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Purpose The aim of this retrospective analysis was to investigate and evaluate differences in functional outcome and satisfaction of patients treated with a TOPS and patients using socket prosthesis after transfemoral amputation. Methods This retrospective comprehensive analysis included patients from a single hospital, and was conducted between February 2017 and December 2018. Overall n = 139 patients with prosthesis were included and divided into two comparable groups (socket- and TOPS group). Incomplete data sets were excluded. This led to n = 36 participants for the socket- and n = 33 for the TOPS group. Functional outcome and satisfaction were evaluated by Patient Reported Outcome Measures (PROMs). The used PROMs were: Questionnaire for Persons with a Transfemoral Amputation (Q-TFA), EQ5D-5L, Satisfaction with Prosthesis Questionnaire (SAT-PRO), Prosthesis Mobility Questionnaire (PMQ 2.0) and Functional Independence Measure (FIM). Results Significant results in favor of TOPS patients were identified for the EQ-5D 5L (p = 0.004), Q-TFA (p = 0.000), SAT-PRO (p = 0.000) and PMQ 2.0 (p = 0.000). For FIM, no statistical significance was found (p = 0.318). Conclusion In this study, transfemoral amputees treated with an osseointegrated prosthetic attachment (TOPS) showed significantly higher scores for mobility and satisfaction. This demonstrates the high potential of TOPS in the prosthetic treatment of patients with transfemoral amputation with regard to their functional abilities in daily life.

To analyse whether a preoperative femoral abduction angle (FAA) correlates with postoperative initial lateral hip pain (LHP) in above-knee amputees (AKA) treated with transcutaneous osseointegrated prosthetic system (TOPS).Pre- and postoperative long-leg radiographs of eighteen unilateral AKA (mean age 51.55y ± 12.16) were retrospectively measured. FAA was measured on both sides. Pain intensity of LHP was measured by numeric rating scale (NRS) preoperatively and every week for four weeks from the first day of weight loading. Pearson's r was calculated for correlation. Furthermore, odds ratio for LHP ≥ 5/10 NRS and relative FAA 13° was calculated.FAA significantly decreased in the postoperative period (pre/post. 15.33° ± 4.22; p 0.001). Median LHP was 0/10 NRS (min.0, max.3) preoperatively and 4/10 NRS (min.2, max. 7, p 0.001) postoperatively after first loading. Interestingly, it decreased within four weeks to a median of 0.5/10 NRS (min.0, max. 3) without intervention. A strong correlation was seen on the amputated side between preoperative FAA and LHP after loading (r = 0.835, p 0.001), as well as the relative FAA to LHP after loading (r = 0.732, p 0.001) and between the gap of pre- to postoperative FAA and LHP. Odds ratio for LHP ≥ 5/10 and relative FAA 13° was 6.4 (95%CI = 0.55; 74.89).The preoperative FAA strongly correlates with postoperative LHP. Surgeons should be aware of high risk of LHP that can limit prosthetic training. High preoperative FAAs should be realised in the decision meeting of TOPS implantation and pre-rehabilitative reduction of the FAA should be taken into consideration.

Background Proximal femoral fractures are a major socioeconomic burden and they occur mainly in geriatric patients. High mortality and complication rates are reported. To reduce the mortality and morbidity of these patients, co-management with geriatricians has been recommended. Most previous studies have focused on relatively comprehensive care models. Models with only a few additions to the usual care have not been extensively evaluated. Methods This retrospective observational study included all patients aged ≥70 years (mean age: 84.5 ± 7.1 years, 70% women) with an isolated proximal femoral fracture treated surgically in our institution from May 2018 to October 2019. In the first 9 months, patients were treated with the usual care (control group, n = 103). In the second 9 months, patients were treated with our multidisciplinary care model (intervention group, n = 104), which included the usual care, plus: (1) one multidisciplinary ward round per week and (2) one “elective” operation slot per day reserved for proximal femoral fractures. Baseline characteristics and outcome measures of the hospital stay were extracted from electronic health records. A 3-month follow-up was conducted by phone. Results Baseline characteristics were comparable between groups (p > 0.05). The hospital stay was shorter in the intervention group than in the control group (7.8 ± 4.3 vs. 9.1 ± 4.5; p = 0.022). The intervention reduced the waiting time for surgery by more than 10 h (intervention: 25.4 ± 24.5 vs. control: 35.8 ± 34.1 h; p = 0.013). A structured phone interview was not performed in 30.9% of the cases. The model reduced the overall dissatisfaction rate by more than half (12.9% vs. 32.4%; p = 0.008). On the other hand, the groups had similar perioperative complication rates (25% vs. 24.3%; p > 0.9999) and mortality (4.8% vs. 3.9%; p > 0.9999) and they remained similar at the 3-month follow-up (complications: 20.3% vs. 17.6% p = 0.831, mortality: 18.2% vs. 15.0% p = 0.573). Conclusion We found that two additions to the usual proximal femoral fracture regimen could significantly improve the overall satisfaction rate, reduce the length of hospital stay and shorten the waiting time for surgery. In contrast to previous studies, we observed no significant improvements in complication or mortality rates. Further changes in the standard care might be needed for this purpose.

