W Rüther

University Medical Center Hamburg - Eppendorf, Hamburg, Hamburg, Germany

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Publications (239)412.81 Total impact

  • M Seller, S Kahl, S Seitz, W Rüther
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    ABSTRACT: This extended classification of joint implant related pathology is a practical histopathologic classification based on defined morphological criteria covering the complete spectrum of pathohistologic changes in periprosthetic tissues. These changes may occur as a consequence of endoprosthetic replacement of large joints and may lead to a reduction in the prosthesis survival rate. We describe the established consensus classification of the periprosthetic membrane, in which aseptic and septic prosthetic loosening can be subdivided into four histological types, as well as histopathological criteria for additional significant pathologies including endoprosthetic-associated arthrofibrosis, particle-induced immunological, inflammatory and toxic mechanisms (adverse reactions), and bone tissue pathologies. These characteristic tissue alterations and their relationships are summarized in the extended classification. Since particle heterogeneity in periprosthetic tissue is high and particle identification is a necessary part of diagnosis, the identification of different types of particles is described in the histopathological particle algorithm. The morphological qualities of prosthetic material particles and the demarcation between abrasion and non-abrasion endogenous particles are also summarized. This feasible classification which is based on low cost standard tissue processing and examination and on well-defined diagnostic criteria is a solid platform for the histological diagnosis of implant associated pathologies providing a stable and reproducible tool for the surgical pathologist. Since this classification is suitable for standardized histopathological diagnostics, it might also provide a useful data set for joint arthroplasty registers, particularly for registers based on so-called routine data.
    Pathology - Research and Practice 12/2014; 210(12). DOI:10.1016/j.prp.2014.09.017 · 1.56 Impact Factor
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    ABSTRACT: In the histopathological diagnostics of synovitis and the synovium-like interface membrane (SLIM) the identification of crystals and crystal-like deposits and the associated inflammatory reactions play an important role. The multitude of endogenous crystals, the range of implant materials and material combinations, and the variability in the formation process of different particles explain the high morphological particle heterogeneity which complicates the diagnostic identification of diagnostic particles. A simple histopathological particle algorithm has been designed which allows methodological particle identification based on (1) conventional transmitted light microscopy with a guide to particle size, shape and color, (2) optical polarization criteria and (3) enzyme histochemical properties (oil red staining and Prussian blue reaction). These methods, the importance for particle identification and the differential diagnostics from non-prosthetic materials are summarized in the so-called histopathological particle algorithm. A total of 35 cases of synovitis and SLIM were analyzed and validated according to these criteria. Based on these criteria and a dichotomous differentiation the complete spectrum of particles in the SLIM and synovia can be defined histopathologically. For histopathological diagnosis a particle score for synovitis and SLIM is recommended to evaluate (1) the predominant type of prothetic wear debris with differentiation between microparticles, and macroparticles, (2) the presence of non-prosthesis material particles and (3) the quantification of particle-association necrosis and lymphocytosis. An open, continuously updated web-based particle algorithm would be helpful to address the issue of particle heterogeneity and include all new particle materials generated in a rapidly changing field.
    Zeitschrift für Rheumatologie 05/2014; DOI:10.1007/s00393-013-1315-6 · 0.46 Impact Factor
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    ABSTRACT: Chronic environmental fluoride exposure under calcium stress causes fragility fractures due to osteoporosis and bone quality deterioration, at least in sheep. Proof of skeletal fluorosis, presenting without increased bone density, calls for a review of fracture incidence in areas with fluoridated groundwater, including an analysis of patients with low bone mass. Understanding the skeletal effects of environmental fluoride exposure especially under calcium stress remains an unmet need of critical importance. Therefore, we studied the skeletal phenotype of sheep chronically exposed to highly fluoridated water in the Kalahari Desert, where livestock is known to present with fragility fractures. Dorper ewes from two flocks in Namibia were studied. Chemical analyses of water, blood and urine were executed for both cohorts. Skeletal phenotyping comprised micro-computer tomography (μCT), histological, histomorphometric, biomechanical, quantitative backscattered electron imaging (qBEI) and energy-dispersive X-ray (EDX) analysis. Analysis was performed in direct comparison with undecalcified human iliac crest bone biopsies of patients with fluoride-induced osteopathy. The fluoride content of water, blood and urine was significantly elevated in the Kalahari group compared to the control. Surprisingly, a significant decrease in both cortical and trabecular bones was found in sheep chronically exposed to fluoride. Furthermore, osteoid parameters and the degree and heterogeneity of mineralization were increased. The latter findings are reminiscent of those found in osteoporotic patients with treatment-induced fluorosis. Mechanical testing revealed a significant decrease in the bending strength, concurrent with the clinical observation of fragility fractures in sheep within an area of environmental fluoride exposure. Our data suggest that fluoride exposure with concomitant calcium deficit (i) may aggravate bone loss via reductions in mineralized trabecular and cortical bone mass and (ii) can cause fragility fractures and (iii) that the prevalence of skeletal fluorosis especially due to groundwater exposure should be reviewed in many areas of the world as low bone mass alone does not exclude fluorosis.
