[Zoster disease after Shingrix vaccination]. / Zostererkrankung nach Shingrix-Impfung.

Shingrix is a recombinant adjuvant subunit vaccine. The vaccine is approved in Germany for prevention of zoster manifestation and postherpetic neuralgia in adults aged ≥60 years. In the case of bullous skin lesions after vaccination with Shingrix a zoster disease should be considered. Unexpected side effects associated with the vaccination should be reported to the Drug Commission of the German Medical Association.

Selective bundle tensioning in double-bundle MPFL reconstruction to improve restoration of dynamic patellofemoral contact pressure.

PURPOSE: To evaluate the optimal graft tension angles in a medial patellofemoral ligament (MPFL) reconstruction with selective bundle tensioning in order to restore patellofemoral contact pressure distributions closest to the native state. METHODS: Twelve human cadaveric knee specimens were mounted with the femur on a custom-made fixation device allowing free range of motion in the knee joint for testing. Using a sensitive pressure film (Tekscan) patellofemoral contact pressure was measured in 15° intervals during a dynamic flexion movement from 0°-90° in the native state, in cut MPFL and after MPFL-reconstruction with a gracilis tendon. The graft was separated in two bundles and was fixed independently on the patella using two knotless anchors. Two groups were made with either the proximal or distal bundle fixed at the femur at a knee flexion angle of 30° and the corresponding other bundle subsequently fixed at the femur at 15°, 45°, 60°, 75° and 90° of knee flexion using extra-cortical fixation and controlled tension of 2N in both groups. The sequence of the flexion angles at the graft fixation was alternated. Pressure measurements were repeated after every fixation of the graft. RESULTS: Cutting the MPFL resulted in significantly reduced patellofemoral contact pressure at all flexion angles. After MPFL reconstruction the patellofemoral contact pressure remained significantly reduced during dynamic knee flexion in all tested double-bundle combinations (p < 0.05) except for fixation of the proximal bundle in 30° and the distal bundle in 75°. Selective evaluation of lateral patellofemoral contact pressure, however, showed significant reduction in all tested double-bundle combinations (p < 0.05) from 15° to 90°. Evaluation of isolated medial patellofemoral pressure changes showed no significant difference in all tested combinations compared to the intact knee. Furthermore, evaluation of the isolated proximal and distal patellofemoral contact pressure also revealed a significantly reduced contact pressure in all tested double-bundle combinations (p < 0.05) except for fixation of the proximal bundle in 30° and the distal bundle in 75°. CONCLUSION: According to this study, selective bundle tensioning in anatomic MPFL-reconstruction should be considered as an easy and more anatomic alternative to current popular techniques to restore patella kinematics and give clear recommendation about knee flexion angle and tension during fixation. Although tensioning two bundles separately may further improve clinical results. If performed, fixation of the graft is recommended under low tension (2N) with the proximal bundle at 30° and the distal bundle at 75° of knee flexion.

[Pityriasis rubra pilaris : Successful treatment with ixekizumab]. / Pityriasis rubra pilaris : Eine erfolgreiche Therapie mit Ixekizumab.

Pityriasis rubra pilaris is a rare papulosquamous chronic skin disease. The disease often exists for years and is difficult to treat. Not only is it clinically similar to psoriasis vulgaris, but both diseases also have a similar cytokine profile. The successful use of biologicals is frequently reported in case reports. Studies with large numbers of cases are lacking.

[Endoprosthetic replacement following intercalary resection]. / Endoprothetische Rekonstruktion nach interkalarer Resektion.