We report on a 19-year-old male renal transplant patient with multiple medical issues who sustained simultaneous bilateral quadriceps tendon ruptures and bilateral femoral neck fractures after 2 generalized tonic-clonic seizures. The quadriceps tendon ruptures were detected early surgically repaired; the femoral neck fractures were not detected and managed with bilateral total hip arthroplasty for almost 2 weeks.Tonic-clonic seizures can be associated with unique and complex acute orthopaedic injuries that can be initially missed. Physicians should be cognizant of the need for a thorough medical history and physical examination to avoid orthopaedic postseizure missed diagnoses.

The aim of this prospective validation study was to translate the Prosthesis Mobility Questionnaire 2.0 (PMQ) into German based on a guideline, following by psychometric testing for its validity and reliability using classical test theory.The PMQ was translated into German according to ISPOR guidelines using double forward and double backward translations, finalized by pilot testing (N=10). Subsequently, assessment of the validity and reliability was performed from March 2020 to August 2020 on N=61 patients with unilateral lower limb amputation. Construct validity was determined by using the German version of the Locomotor Capabilities Index-5 (LCI-5-D), the Rivermead Mobility Index (RMI), the Timed up and go Test (TUG), and K-levels. Cronbach's alpha was calculated to check internal consistency and discriminatory power was determined by item correlations. Test-retest reliability was calculated using ICC (2,1). Based on the ICC, the minimum detectable difference (MDC) was calculated.The translation process required small changes after the pilot test. The validation study was performed on N=61 patients (56.59±13.16 years, m/f=38/23). A mean PMQ of 26.23±8.89 points was achieved. Ceilings or floor effects for total score did not appear. Construct validity showed strong positive correlations to LCI-5-D (r=0.74, p0.001), RMI (r=0.63 p0.001) as well as k-levels (r=0.61 p0.001) and moderate negative correlation to TUG (r=- 0.49, p0.001). Internal consistency was excellent with Cronbach's alpha=0.95). All items showed a value greater than r=0.40 for item-to-total score correlation. Test-retest reliability was excellent with an ICC (2,1)=0.98 with a timespan between T0 and T1 of 3.2±2.83 days. Based on this results, the MDC was 3.40 points.The German version of the Prosthesis Mobility Questionnaire 2.0 is a valid, reliable patient reported outcome measure (PROM) for measuring mobility and functional ability of patients with exoprosthesis due to unilateral lower limb amputation. It can be used for a German-speaking population.Das Ziel dieser prospektiven Validierungsstudie war es, den Prosthesis Mobility Questionnaire 2.0 (PMQ) leitlinienkonform ins Deutsche zu übersetzen und anschließend mittels Verfahren der klassischen Test-Theorie auf Validität und Reliabilität zu überprüfen.Der PMQ wurde gemäß ISPOR-Leitlinien zweifach vorwärts- und zweifach rückwärtsübersetzt und mittels Pilottest (N=10) finalisiert. Anschließend erfolgte eine Überprüfung der Gütekriterien an N=61 Patienten mit unilateraler Majoramputation der unteren Extremität von März 2020 bis August 2020. Die konvergente Konstruktvalidität wurde mittels der deutschen Version des Locomotor Capabilities Index-5 (LCI-5-D), dem Rivermead Mobility Index (RMI), dem Timed up and go Test (TUG) sowie anhand der Mobilitätsgrade ermittelt. Zur Überprüfung der internen Konsistenz wurde Cronbachs Alpha berechnet sowie die Trennschärfe durch Item-Skala-Korrelationen ermittelt. Die Test-Retest-Reliabilität wurde mittels ICC (2,1) berechnet. Darauf aufbauend wurde die minimale detektierbare Differenz berechnet.Der Übersetzungsprozess