Reverse total shoulder arthroplasty policy in Germany - an analysis of the health care reality from 2010 to 2022.

BACKGROUND: The last few years have been characterized by increasing numbers of reverse shoulder arthroplasties. In addition to the classic indication of cuff tear arthropathy, the use for complex proximal humeral fractures (PHFs) and rotator cuff tear (RCT) in very old patients have been established. The objective of this study is to clarify and substantiate the above statements specifically for Germany (based on official data from 2010 to 2022). Since substantial changes in the structure of the population are expected over time, all data must be adjusted for these changes. The hypotheses are (1) the German population is ageing with a shift to more elderly patients over time, and (2) the general use of shoulder arthroplasty (total anatomic - shoulder arthroplasty (aTSA) and reverse - rTSA) has increased during the time period, but the effect is beyond the shift of age stratification but attributable to a change of hospital admissions and surgical therapy for PHF and RCT. METHODS: In this retrospective study, data were collected from the National Bureau of Statistics in Germany for the period of 2010 to 2022. Three different data sources were combined for the analysis: a database regarding the structure of the population in age groups for every year, a database reporting relevant operation codes, and the data on hospital admissions based on ICD-10 codes. The relevant data were extracted and combined using Excel spread sheets (Microsoft Corporation, version 2019). Absolute numbers are reported and adjusted for 100.000 inhabitants in each age group in order to calculate the incidence. RESULTS: Only slight change in absolute numbers of the population (n = 81751602 to 84358845, +3%) was observed, but a substantial shift toward the group of elderly people: the peak age group has shifted from 40-50 to 55-65. The number of TSA has significantly increased (n = 15000 to n = 28117, +187%; incidence 18.35 to 28.53, +155%). The number of rTSA has largely increased (n = 5326 to n = 24067, +452%; incidence 6.51 to 28.53, +438%), whereas the number of aTSA steadily decreased (n = 9674 to n = 4050, -42%; incidence 11.83 to 4.80, -41%). The number of revision arthroplasties has increased 1.8-fold (n = 2179 to n = 3893; incidence 1.7-fold). The peak revision rate shifted from the age group 70-75 toward 90- 95; 76% of all revision cases were performed in patients 65 years and older in 2010 increasing to 87% in 2022. Hospital admissions for PHF have increased 7.8-fold (n = 110091 to n = 810907). The peak in the age groups has shifted by a decade from 70-74 to 80-84. The absolute number of surgical therapy for PHF has decreased (n = 12816 to n = 9562, 75%; incidence 72%). The number of hospital admissions for RCT increased by 2.6-fold (n = 47004 to n = 124096; incidence + 255%). The number of surgical interventions for RCT increased by 3.7% (n = 51350 to n = 53294; incidence 62.8 to 63.2). Combined numbers for the operative therapy of PHF, RCT, and rTSA show an increase of +124% (n = 69491 to n = 86715) with a peak shift on one decade toward the age group 60-94 with 79% of the patients in 2022. The increased use of rTSA, as expressed by incidence, is strongly correlated with the increasing proportion of people aged 65 and over. CONCLUSION: The data show a substantial increase in the use of shoulder arthroplasty procedures in Germany in the observed time period, with the main driving factor being the increase of rTSA, whereas aTSA numbers decreased. The combined analysis of the hospital admissions and operative procedures performed to treat PHF and RCT indicated a shift of treatment numbers from open reduction and internal fixation and rotator cuff repair in the elderly toward the alternative use of rTSA in this age group. The observed shift of the stratification of age groups gives a further explanation for the increase in rTSA use: the number of patients in the age groups with the typical and alternative indications for rTSA substantially increased with a shift of the peak age group towards the elderly of one decade. Healthcare officials should be aware of these fundamental changes in the population, which create further demands on the health care system. The expected continuation of rising numbers of rTSA needs to be addressed by providing adequate resources such as reimbursement, surgical and rehabilitation facilities, and staff.

[Surgical or non-operative treatment of acute Achilles tendon rupture : What does the current literature say?] / Operative oder konservative Behandlung der akuten Achillessehnenruptur : Was sagt die aktuelle Literatur?

BACKGROUND: The Achilles tendon is the strongest tendon in humans and is frequently injured, especially in the physically active young to middle-aged population. An increasing frequency of Achilles tendon ruptures (ATR) has been reported in several studies. However, there is no international consensus regarding possible non-operative (N-OP) or operative (surgical) treatment (OP). OBJECTIVES: The aim of this article is to semi-quantitatively compare both treatment options for ATR by analyzing the results reported in the literature. MATERIAL AND METHODS: For this purpose, relevant categories were identified, and the literature was then evaluated in a PubMed analysis. Ten meta-analyses and two cost analyses were included. The data was extracted according to the categories and evaluated comparatively. RESULTS: OP and N­OP for acute ATR can lead to equally good restitution of clinical function if early functional rehabilitation is applied. The lower re-rupture rate is an advantage of OP, whereas the lower general complications speak in favor of N­OP. The minimally invasive or percutaneous surgical technique (M-OP) appears to be advantageous over the open surgical technique (O-OP), although studies show an increased rate of lesions of the sural nerve. CONCLUSION: There is no consensus regarding the superiority of OP or N­OP for acute ATR, as several studies conducted since the introduction of early mobilization protocols have shown similar results for these two interventions. Results and complications of M­OP and O­OP are also comparable. Considering the available data on the various surgical procedures, the authors prefer the M­OP technique with adequate sural nerve protection for repair of acute ATR, combined with an early mobilization protocol.