    Osteoporosis International 04/2014; DOI:10.1007/s00198-014-2707-4 · 4.04 Impact Factor
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    ABSTRACT: The term rapid destructive hip disease (RDHD) designates a rare coxarthropathy characterized by a rapid destruction of the femoral head within a few weeks to several months. The etiology and pathogenesis of RDHD are not understood. The goal of this study was to define the histological and histomorphometric hallmarks of RDHD to provide a basis for a deeper understanding of the underlying mechanisms. Fifteen consecutive RDHD patients (mean age 78.9 ± 6.4 years, 14 females) demonstrated the characteristic radiographic appearance of vanishing femoral head bone stock without signs of reactive anabolic changes. Histologic and histomorphometric analyses revealed severe bone resorption with significantly increased numbers of morphologically altered giant osteoclasts, the formation of giant cell granulomas both in bone marrow and the synovium and significantly increased osteoblast numbers and osteoid as compared to controls with primary osteoarthritis (OA). These results suggest that in RDHD, an unknown stimulus leads to a massive activation of osteoclasts and this in turn provokes a reactive increase in osteoblast activity that is too weak to counteract the rapid destruction of the hip, thus providing a rationale for a prospective systematic search for the stimuli upstream of the massively increased osteoclast activation in RDHD. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
    Journal of Orthopaedic Research 01/2014; 32(5). DOI:10.1002/jor.22573 · 2.88 Impact Factor
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    ABSTRACT: A number of unexpected molecules were recently identified as products of osteoblasts, linking bone homeostasis to systemic energy metabolism. Here we identify the lipolytic enzyme hepatic lipase (HL, encoded by Lipc) as a novel cell-autonomous regulator of osteoblast function. In an unbiased genome-wide expression analysis, we find Lipc to be highly induced upon osteoblast differentiation, verified by quantitative Taqman analyses of primary osteoblasts in vitro and of bone samples in vivo. Functionally, loss of HL in vitro leads to increased expression and secretion of osteoprotegerin (OPG), while expression of some osteoblast differentiation makers is impaired. When challenging energy metabolism in a diet-induced obesity (DIO) study, lack of HL leads to a significant increase in bone formation markers and a decrease in bone resorption markers. Accordingly, in the DIO setting, we observe in Lipc(-/-) animals but not in wild-type controls a significant increase in lumbar vertebral trabecular bone mass and formation rate as well as in femoral trabecular bone mass and cortical thickness. Taken together, we demonstrate that HL expressed by osteoblasts has an impact on osteoblast OPG expression and that lack of HL leads to increased bone mass in DIO. These data provide a novel and completely unexpected molecular link in the complex interplay of osteoblasts and systemic energy metabolism.
    Bone 01/2014; DOI:10.1016/j.bone.2014.01.001 · 4.46 Impact Factor
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    ABSTRACT: Several factors have been implicated in unsatisfactory results after total hip replacement (THR). We examined whether femoral offset, as measured on digitised post-operative radiographs, was associated with pain after THR. The routine post-operative radiographs of 362 patients (230 women and 132 men, mean age 70.0 years (35.2 to 90.5)) who received primary unilateral THRs of varying designs were measured after calibration. The femoral offset was calculated using the known dimensions of the implants to control for femoral rotation. Femoral offset was categorised into three groups: normal offset (within 5 mm of the height-adjusted femoral offset), low offset and high offset. We determined the associations to the absolute final score and the improvement in the mean Western Ontario and McMaster Universities osteoarthritis index (WOMAC) pain subscale scores at three, six, 12 and 24 months, adjusting for confounding variables. The amount of femoral offset was associated with the mean WOMAC pain subscale score at all points of follow-up, with the low-offset group reporting less WOMAC pain than the normal or high-offset groups (six months: 7.01 (sd 11.69) vs 12.26 (sd 15.10) vs 13.10 (sd 16.20), p = 0.006; 12 months: 6.55 (sd 11.09) vs 9.73 (sd 13.76) vs 13.46 (sd 18.39), p = 0.010; 24 months: 5.84 (sd 10.23) vs 9.60 (sd 14.43) vs 13.12 (sd 17.43), p = 0.004). When adjusting for confounding variables, including age and gender, the greatest improvement was seen in the low-offset group, with the normal-offset group demonstrating more improvement than the high-offset group. Cite this article: Bone Joint J 2014;96-B:36-42.