erforderte kleine Änderungen nach dem Pilottest. Die Validierungsstudie wurde an N=61 Patienten durchgeführt (56,59±13,16 Jahre, m/w=38/23). Im Mittel konnte ein PMQ von 26,23±8,89 Punkten erreicht werden. Decken- oder Bodeneffekte zeigten sich im Gesamtscore nicht. Die Konstruktvalidität zeigte starke positive Korrelationen zum LCI-5-D (r=0,74, p0,001), RMI (r=0,63 p0,001) sowie Mobilitätsgraden (r=0,61 p0,001). Ebenso eine moderate negative Korrelation zum TUG (r=− 0,49, p0,001). Die interne Konsistenz war sehr gut (Cronbachs Alpha=0,95). Alle Items zeigten einen Wert größer r=0,40 bei der Item-zu-Gesamtscore Korrelation. Test-Retest-Reliabilität war mit einem ICC (2,1)=0,98 exzellent bei einem Erhebungsintervall zwischen T0 und T1 von 3,2±2,83 Tagen. Darauf aufbauend betrug die minimale detektierbare Differenz 3,40 Punkte.Die deutsche Version des Prosthesis Mobility Questionnaire 2.0 ist ein valides und reliables Selbsteinschätzungs-Instrument zur Messung der Mobilität und Funktionsfähigkeit von Patienten mit Exoprothese bei unilateraler Majoramputation der unteren Extremität. Es kann für den deutschsprachigen Raum verwendet werden.

The treatment of patients with complex regional pain syndrome (CRPS) takes place in an interdisciplinary and multimodal setting. Physical therapies represent a major treatment focus along with physiotherapy, occupational therapy, and analgetic treatments. This review explains their importance in current clinical practice and gives an impression of the evidence on different treatments including electrotherapy, neuromodulating procedures, manual lymphatic drainage, CODie Behandlung von Patienten mit komplexem regionalem Schmerzsyndrom („complex regional pain syndrome“ [CRPS]) findet in einem interdisziplinären und multimodalen Setting statt. Physikalische Therapien stellen neben physio- und ergotherapeutischen sowie analgetischen Behandlungen einen wesentlichen Behandlungsschwerpunkt dar. Die vorliegende Übersicht erläutert den Stellenwert im aktuellen klinischen Alltag und vermittelt einen Eindruck der Evidenzlage verschiedener Behandlungen, beispielsweise zu Elektrotherapie, neuromodulierenden Verfahren, manueller Lymphdrainage, CO

This study aimed to compare, through Rasch analysis, the psychometric properties of the Locomotor Capabilities Index (LCI-5) and Prosthetic Mobility Questionnaire (PMQ 2.0) in German lower-limb prosthesis users. The questionnaires were concurrently administered to a convenience sample of 98 consecutively recruited individuals with lower limb amputation (LLA) (male/female = 61/37; mean age 57 ± 14 years). LCI-5 showed disordered rating scale thresholds (one response option in three items required collapsing); local dependence between two items (resolved by creating a testlet); underfit of one item ('Get up from the floor'); and presence of a second weak dimension. PMQ 2.0 showed a correctly functioning rating scale; good fit of the data to the model (apart from some overfit); local dependence between two items (absorbed by creating a testlet); and essential unidimensionality. At scale co-calibration onto a common interval-scaled metric, PMQ 2.0 was better targeted than LCI-5 (i.e. the extent of item difficulty was more appropriate for the sample) and its operational range allowed a more precise measurement of higher locomotor abilities. The correlation between LCI-5 and PMQ 2.0 scores was rho = 0.78. In conclusion, LCI-5 revealed some drawbacks, confirming a previous Rasch study; refinement of its rating scale and item selection seems therefore warranted. The PMQ 2.0 demonstrated good overall measurement quality, in line with previous Italian and Slovene studies. The operational range of the PMQ 2.0 makes it more suitable than LCI-5 for assessing people with high locomotor abilities.

