tested and is therefore not recommended in transhumeral amputations resulting from vascular disease. This method could theoretically be superior to socket prostheses, especially in transhumeral amputees with very short residual humerus in which the suspension of a conventional prosthesis is difficult. Comparative studies are needed to support its potential superiority. Moreover, the radiological findings in this study need to be followed over time because some of them are of uncertain long-term clinical relevance

Osteomyelitis Risk in Patients With Transfemoral Amputations Treated With Osseointegration Prostheses.

BackgroundPercutaneous anchoring of femoral amputation prostheses using osseointegrating titanium implants has been in use for more than 25&nbsp;years. The method offers considerable advantages in daily life compared with conventional socket prostheses, however long-term success might be jeopardized by implant-associated infection, especially osteomyelitis, but the long-term risk of this complication is unknown.Questions/purposes(1) To quantify the risk of osteomyelitis, (2) to characterize the clinical effect of osteomyelitis (including risk of implant extraction and impairments to function), and (3) to determine whether common patient factors (age, sex, body weight, diabetes, and implant component replacements) are associated with osteomyelitis in patients with transfemoral amputations treated with osseointegrated titanium implants.MethodsWe retrospectively analyzed our first 96 patients receiving femoral implants (102 implants; mean implant time, 95&nbsp;months) treated at our center between 1990 and 2010 for osteomyelitis. Six patients were lost to followup. The reason for amputation was tumor, trauma, or ischemia in 97 limbs and infection in five. All patients were referred from other orthopaedic centers owing to difficulty with use or to be fitted with socket prostheses. If found ineligible for this implant procedure no other treatment was offered at our center. Osteomyelitis was diagnosed by medical chart review of clinical signs, tissue culture results, and plain radiographic findings. Proportion of daily prosthetic use when osteomyelitis was diagnosed was semiquantitatively graded as 1 to 3. Survivorship free from implant- associated osteomyelitis and extraction attributable to osteomyelitis respectively was calculated using the Kaplan-Meier estimator. Indication for extraction was infection not responsive to conservative treatment with or without minor débridement or loosening of implant.ResultsImplant-associated osteomyelitis was diagnosed in 16 patients corresponding to a 10-year cumulative risk of 20% (95% CI 0.12-0.33). Ten implants were extracted owing to osteomyelitis, with a 10-year cumulative risk of 9% (95% CI 0.04-0.20). Prosthetic use was temporarily impaired in four of the six patients with infection who did not undergo implant extraction. With the numbers available, we did not identify any association between age, BMI, or diabetes with osteomyelitis; however, this study was underpowered on this endpoint.ConclusionThe increased risk of infection with time calls for numerous measures. First, patients should be made aware of the long-term risks, and the surgical team should have a heightened suspicion in patients with method-specific presentation of possible infection. Second, several research questions have been raised. Will the surgical procedure, rehabilitation, and general care standardization since the start of the program result in lower infection rates? Will improved diagnostics and early treatment resolve infection and prevent subsequent extraction? Although not supported in this study, it is important to know if most infections arise as continuous bacterial invasion from the skin and implant interface and if so, how this can be prevented?Level of evidenceLevel IV, therapeutic study

Clinical course in synovial sarcoma : A Scandinavian sarcoma group study of 104 patients

We analyzed treatment and outcome in 104 Scandinavian patients with synovial sarcoma in the extremities or trunk wall, diagnosed between 1986 and 1994. Only surgically treated patients without metastases at diagnosis were included. Median follow-up of survivors was 6 (3-11) years. 34 patients developed metastases. The overall 5- and 7-year survival rates were 0.76 (95% Cl 0.66-0.83) and 0.69 (0.58-0.78), respectively. Large tumor size and amputation were significantly associated with impaired metastasis-free survival. Patients with local recurrence had a higher risk of metastases following the local event. Local excision with inadequate margin was associated with a higher risk of local recurrence

Monitoring referral and treatment in soft tissue sarcoma: study based on 1,851 patients from the Scandinavian Sarcoma Group Register

This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The median age at diagnosis was 65 years and the male-to-female ratio was 1.1:1. One third of the tumors were subcutaneous, one third deep, intramuscular and one third deep, extramuscular. The median size was 7 (1-35) cm and 75% were high grade (III-IV). Metastases at presentation were diagnosed in 8% of the patients. Two thirds of STS patients were referred before surgery and the referral practices have improved during the study. The preoperative morphologic diagnosis was made with fine-needle aspiration cytology in 81%, core-needle biopsy in 9% and incisional biopsy in 10%. The frequency of amputations has decreased from 15% in 198688 to 9% in 1995-1997. A wide surgical margin was achieved in 77% of subcutaneous and 60% of deep-seated lesions. Overall, 24% of operated STS patients had adjuvant radiotherapy. The use of such therapy at sarcoma centers increased from 20% 1986-88 to 30% in 1995-97. Follow-up has been reported in 96% of the patients. The cumulative local recurrence rate was 0.20 at 5 years and 0.24 at 10 years. The 5-year metastasis-free survival rate was 0.70

Local recurrence of deep-seated, high-grade, soft tissue sarcoma: 459 patients from the Scandinavian Sarcoma Group Register

This study was based on 459 adult patients with deep, high-grade, soft tissue sarcoma of extremities or trunk wall reported to the Scandinavian Sarcoma Group Register (1986-1993). All patients had their definitive surgery for primary tumor at a sarcoma center. The median follow-up was 7.5 (3-12) years. 204 patients are still alive. 68 patients had amputations and 391 underwent limb-sparing surgery. Among 183 patients with intralesional or marginal margins after limb-sparing surgery, 65% had postoperative radiotherapy and 9% of the 198 patients with wide margins. The local recurrence rate after limb-sparing surgery was 26%. The rate with an intralesional or marginal margin was 39% without postoperative radiotherapy versus 24% when radiotherapy was given. It was 25% after a wide margin, and no recurrences were noted among the 10 patients with a compartmental surgical margin. Among patients with a wide margin, a subset fulfilling criteria for a myectomy was defined. The local recurrence rate was 26% among these 62 and there was no advantage of myectomy over other wide margins. More radical surgical margins would improve the local recurrence rate, but this can hardly be achieved in center-operated patients without increasing the amputation rate. Instead, increased use of radiotherapy in all patients with inadequate margins, and to a larger extent in those with wide margins will improve local control