    01/2014; 96(1):36-42. DOI:10.1302/0301-620X.96B1.31530
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    ABSTRACT: When it comes to endoprosthesis pathologies, for example implant-allergic/toxic problems, as a cause of implant failure, particle identification has an important role to play in the histopathological diagnostics of the neosynovial/periprosthetic membrane (synovial-like interface membrane, SLIM). The variability of materials in endoprosthetics and differences in particle pathogenesis explain the particle heterogeneity that hampers the diagnostic identification of particles. For this reason, a histopathological particle algorithm has been developed that, with minimal methodical complexity, offers a guide to particle identification. Light microscopic-morphological as well as enzyme-histochemical characteristics and polarization-optical proporties have been defined. Particles are characterized in accordance with a dichotomous principle. Based on these criteria, identification and validation of the particles was carried out in 105 joint endoprosthesis pathological cases. A particle score is proposed that summarizes the most important information for the orthopedist.
    Seminars in Arthroplasty 01/2014; DOI:10.1053/j.sart.2014.01.013
  • 12/2013; DOI:10.1007/s12570-013-0179-1
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    ABSTRACT: Ceramic components in total knee arthroplasty (TKA) are evolving. We analyze the first case of BIOLOX delta ceramic femoral component fracture. A longitudinal midline fracture in the patellar groove was present, with an intact cement mantle and no bony defects. Fractographic analysis with laser scanning microscopy and white light interferometry showed no evidence of arrest lines, hackles, wake hackles, material flaws, fatigue or crack propagation. Analysis of periprosthetic tissues with Fourier-transform infrared (FT-IR) microscopy, contact radiography, histology, and subsequent digestion and high-speed centrifugation did not show ceramic debris. A macrophage-dominated response was present around polyethylene debris. We conclude that ceramic femoral component failure in this case was related to a traumatic event. Further research is needed to determine the suitability of ceramic components in TKA.
    The Journal of arthroplasty 11/2013; DOI:10.1016/j.arth.2013.11.003 · 2.37 Impact Factor
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    ABSTRACT: Hintergrund Zu den Ergebnissen der Schulterendoprothetik im Langzeitverlauf bei Patienten mit rheumatoider Arthritis (RA) ist wenig bekannt. Das Ziel dieser Studie war die Evaluation der Ergebnisse nach zementiertem Oberflächenersatz des proximalen Humerus als Hemiprothese bei Patienten mit RA nach mindestens 10 Jahren postoperativ. Patienten und Methoden Im Zeitraum 1997–2000 wurden 42 zementierte Oberflächenersatz-Hemiprothesen bei 35 Patienten (Durchschnittsalter 61 Jahre) implantiert und in eine prospektive Verlaufsbeobachtungsstudie mit Follow-up nach 3, 12, > 60 und > 120 Monaten eingeschlossen. Nach 131 ± 21 Monaten konnten 16 Schultern (14 Patienten, Durchschnittsalter 70,9 Jahre) radiologisch und klinisch mittels Constant Murley Score (CMS) evaluiert werden. Sieben Patienten waren nicht reisefähig und wurden mittels CMS-Selbstevaluationsbogen sowie übermittelten Röntgenaufnahmen radiologisch erfasst. Ergebnisse Der mittlere CMS betrug 62,6 ± 10,6 Punkte (präoperativ 20,8 ± 8,3). Mit dem Behandlungsergebnis „zufrieden“ oder „sehr zufrieden“ waren 88 % der Patienten. Radiologisch zeigte sich eine deutliche Zunahme der proximalen Migration des Drehzentrums sowie der zentralen Glenoidarrosion (Glenoidtiefe). Die radiologischen Veränderungen korrelierten weder mit dem CMS noch mit der subjektiven Patientenzufriedenheit. Schlussfolgerung Der zementierte Oberflächenersatz des proximalen Humerus als Hemiprothese stellt für ältere Patienten mit RA der Schulter eine sinnvolle Versorgungsoption dar.