Objective The aim of this study was to investigate the interrater reliability and intrarater reliability of the flexor pollicis longus muscle stretch reflex (FPLR) and compare it with clinically established reflexes. Design A total of 71 healthy volunteers participated. The FPLR, biceps reflex, brachioradialis reflex, and patellar tendon reflex of each participant were tested bilaterally and rated by eight examiners (four experienced, four inexperienced). For intrarater reliability evaluation, five examiners rated the reflexes of four volunteers at four different points in time. Results Analysis of the interrater reliability with Gwet's AC1 demonstrated almost perfect agreement for FPLR (Gwet's AC1 = 0.90), biceps reflex (Gwet's AC1 = 0.90), and patellar tendon reflex (Gwet's AC1 = 0.95) when using binary data (reflex present vs. absent). Only fair agreement was found for the brachioradialis reflex (Gwet's AC1 = 0.56). Experienced raters had a higher agreement than inexperienced raters did when rating the biceps reflex and the patellar tendon reflex. The intrarater reliability was almost perfect for the patellar tendon reflex (Gwet's AC1 = 0.94), followed by the FPLR (Gwet's AC1 = 0.83) with substantial agreement and the biceps reflex (Gwet's AC1 = 0.57) with moderate agreement. Conclusion The FPLR is a reliable diagnostic neuromuscular test and may therefore be useful in the clinical examination for C8/T1 nerve root lesions or pathologies of the interosseous anterior nerve. To claim cme credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. Cme objectives Upon completion of this article, the reader should be able to: (1) Elicit the flexor pollicis longus muscle stretch reflex; (2) Discuss the disadvantage of kappa statistics in assessing the interrater reliability when the prevalence of the studied trait is very high or very low; and (3) Name the spinal nerves involved in the innervation of the flexor pollicis longus muscle. Level Advanced. Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Introduction Transcutaneous osseointegrated prosthetic systems (TOPS) are anchored prosthetic systems for major limb loss. Sometimes TOPS patients suffer from periprosthetic fractures. The aim of this study was to analyze the management and outcomes of periprosthetic fractures in patients with TOPS and to introduce a novel classification system for this entity. Material/methods Since 2010, 140 patients were treated with TOPS after transfemoral amputation in two centers in Germany. Fifteen patients sustained periprosthetic fractures, with five intra- and ten postoperative fractures. The outcome was analyzed by Prosthesis Mobility Questionnaire (PMQ), K-level and prosthesis wear time per day. A subgroup analysis for the body mass index (BMI) was performed. Results All postoperative fractures were treated with implant-retaining osteosynthesis. Fourteen fractures healed without complications after a mean of 3 months. One postoperative fracture developed a clinically asymptomatic firm non-union. No Endo-Fixstem had to be removed. For the fracture and control group, a significant increase of the PMQ (p p p = 0.002) and overweight patients (p Conclusion Periprosthetic fractures do not necessarily worsen outcomes of TOPS treatment. Proper classification and standardized appropriate treatment strategies according to fracture morphology are paramount for reliably good outcomes. We recommend to not remove or exchange the implant (Endo-Fixstem) even if it is assembly. Higher BMI did not have an impact onto rehabilitation success after TOPS to major limb loss of the lower extremity.