BACKGROUND: Endoprosthetic replacement is a valuable treatment option following intercalary resection of bone tumours in the diaphysis. OBJECTIVES: To identify indication, operative technique, implants currently available, literature results and alternative procedures for the alloplastic reconstruction of segmental bone defects. MATERIALS AND METHODS: This review article summarizes the authors' own experiences and relevant clinical studies focussing on this topic. RESULTS: According to the literature, 10-year-survival rates of intercalary endoprostheses range between 64 and 80%. Yet, comparisons between different publications are difficult due to the limited number of cases, different implants, follow-up periods and the heterogeneous patient populations. Biological alternatives for reconstruction are autologous bone transplantation, distraction osteogenesis and bone transport, allogenic bone transplantation, and the induced membrane technique. Innovative tissue engineering approaches are still limited to preclinical testing. CONCLUSIONS: Short- to mid-term results for segmental endoprostheses following intercalary resections are satisfactory and may be regarded as superior to those of biological reconstructions due to the immediate full weight-bearing capability. However, they are mainly applied for elderly patients and in palliative situations because of potential long-term complications.

[Diagnostics and treatment of osteoid osteoma]. / Diagnostik und Therapie des Osteoidosteoms.

BACKGROUND: Osteoid osteoma is the third most common benign bone tumor and typically induces pain that is worse at night. OBJECTIVE: To identify the epidemiological, pathogenetic, histological and radiological characteristics of osteoid osteoma and to present the broad variety of treatment options. MATERIAL AND METHODS: This review article summarizes relevant clinical studies and meta-analyses on this topic. RESULTS: Osteoid osteoma is characterized by a central nidus smaller than 1.5 cm in diameter with surrounding bone sclerosis. In the majority of cases, the tumor occurs in the long bones of the lower extremities and is predominantly manifested in patients aged between 5 and 25 years. Pain is mediated by prostaglandins, which stimulate afferent peripheral nerve fibers. Besides plain radiographs, thin-section computed tomography represents the gold standard of diagnostics but should be complemented by magnetic resonance or nuclear medicine imaging modalities. The conservative treatment consists of long-term therapy with non-steroidal anti-inflammatory drugs. Minimally invasive radiofrequency ablation of the nidus is the current operative treatment of choice. CONCLUSION: Success rates of radiofrequency ablation and other minimally invasive procedures are high while treatment costs and length of hospital stay are low. Thus, open surgical curettage is reserved for rare indications and en bloc excision of the nidus should only be performed in cases of recurrent lesions.

[Patella position and patellofemoral osteoarthritis after unicompartmental arthroplasty]. / Patellaposition und Patellofemoralarthrose nach unikompartimentellem Kniegelenkersatz.

BACKGROUND: Changes of patellar position (height, tilt, and shift) and arthritis of the patellofemoral joint might potentially influence outcome after unicompartmental knee replacement. OBJECTIVES: The purpose of this work is to evaluate the influence of the aforementioned parameters on postoperative outcome. METHODS: Literature analysis via PubMed. RESULTS: A total of 12 relevant studies (three about Patellar height, two about patellar tilt and shift, seven about patellofemoral osteoarthritis) could be identified. Regarding Patellar height, two out of three studies demonstrated a postoperative decrease. With regard to patellar tilt and shift, only one study identified postoperative lateralization of the patella to be a predictor for poor outcome. The radiological appearance of arthritis of the patellofemoral joint does not significantly influence postoperative knee function except for cases where only the lateral patellar facet is affected. Anterior knee pain has no influence on clinical outcome. CONCLUSION: Literature data do not allow for a precise statement about the possible influence of patellar position on the outcome after unicompartmental knee replacement. With proper patient selection, good results can be achieved despite patellofemoral osteoarthritis.

[Medial unicondylar knee replacement]. / Die mediale monokondyläre Kniegelenkprothese.

BACKGROUND: Unicondylar knee replacement (UKA) is a viable alternative to high tibial osteotomy (HTO) and total knee replacement in the treatment of medial osteoarthritis of the knee. With the correct indication, the results of UKA and HTO are comparable. RESULTS: In comparison with the results of total knee replacements, UKA leads to faster rehabilitation, superior postoperative range of motion, and higher postoperative activity levels. Despite the excellent long-term results, the survival rate is inferior to the results of total knee replacement. The major causes for failure are progression of osteoarthritis in the lateral and patellofemoral joint as well as the loosening of the tibial component. CONCLUSION: The conversion to total knee replacement can mostly be performed without problems. However, the expected results are inferior to primary total knee replacement and the reported revision rates are higher.