    Obere Extremität 09/2013; 8(3):150-156. DOI:10.1007/s11678-013-0219-z
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    ABSTRACT: Die Pathophysiologie der palmaren Fibromatose (Morbus Dupuytren) ist bis heute nicht vollständig verstanden. In den meisten Fällen jedoch können reaktive und reparative Prozesse des sehnenartigen Gewebes klinisch und histopathologisch ausgeschlossen werden. Vorgestellt wird der Fall eines 62-jährigen Patienten, bei dem eine palmare Fibromatose diagnostiziert wurde, nachdem es durch die Zerstörung einer 30 Jahre zuvor implantierten Silikonspacerprothese des Os lunatum zur Ausbildung eines Silikonoms kam. Obwohl Silikonabriebpartikel deutlich distal der ursprünglichen Lokalisation des Lunatumsilikonspacers histologisch identifiziert werden konnten, zeigte das resezierte Gewebe der Palmaraponeurose morphologische Befunde wie bei einer palmaren Fibromatose mit starken degenerativen Veränderungen. Diskutiert werden soll dieser Fall vor dem Hintergrund der aktuell verfügbaren Literatur zum Morbus Dupuytren.
    Der Orthopäde 08/2013; 42(8). DOI:10.1007/s00132-013-2137-6 · 0.67 Impact Factor
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    ABSTRACT: The pathophysiological mechanisms of palmar fibromatosis (Dupuytren's contracture) are still not yet fully understood. In the vast majority of cases, however, reactive changes and reparative processes of tendon tissue can easily be ruled out by clinical and histopathological investigations. This article presents the case of a 62-year-old male patient suffering from palmar fibromatosis associated with a failed silicon spacer of the lunate bone 30 years after index surgery. Although silicon wear particles were observed in distal locations, proximal tendon tissues showed changes consistent with a degenerative palmar fibromatosis in the absence of a pathological wear reaction. The findings are discussed in the light of the current literature on Dupuytren's contracture.
    Der Orthopäde 06/2013; · 0.51 Impact Factor
  • B Fink, A Niemeier, W Rüther
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    ABSTRACT: Cup resurfacing of the humeral head is one of the possible prosthetic solutions for severe destruction of the glenohumeral joint. Because neurological complications are not uncommon after total shoulder arthroplasty using surface replacement, these cups are indicated when hemiarthroplasty is possible. The advantages of humeral head resurfacing are bone preservation and the technically easy exchange if revision is necessary; therefore, young patients are candidates for this type of endoprosthesis. At present humeral head resurfacing is indicated for osteoarthritic destruction of Walch types A1 and C, for rheumatic destruction with deficient cuff in younger patients, cuff arthropathy in younger patients with Seebauer types 1A and 1B, humeral head necrosis with normal glenoid and necrotic bone in less than one third of the humeral head and dislocation arthropathy in younger patients.
    Der Orthopäde 05/2013; 42(7). DOI:10.1007/s00132-012-2019-3 · 0.51 Impact Factor
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    ABSTRACT: We investigated whether an asymmetric extension gap seen on routine post-operative radiographs after primary total knee replacement (TKR) is associated with pain at three, six, 12 and 24 months' follow-up. On radiographs of 277 patients after primary TKR we measured the distance between the tibial tray and the femoral condyle on both the medial and lateral sides. A difference was defined as an asymmetric extension gap. We considered three groups (no asymmetric gap, medial-opening and lateral-opening gap) and calculated the associations with the Western Ontario and McMaster Universities osteoarthritis index pain scores over time. Those with an asymmetric extension gap of ≥ 1.5 mm had a significant association with pain scores at three months' follow-up; patients with a medial-opening extension gap reported more pain and patients with a lateral-opening extension gap reported less pain (p = 0.036). This effect was still significant at six months (p = 0.044), but had lost significance by 12 months (p = 0.924). When adjusting for multiple cofounders the improvement in pain was more pronounced in patients with a lateral-opening extension gap than in those with a medial-opening extension gap at three (p = 0.037) and six months' (p = 0.027) follow-up. Cite this article: Bone Joint J 2013;95-B:472-7.