Transcutaneous osseointegrated prosthetic systems (TOPS) are an established optional procedure for the prosthetic treatment of amputations. Under the term endo-exo-prosthesis (EEP), the endosteal adapted exo-prosthesis (Dr. Grundei®) is currently used as the only standard prosthesis for clinical application in Germany. The prosthetic treatment with EEP involves a two-stage surgical procedure. In a first surgical step, the endo-fixed stem is implanted into the bone; in a second operation, approx. 2-6 weeks later, the skin/soft tissue stoma is created, through which the exoprosthetic components can be coupled transcutaneously.The aim of this manuscript was to retrospectively collect descriptive 3‑year statistics (2017-2019) from clinical follow-ups and to analyze them with regard to possible effects of TOPS on the mobility level measured by k‑levels. In addition, a brief description of the current standard of care in Germany regarding TOPS will be given.All patients who underwent EEP after major amputation from February 2017 to December 2019 (n = 72, with 76 implants) were included in this study. The data of the EEP patients were collected in standardized follow-ups. K‑levels were compared preoperatively to 6 months postoperatively.A total of N = 72 patients (N = 76 implantations) was analyzed in the described period. The main cause of amputations was trauma (68.9%). Main complications were myofascial complaints. Implant loosening and deep infections were observed in two cases (2.7%) during this period. Stoma problems occurred with a 3-year average of 25.7%. In terms of K‑levels, there was a high significant increase from preoperative 1.8 ± 0.8 to 3.0 ± 0.4 after a 6-month period.TOPS is an established optional procedure for the treatment of limb loss. In Germany, only one implant is currently regularly implanted (endo-exo prosthesis), and the restoration is currently focused on the lower limb. The restoration of patients with major amputation of the lower extremity by means of TOPS can lead to an increase in mobility and, thus, to an increase in daily activities and participation in daily living.EINLEITUNG: Transkutane osseointegrierte Prothesensysteme (TOPS) sind ein etabliertes optionales Verfahren zur prothetischen Versorgung von Amputationen. Unter dem Begriff der Endo-Exo-Prothetik (EEP) kommt die endostieladaptierte Exoprothese nach Dr. Grundei® derzeit in Deutschland als Standardprothese zur klinischen Anwendung. Die prothetische Versorgung mittels EEP beinhaltet ein zweizeitiges operatives Vorgehen. In einem ersten Operationsschritt wird der Endofixstiel im Knochen implantiert. In einer zweiten Operation, ca. 2–6 Wochen später, wird das Haut‑/Weichteilstoma angelegt, worüber die exoprothetischen Bauteile transkutan gekoppelt werden können. ZIEL: Ziel dieser Arbeit war es, aus klinischen Follow-Ups retrospektiv eine deskriptive 3‑Jahres-Statistik (2017–2019) zu erheben und hinsichtlich etwaiger Effekte einer EEP-Versorgung auf die Mobilitätsgrade (MG) zu analysieren. Daneben soll eine kurze Darstellung des derzeitigen Versorgungsstandards in Deutschland bezüglich der EEP-Versorgung erfolgen.Eingeschlossen in diese Studie wurden alle Patienten, die sich von Februar 2017 bis Dezember 2019 (n = 72, mit 76 Implantaten) einer EEP-Versorgung nach Majoramputation unterzogen haben. Die Daten der EEP-Patienten wurden im Rahmen standardisierter Follow-Up-Untersuchungen erhoben. Der Mobilitätsgrad wurde präoperativ und 6 Monate postoperativ verglichen.Insgesamt wurden im beschriebenen Zeitraum N = 72 Patienten (N = 76 Implantationen) analysiert. Die Hauptursache der Amputationen war Trauma (68,9 %). Hauptkomplikationen waren myofasziale Beschwerden. Eine Explantation des Endofixstiels aufgrund einer septischer Prothesenlockerung wurde in dem Zeitraum in zwei Fällen (2,7 %) beobachtet. Stomaprobleme traten im 3‑Jahres-Durchschnitt bei 25,7 % auf. Hinsichtlich der Mobilitätsgrade zeigte sich im Durchschnitt über einen Zeitraum von 6 Monaten eine signifikante Steigerung von präoperativ durchschnittlich MG 1,8 ± 0,8 zu 3,0 ± 0,4.TOPS sind ein etabliertes optionales Verfahren zur Wiederherstellung der Gehfähigkeit nach Gliedmaßenverlust. In Deutschland wird derzeit nur ein Implantatmodell regelhaft implantiert (EEP) und die Versorgung fokussiert sich derzeit auf die untere Extremität. Die Versorgung von Patienten mit Majoramputation der unteren Extremität mittels TOPS führt mit hoher Frequenz zu einer Steigerung der Mobilität und Aktivität im täglichen Leben.