Parathyroid hormone [1-34] improves articular cartilage surface architecture and integration and subchondral bone reconstitution in osteochondral defects in vivo.

OBJECTIVE: The 1-34 amino acid segment of the parathyroid hormone (PTH [1-34]) mediates anabolic effects in chondrocytes and osteocytes. The aim of this study was to investigate whether systemic application of PTH [1-34] improves the repair of non-osteoarthritic, focal osteochondral defects in vivo. DESIGN: Standardized cylindrical osteochondral defects were bilaterally created in the femoral trochlea of rabbits (n = 8). Daily subcutaneous injections of 10 µg PTH [1-34]/kg were given to the treatment group (n = 4) for 6 weeks, controls (n = 4) received saline. Articular cartilage repair was evaluated by macroscopic, biochemical, histological and immunohistochemical analyses. Reconstitution of the subchondral bone was assessed by micro-computed tomography. Effects of PTH [1-34] on synovial membrane, apoptosis, and expression of the PTH receptor (PTH1R) were determined. RESULTS: Systemic PTH [1-34] increased PTH1R expression on both, chondrocytes and osteocytes within the repair tissue. PTH [1-34] ameliorated the macro- and microscopic aspect of the cartilaginous repair tissue. It also enhanced the thickness of the subchondral bone plate and the microarchitecture of the subarticular spongiosa within the defects. No significant correlations were established between these coexistent processes. Apoptotic levels, synovial membrane, biochemical composition of the repair tissue, and type-I/II collagen immunoreactivity remained unaffected. CONCLUSIONS: PTH [1-34] emerges as a promising agent in the treatment of focal osteochondral defects as its systemic administration simultaneously stimulates articular cartilage and subchondral bone repair. Importantly, both time-dependent mechanisms of repair did not correlate significantly at this early time point and need to be followed over prolonged observation periods.

Alterations of the subchondral bone in osteochondral repair--translational data and clinical evidence.

Alterations of the subchondral bone are pathological features associated with spontaneous osteochondral repair following an acute injury and with articular cartilage repair procedures. The aim of this review is to discuss their incidence, extent and relevance, focusing on recent knowledge gained from both translational models and clinical studies of articular cartilage repair. Efforts to unravel the complexity of subchondral bone alterations have identified (1) the upward migration of the subchondral bone plate, (2) the formation of intralesional osteophytes, (3) the appearance of subchondral bone cysts, and (4) the impairment of the osseous microarchitecture as potential problems. Their incidence and extent varies among the different small and large animal models of cartilage repair, operative principles, and over time. When placed in the context of recent clinical investigations, these deteriorations of the subchondral bone likely are an additional, previously underestimated, factor that influences the long-term outcome of cartilage repair strategies. Understanding the role of the subchondral bone in both experimental and clinical articular cartilage repair thus holds great promise of being translated into further improved cell- or biomaterial-based techniques to preserve and restore the entire osteochondral unit.

Evaluation of the antinociceptive activity of Ocimum gratissimum L. (Lamiaceae) essential oil and its isolated active principles in mice.

Ocimum gratissimum is used in popular medicine to treat painful diseases. The antinociceptive properties of O. gratissimum essential oil (OgEO) and two of its active principles (eugenol and myrcene) were tested in classic models of pain (hot plate test and formalin test). Adult male C57BL/6 J mice acutely received corn oil (control group, p.o.), morphine (positive control group, 5 mg/kg, i.p.), OgEO (10, 20, or 40 mg/kg, p.o.), eugenol or myrcene (both at 1, 5, or 10 mg/kg, p.o.). The highest doses of all tested drugs significantly increased the latency to lick the paw(s) in the hot plate test compared with the control group. OgEO at a dose of 40 mg/kg and eugenol and myrcene at a dose of 10 mg/kg were effective in minimizing animal pain in the first and second phases of the formalin test. The antinociceptive effect shown by all drugs tested in hot plate test was reverted by naloxone administration (1 mg/kg), indicating opiod system participation. These results demonstrate the beneficial effects of OgEO and its active principles against neurogenic and inflammatory pain. Our findings demonstrate that OgEO and its isolated active principles exhibited antinociceptive activity in murine pain models.