    04/2013; 95-B(4):472-7. DOI:10.1302/0301-620X.95B4.31080
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    ABSTRACT: Object Disc-related disorders such as herniation and chronic degenerative disc disease (DDD) are often accompanied by acute or chronic pain. Different mediators have been identified in the development of radicular pain and DDD. Previous studies have not analyzed individual cytokine profiles discriminating between acute sciatic and chronic painful conditions, nor have they distinguished between different anatomical locations within the disc. The aim of this study was to elucidate the protein biochemical mechanisms in DDD. Methods The authors determined expression levels of matrix metalloproteinase-3, transforming growth factor-β (TGF-β), tumor necrosis factor-α, interleukin-1α, and pro-substance P using enzyme-linked immunosorbent assay and Western blot analyses in patients suffering from DDD (n = 7), acute back pain due to herniated discs with radiculopathy (n = 7), and a control group (n = 7). Disc tissue samples from the anulus fibrosus (AF) and nucleus pulposus (NP) were analyzed. Statistical analysis was performed using nonparametric tests. Results A distinct distribution of cytokines was found in different anatomical regions of intervertebral discs in patients with DDD and herniated NP. Increased TGF-β levels were predominantly found in DDD. Matrix metalloproteinase-3 was increased in acute herniated disc material. Increased levels of substance P were found in patients suffering from DDD but not in patients with disc herniation. The data showed significantly higher levels of proinflammatory cytokines in the AF and NP of patients with DDD, and the expression levels in the AF were even higher than in the NP, suggesting that the inflammatory response initiates from the AF. Conclusions These results highlight the complex mechanisms involved during disc degeneration and the need to distinguish between acute and chronic processes as well as different anatomical regions, namely the AF and NP. They also highlight potential problems in disc nucleus replacement therapies because the results suggest a biochemical link between AF and NP cytokine expression.
    Journal of neurosurgery. Spine 03/2013; DOI:10.3171/2013.1.SPINE12483 · 1.61 Impact Factor
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    ABSTRACT: The revised classification of the periprosthetic membrane (synovial-like interface membrane SLIM) encompasses all pathological alterations which can occur as a result of endoprosthetic replacement of major joints and lead to a reduction in durability of prostheses. This also includes the established consensus classification of SLIM by which aseptic and septic prosthetic loosening can be subdivided into four histological types and histopathological criteria for additional pathologies: endoprosthesis-associated arthrofibrosis, immunological/allergic alterations and osseous pathologies. This revision represents the foundation for the histopathological diagnostics of the total spectrum of diseases associated with joint prostheses, is a suitable basis for a standardized diagnostic procedure and etiological clarification of endoprosthesis failure and also as a data standard for endprosthesis registers, in particular for registers based on routine data (e.g. German endoprosthesis register).
    Zeitschrift für Rheumatologie 02/2013; 72(4). DOI:10.1007/s00393-012-1099-0 · 0.46 Impact Factor
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    ABSTRACT: Chronic pain appears to be associated with brain gray matter reduction in areas ascribable to the transmission of pain. The morphological processes underlying these structural changes, probably following functional reorganisation and central plasticity in the brain, remain unclear. The pain in hip osteoarthritis is one of the few chronic pain syndromes which are principally curable. We investigated 20 patients with chronic pain due to unilateral coxarthrosis (mean age 63.25±9.46 (SD) years, 10 female) before hip joint endoprosthetic surgery (pain state) and monitored brain structural changes up to 1 year after surgery: 6-8 weeks, 12-18 weeks and 10-14 month when completely pain free. Patients with chronic pain due to unilateral coxarthrosis had significantly less gray matter compared to controls in the anterior cingulate cortex (ACC), insular cortex and operculum, dorsolateral prefrontal cortex (DLPFC) and orbitofrontal cortex. These regions function as multi-integrative structures during the experience and the anticipation of pain. When the patients were pain free after recovery from endoprosthetic surgery, a gray matter increase in nearly the same areas was found. We also found a progressive increase of brain gray matter in the premotor cortex and the supplementary motor area (SMA). We conclude that gray matter abnormalities in chronic pain are not the cause, but secondary to the disease and are at least in part due to changes in motor function and bodily integration.