Attitude of aspiring orthopaedic surgeons towards artificial intelligence: a multinational cross-sectional survey study.

INTRODUCTION: The purpose of this study was to evaluate the perspectives of aspiring orthopaedic surgeons on artificial intelligence (AI), analysing how gender, AI knowledge, and technical inclination influence views on AI. Additionally, the extent to which recent AI advancements sway career decisions was assessed. MATERIALS AND METHODS: A digital survey was distributed to student members of orthopaedic societies across Germany, Switzerland, and Austria. Subgroup analyses explored how gender, AI knowledge, and technical inclination shape attitudes towards AI. RESULTS: Of 174 total respondents, 86.2% (n = 150) intended to pursue a career in orthopaedic surgery and were included in the analysis. The majority (74.5%) reported 'basic' or 'no' knowledge about AI. Approximately 29.3% believed AI would significantly impact orthopaedics within 5 years, with another 35.3% projecting 5-10 years. AI was predominantly seen as an assistive tool (77.8%), without significant fear of job displacement. The most valued AI applications were identified as preoperative implant planning (85.3%), administrative tasks (84%), and image analysis (81.3%). Concerns arose regarding skill atrophy due to overreliance (69.3%), liability (68%), and diminished patient interaction (56%). The majority maintained a 'neutral' view on AI (53%), though 32.9% were 'enthusiastic'. A stronger focus on AI in medical education was requested by 81.9%. Most participants (72.8%) felt recent AI advancements did not alter their career decisions towards or away from the orthopaedic specialty. Statistical analysis revealed a significant association between AI literacy (p = 0.015) and technical inclination (p = 0.003). AI literacy did not increase significantly during medical education (p = 0.091). CONCLUSIONS: Future orthopaedic surgeons exhibit a favourable outlook on AI, foreseeing its significant influence in the near future. AI literacy remains relatively low and showed no improvement during medical school. There is notable demand for improved AI-related education. The choice of orthopaedics as a specialty appears to be robust against the sway of recent AI advancements. LEVEL OF EVIDENCE: Cross-sectional survey study; level IV.

Orthopaedic surgeons display a positive outlook towards artificial intelligence: A survey among members of the AGA Society for Arthroscopy and Joint Surgery.

Purpose: The purpose of this study was to evaluate the perspective of orthopaedic surgeons on the impact of artificial intelligence (AI) and to evaluate the influence of experience, workplace setting and familiarity with digital solutions on views on AI. Methods: Orthopaedic surgeons of the AGA Society for Arthroscopy and Joint Surgery were invited to participate in an online, cross-sectional survey designed to gather information on professional background, subjective AI knowledge, opinion on the future impact of AI, openness towards different applications of AI, and perceived advantages and disadvantages of AI. Subgroup analyses were performed to examine the influence of experience, workplace setting and openness towards digital solutions on perspectives towards AI. Results: Overall, 360 orthopaedic surgeons participated. The majority indicated average (43.6%) or rudimentary (38.1%) AI knowledge. Most (54.5%) expected AI to substantially influence orthopaedics within 5-10 years, predominantly as a complementary tool (91.1%). Preoperative planning (83.8%) was identified as the most likely clinical use case. A lack of consensus was observed regarding acceptable error levels. Time savings in preoperative planning (62.5%) and improved documentation (81%) were identified as notable advantages while declining skills of the next generation (64.5%) were rated as the most substantial drawback. There were significant differences in subjective AI knowledge depending on participants' experience (p = 0.021) and familiarity with digital solutions (p < 0.001), acceptable error levels depending on workplace setting (p = 0.004), and prediction of AI impact depending on familiarity with digital solutions (p < 0.001). Conclusion: The majority of orthopaedic surgeons in this survey anticipated a notable positive impact of AI on their field, primarily as an assistive technology. A lack of consensus on acceptable error levels of AI and concerns about declining skills among future surgeons were observed. Level of Evidence: Level IV, cross-sectional study.

Prognostic relevance of global work index and global constructive work in patients with non-ischemic dilated cardiomyopathy.