A retrospective analysis of clinical outcomes and complication rates of patients treated with the latest implant design of the so-called Endo-Exo-Femoral Prosthesis (EEFP) was performed. The aim is to gain specific information on long-term complications of this treatment-method.In January 2019, data of all transfemoral amputees who were treated with TOPS at an acute clinic in Schleswig-Holstein from 2010 to 2016 were retrospectively analysed. This was done with special consideration of postoperative complications. For this purpose, all examination findings from routine clinical follow-up examinations were used. The complications were divided into stoma problems, orthopaedic-technical (OT) problems, fractures and explantations. All EEFPs had the same implant design (3rd generation). This implant is currently the only TOPS in Germany that is clinically used. Descriptive statistics as well as ratio information about occurred complications were calculated.A total of 68 implantations were performed during this period. Average observation time was 6.32 years (±2.16 years). The mean age of the patients was 51.84 years±12.12 years. Cause of amputation was mainly trauma (82,35%). Stoma-associated problems had the highest incidence (7%) among all observed patient-related complications and posed the greatest challenges during the rehabilitation process. Looking only at surgical complications, 81% had no complications at all. In total, 15% had technical problems, 6% had peri-prosthetic fractures, 7% had stoma problems and 3% had to be explanted due to infection.The analysis of collected data shows that TOPS (here the 3rd generation EEFP) can be a successful alternative treatment method to shaft prostheses after transfemoral amputation. The indication should only be given after the failure of a shaft-prosthesis and contraindications must be comprehensively excluded. The greatest challenges in the rehabilitation process are the avoidance of stoma complications, infections and OT-problems. The rehabilitation of amputees treated with TOPS therefore requires an interdisciplinary, specialized rehabilitation team and lifelong rehabilitative care.Durchgeführt wurde eine retrospektive Analyse der klinischen Ergebnisse und Komplikationsraten aller oberschenkelamputierten Patienten eines Zentrums, die mit dem neuesten Implantatdesign der sogenannten Endo-Exo-Femur-Prothese (EEFP, dritte Generation) versorgt wurden. Ziel ist es, spezifische Informationen zu Langzeitkomplikationen dieser Amputationsversorgungsform zu gewinnen.Im Januar 2019 wurden Daten aller Oberschenkelamputierten, die von 2010 bis 2016 an einer Akutklinik aus Schleswig-Holstein mit TOPS versorgt wurden, retrospektiv analysiert. Dies geschah unter besonderer Berücksichtigung der postoperativen Komplikationen. Hierfür wurden alle Untersuchungsbefunde der klinischen Routine-Nachsorge-Untersuchungen herangezogen. Die Komplikationen wurden unterteilt in Stomaprobleme, orthopädie-technische Probleme, Frakturen und Explantationen. Alle EEFPs besaßen das gleiche Implantatdesign (dritte Generation). Dieses Implantat findet derzeit als einziges TOPS in Deutschland klinische Anwendung. Eine deskriptive Statistik des Patientenkollektivs, sowie Verhältnisangaben über aufgetretene Komplikationen wurden berechnet.Insgesamt wurden in diesem Zeitraum 68 Implantationen durchgeführt. Durchschnittliche Beobachtungszeit war 6,32 Jahre (±2,16 Jahre). Das mittlere Alter der Patienten betrug 51,84 Jahre±12,12 Jahre. Ursache der Amputation waren überwiegend Traumata (82,35%). Stoma-assoziierte Probleme zeigten mit 7% die höchste Inzidenz innerhalb aller beobachteten, patientenassoziierten Komplikationen und stellten die größten Herausforderungen während des Rehabilitationsprozesses dar. Betrachtet man nur die chirurgischen Komplikationen, so hatten 81% überhaupt keine Komplikationen. Insgesamt wiesen 15% orthopädie-technische Probleme auf, 6% eine peri-prothetische Fraktur, 7% Probleme am Stoma und 3% mussten aufgrund einer Infektion explantiert werden.Die erhobene Datenanalyse zeigt, dass TOPS (hier die EEFP der dritten Generation) eine erfolgreiche alternative Behandlungsmethode zur Schaftprothesenversorgung für Patienten mit Oberschenkelknochenverlust darstellen können. Die Indikation sollte erst nach dem Versagen einer Schaftversorgung erfolgen und Kontraindikationen müssen umfassend ausgeschlossen werden. Die größten Herausforderungen im Rehabilitationsprozess stellen die Vermeidung von Stomakomplikationen, Infektionen und orthopädie-technischen Problemen dar. Die Rehabilitation von Amputierten, die mit TOPS behandelt werden, erfordert daher ein interdisziplinäres, spezialisiertes Rehabilitations-Team und eine lebenslange rehabilitative Versorgung.

This article presents the case of a 46-year-old woman with fibromyalgia with an undetected fracture of the coccyx. The heterogeneity of the symptoms of patients suffering from fibromyalgia including chronic widespread pain, vegetative and functional disorders, mental and physical exhaustion as well as sleep disorders can cause accidentally undetected comorbidities, especially if these are rare and predominantly present with pain as the main symptom. In the present case the reason for symptoms was detected only after 14 months of ineffective therapies and diagnostic procedures. The coccygeal pain was eliminated through a coccygectomy as ultima ratio. It should be nevertheless emphasized that patients with fibromyalgia suffer from a central pain-processing disorder. Indications for operative treatment must be very carefully considered. Surgery should only be considered in consultation with the patient and after failed conservative therapy.