Differences in fixation stability between spacer plate and plate fixator following high tibial osteotomy.

PURPOSE: Since in vivo stability following high tibial osteotomy is unknown, surgeons customize the postoperative rehabilitation to the assumed implant stability, leaving us with numerous rehabilitation protocols. The purpose of the study is to quantify the fixation stability of different open-wedge high tibial osteotomy implants. It is hypothesized that the higher fixation stability of a plate fixator justifies early weight bearing. METHODS: In this prospective 30-subject clinical trial, fixation stability was determined over a 2-year period using radiostereometric analysis (RSA). Patients were assigned to two angle-stable osteotomy plates: a spacer plate with 6 postoperative weeks of feather-touch weight bearing versus a plate fixator with 2 postoperative weeks of feather-touch weight bearing. RESULTS: Postoperative RSA data showed a significant higher lateral translation of the distal tibia and a significantly increased subsidence, varus and internal rotation of the tibial head in the spacer plate compared to the plate fixator group. Weight bearing following spacer plate fixation induced significant micromotion 6 weeks after surgery. Three months after surgery, bone healing was achieved regardless of the used implant. CONCLUSIONS: Early weight bearing is appropriate for plate fixator fixation. The 6-week period of delayed weight bearing following spacer plate fixation is inadequate and should be prolonged presumably up to 8-10 weeks to avoid pseudarthrosis and/or recurrence of varus angulation. LEVEL OF EVIDENCE: Level II, diagnostic study--investigating a diagnostic test.

[Osteotomy of the greater trochanter]. / Osteotomien des Trochanter major.

The increasing number of total hip arthroplasty procedures lead to an increasing number of revision surgeries. The trochanteric osteotomy technique is an established procedure in selected cases with the necessity of extending the usual surgical approach. Trochanteric osteotomy is also successfully performed in other areas, such as trauma surgery and joint-preserving surgery (surgical dislocation). Several techniques for trochanteric osteotomy are availably employing various fixation techniques and implants. This article presents the most common trochanteric osteotomy techniques for extension of the surgical approach (the classical according to Charnley, the trochanter slide, the extended trochanteric, and the stepped osteotomy) as well as clinical results and biomechanical experiences.

[Osteotomy for approaches to the knee joint. Tibial tubercle, lateral epicondyle of the femur and head of the fibula]. / Osteotomie bei Zugängen zum Kniegelenk: Tuberositas tibiae, Epicondylus femoris lateralis und Caput fibulae.

The present article summarizes the different osteotomy techniques for an extension of standard surgical approaches to the knee joint in selected patients. The aim is to achieve satisfactory exposure and reduce potential postoperative complications compared to alternative techniques, such as the V-Y plasty or the quadriceps snip procedures. Osteotomy of the tibial tubercle is a reasonable extension of the anteromedial or the anterolateral surgical approach in selected patients undergoing revision total knee replacement. This osteotomy will provide excellent surgical exposure of the knee without the risk of avulsion of the patellar tendon and will preserve the blood supply of the patella and the surrounding soft tissue. Moreover, functional clinical outcome will be improved by minimizing damage to the extensor mechanism. Osteotomy of the lateral femoral condyle gives excellent exposure of the posterolateral aspect of the knee joint which might be necessary in some patients with fractures of the posterolateral tibial plateau as well as patients undergoing open allograft transplantation of the lateral meniscus. An alternative option for an extended exposure to the posterolateral knee joint is accomplished by osteotomy or partial resection of the fibular head which is also described as having good clinical results and a low complication rate.

Temporal and spatial migration pattern of the subchondral bone plate in a rabbit osteochondral defect model.