    PLoS ONE 02/2013; 8(2):e54475. DOI:10.1371/journal.pone.0054475 · 3.53 Impact Factor
    This article is viewable in ResearchGate's enriched format
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    ABSTRACT: Although the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index was originally developed for the assessment of non-operative treatment, it is commonly used to evaluate patients undergoing either total hip (THR) or total knee replacement (TKR). We assessed the importance of the 17 WOMAC function items from the perspective of 1198 patients who underwent either THR (n = 704) or TKR (n = 494) in order to develop joint-specific short forms. After these patients were administered the WOMAC pre-operatively and at three, six, 12 and 24 months' follow-up, they were asked to nominate an item of the function scale that was most important to them. The items chosen were significantly different between patients undergoing THR and those undergoing TKR (p < 0.001), and there was a shift in the priorities after surgery in both groups. Setting a threshold for prioritised items of ≥ 5% across all follow-up, eight items were selected for THR and seven for TKR, of which six items were common to both. The items comprising specific WOMAC-THR and TKR function short forms were found to be equally responsive compared with the original WOMAC function form. Cite this article: Bone Joint J 2013;95-B:239-43.
    02/2013; 95-B(2):239-43. DOI:10.1302/0301-620X.95B2.28383
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    ABSTRACT: Die erweiterte Klassifikation der periprothetischen Membran (,,synovial-like interface membrane“, SLIM) umfasst die Gesamtheit der pathologischen Veränderungen, die als Folge der endoprothetischen Versorgung großer Gelenke auftreten können und zu einer Reduktion der Prothesenstandzeit führen. Hierzu gehören die etablierte Konsensusklassifikation der SLIM, mit der sich die aseptische und septische Prothesenlockerung in 4 histologische Typen einteilen lassen, sowie histopathologische Kriterien für weitere Pathologien: Endoprothesen-assoziierte Arthrofibrose, immunologische/allergische Befunde und ossäre Pathologien. Diese Erweiterung stellt eine Grundlage für die histopathologische Diagnostik des gesamten Spektrums von Gelenkendoprothesen-assoziierten Erkrankungen dar und eignet sich als Basis für eine standardisierte Diagnostik und ätiologische Abklärung des Endoprothesenversagens und auch als Datenstandard für Endoprothesenregister, insbesondere für Register, die auf Routinedaten basieren (z. B. Deutsches Endoprothesenregister).
    Zeitschrift für Rheumatologie 01/2013; 72(4). · 0.46 Impact Factor

Publication Stats

2k Citations
412.81 Total Impact Points


  • 1997–2014
    • University Medical Center Hamburg - Eppendorf
      • • Department of Orthopaedics
      • • Department of Osteology and Biomechanics
      Hamburg, Hamburg, Germany
  • 2013
    • Orthopädische Klinik Markgröningen
      Ludwigsburg, Baden-Württemberg, Germany
  • 2011–2013
    • University Hospital Magdeburg
      Magdeburg, Saxony-Anhalt, Germany
    • Asklepios Klinikum Bad Abbach
      Abach, Bavaria, Germany
    • Medbaltic
      Kiel, Schleswig-Holstein, Germany
  • 2010–2013
    • University Medical Center Schleswig-Holstein
      Kiel, Schleswig-Holstein, Germany
  • 1997–2013
    • University of Hamburg
      • • Department of Orthopaedics
      • • Department of Pathology
      Hamburg, Hamburg, Germany
  • 2012
    • Johannes Gutenberg-Universität Mainz
      Mayence, Rheinland-Pfalz, Germany
    • William Harvey Research Institute
      Londinium, England, United Kingdom
  • 2002–2011
    • Schön Klinik Bad Bramstedt
      Chiemsee, Bavaria, Germany
    • Medical School Hamburg
      Hamburg, Hamburg, Germany
  • 2008
    • Technische Universität Hamburg-Harburg
      Hamburg, Hamburg, Germany
  • 2007
    • Ruhr-Universität Bochum
      • Medizinische Klinik I
      Bochum, North Rhine-Westphalia, Germany
  • 2006
    • Evangelisches Waldkrankenhaus Spandau
      Berlin, Germany
  • 2004–2006
    • Charité Universitätsmedizin Berlin
      • Institute of Pathology
      Berlin, Land Berlin, Germany
    • Universitätsklinikum Schleswig - Holstein
      Kiel, Schleswig-Holstein, Germany
  • 1996–2003
    • Orthopädische Universitätsklinik Friedrichsheim
      Frankfurt, Hesse, Germany
  • 1995–2003
    • Heinrich-Heine-Universität Düsseldorf
      • Orthopädische Klinik
      Düsseldorf, North Rhine-Westphalia, Germany
  • 2001
    • Aarhus University Hospital
      Aarhus, Central Jutland, Denmark