OBJECTIVE: Upward migration of the subchondral bone plate is associated with osteochondral repair. The aim of this study was to quantitatively monitor the sequence of subchondral bone plate advancement in a lapine model of spontaneous osteochondral repair over a 1-year period and to correlate these findings with articular cartilage repair. DESIGN: Standardized cylindrical osteochondral defects were created in the rabbit trochlear groove. Subchondral bone reconstitution patterns were identified at five time points. Migration of the subchondral bone plate and areas occupied by osseous repair tissue were determined by histomorphometrical analysis. Tidemark formation and overall cartilage repair were correlated with the histomorphometrical parameters of the subchondral bone. RESULTS: The subchondral bone reconstitution pattern was cylindrical at 3 weeks, infundibuliform at 6 weeks, plane at 4 and 6 months, and hypertrophic after 1 year. At this late time point, the osteochondral junction advanced 0.19 [95% confidence intervals (CI) 0.10-0.30] mm above its original level. Overall articular cartilage repair was significantly improved by 4 and 6 months but degraded after 1 year. Subchondral bone plate migration correlated with tidemark formation (r = 0.47; P < 0.0001), but not with the overall score of the repair cartilage (r = 0.11; P > 0.44). CONCLUSIONS: The subchondral bone plate is reconstituted in a distinct chronological order. The lack of correlation suggests that articular cartilage repair and subchondral bone reconstitution proceed at a different pace and that the advancement of the subchondral bone plate is not responsible for the diminished articular cartilage repair in this model.

Influence of the initial rupture size and tendon subregion on three-dimensional biomechanical properties of single-row and double-row rotator cuff reconstructions.

PURPOSE: Influence of the initial rotator cuff tear size and of different subregions of the SSP tendon on the cyclic loading behavior of a modified single-row reconstruction compared to a suture-bridging double-row repair. METHODS: Artificial tears (25 and 35 mm) were created in the rotator cuff of 24 human cadaver shoulders. The reconstructions were performed as a single-row repair (SR) using a modified suture configuration or a suture-bridge double-row repair (DR). Radiostereometric analysis was used under cyclic loading (50 cycles, 10­180 N, 10­250 N) to calculate cyclic displacement in three different planes (anteroposterior (x), craniocaudal (y) and mediolateral (z) level). Cyclic displacement was recorded, and differences in cyclic displacement of the anterior compared to the posterior subregions of the tendon were calculated. RESULTS: In small-to-medium tears (25 mm) and medium-to-large tears (35 mm), significant lower cyclic displacement was seen for the SR-reconstruction compared to the DR-repair at 180 N (p ≤ 0.0001; p = 0.001) and 250 N (p = 0.001; p = 0.007) in the x-level. These results were confirmed in the y-level at 180 N (p = 0.001; p = 0.0022) and 250 N (p = 0.005; p = 0.0018). Comparison of the initial tear sizes demonstrated significant differences in cyclic displacement for the DR technique in the x-level at 180 N (p = 0.002) and 250 N (p = 0.004). Comparison of the anterior versus the posterior subregion of the tendon revealed significant lower gap formation in the posterior compared to the anterior subregions in the x-level for both tested rotator cuff repairs (p ≤ 0.05). CONCLUSIONS: The tested single-row repair using a modified suture configuration achieved superior results in three-dimensional measurements of cyclic displacement compared to the tested double-row suture-bridge repair. The results were dependent on the initial rupture size of the rotator cuff tear. Furthermore, significant differences were found between tendon subregions of the rotator cuff with significantly higher gap formation for the anterior compared to the posterior subregions.

[Femoral osteonecrosis - Ahlbaeck's disease]. / Femorale Osteonekrose - Morbus Ahlbäck.

Osteonecrosis of the knee can present as a spontaneous, primary (SPON) or a secondary clinical entity (SON). The natural history of SPON follows a course of several sequential stages which seem to be irreversible in later stages of both entities. Early diagnosis of ON is crucial and the earlier the stage of the lesion at the time of diagnosis, the better the prognosis. Clinically, early diagnosis and treatment of ON might prevent unnecessary surgery in cases with a concomitant degenerative meniscal tear. From a medicolegal viewpoint early-stage ON should be ruled out prior to surgery as arthroscopy has recently been associated with ON. Recent biopsy studies showed that SPONK is most likely caused by insufficiency fractures which seem to appear as osteonecrotic lesions in later stages of the disease due to failed bone healing.