Myocardial work (MW) derived from pressure-strain loops is a novel non-invasive tool to assess left ventricular (LV) function, incorporating global longitudinal strain (GLS) by speckle tracking echocardiography and non-invasively assessed blood pressure. Studies on the role of MW in dilated cardiomyopathy (DCM) are still limited. Therefore, the aim of this study was to evaluate the potential value of MW for predicting adverse outcomes in patients with DCM. 116 consecutive patients with DCM who underwent heart catheterization were retrospectively recruited from June 2009 to July 2014. 34 patients (30%) met the composite endpoints for major adverse cardiac events (MACE) of cardiac transplantation, need for implantable cardioverter-defibrillator (ICD) therapy, heart failure hospitalization and all-cause mortality. Patients with DCM were followed up for a mean of 5.1 years (IQR: 2.2-9.1 years). Global work index (GWI) and global constructive work (GCW) were not only independent predictors but also provided incremental predictive values (Integrated discrimination improvement [IDI] > 0) of MACE in multivariate Cox models. Furthermore, Patients with GWI < 788 mm Hg% (HR 5.46, 95%CI 1.66-17.92, p = 0.005) and GCW < 1,238 mm Hg% (HR 4.46, 95%CI 1.53-12.98, p = 0.006) had higher risks of MACE. GWI and GCW assessed by strain imaging echocardiography may have an additional value beyond LV-EF and GLS for predicting adverse outcomes in DCM.

Operative management of osteochondral lesions of the talus: 2024 recommendations of the working group 'clinical tissue regeneration' of the German Society of Orthopedics and Traumatology (DGOU).

The working group 'Clinical Tissue Regeneration' of the German Society of Orthopedics and Traumatology (DGOU) issues this paper with updating its guidelines. Literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLT) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available with a grade of recommendation. All group members rated the statements to identify possible gaps between literature and current clinical practice. Fixation of a vital bony fragment should be considered in large fragments. In children with open physis, retrograde drilling seems to work better than in adults, but even there, the revision rate reaches 50%. The literature supports debridement with bone marrow stimulation (BMS) in lesions smaller than 1.0 cm² without bony defect. The additional use of a scaffold can be recommended in lesions larger than 1.0 cm². For other scaffolds besides AMIC®/Chondro-Gide®, there is only limited evidence. Systematic reviews report good to excellent clinical results in 87% of the patients after osteochondral transplantation (OCT), but donor site morbidity is of concern, reaching 16.9%. There is no evidence of any additional benefit from autologous chondrocyte implantation (ACI). Minced cartilage lacks any supporting data. Metallic resurfacing of OLT can only be recommended as a second-line treatment. A medial malleolar osteotomy has a minor effect on the clinical outcome compared to the many other factors influencing the clinical result.

Acute changes in cardiac dimensions, function, and longitudinal mechanics in healthy individuals with and without high-altitude induced pulmonary hypertension at 4559 m.

BACKGROUND: High-altitude pulmonary hypertension (HAPH) has a prevalence of approximately 10%. Changes in cardiac morphology and function at high altitude, compared to a population that does not develop HAPH are scarce. METHODS: Four hundred twenty-one subjects were screened in a hypoxic chamber inspiring a FiO2  = 12% for 2 h. In 33 subjects an exaggerated increase in systolic pulmonary artery pressure (sPAP) could be confirmed in two independent measurements. Twenty nine of these, and further 24 matched subjects without sPAP increase were examined at 4559 m by Doppler echocardiography including global longitudinal strain (GLS). RESULTS: SPAP increase was higher in HAPH subjects (∆ = 10.2 vs. ∆ = 32.0 mm Hg, p < .001). LV eccentricity index (∆ = .15 vs. ∆ = .31, p = .009) increased more in HAPH. D-shaped LV (0 [0%] vs. 30 [93.8%], p = .00001) could be observed only in the HAPH group, and only in those with a sPAP ≥50 mm Hg. LV-EF (∆ = 4.5 vs. ∆ = 6.7%, p = .24) increased in both groups. LV-GLS (∆ = 1.2 vs. ∆ = 1.1 -%, p = .60) increased slightly. RV end-diastolic (∆ = 2.20 vs. ∆ = 2.7 cm2 , p = .36) and end-systolic area (∆ = 2.1 vs. ∆ = 2.7 cm2 , p = .39), as well as RA end-systolic area index (∆ = -.9 vs. ∆ = .3 cm2 /m2 , p = .01) increased, RV-FAC (∆ = -2.9 vs. ∆ = -4.7%, p = .43) decreased, this was more pronounced in HAPH, RV-GLS (∆ = 1.6 vs. ∆ = -.7 -%, p = .17) showed marginal changes. CONCLUSIONS: LV and LA dimensions decrease and left ventricular function increases at high-altitude in subjects with and without HAPH. RV and RA dimensions increase, and RV longitudinal strain increases or remains unchanged in subjects with HAPH. Changes are negligible in those without HAPH.

Importance of IL-6 trans-signaling and high autocrine IL-6 production in human osteoarthritic chondrocyte metabolism.

OBJECTIVE: Neutralization of Interleukin (IL)-6-signaling by antibodies is considered a promising tool for the treatment of osteoarthritis (OA). To gain further insight into this potential treatment, this study investigated the effects of IL-6-signaling and IL-6 neutralization on chondrocyte metabolism and the release of IL-6-signaling-related mediators by human chondrocytes. DESIGN: Chondrocytes were collected from 49 patients with advanced knee/hip OA or femoral neck fracture. Isolated chondrocytes were stimulated with different mediators to analyze the release of IL-6, soluble IL-6 receptor (sIL-6R) and soluble gp130 (sgp130). The effect of IL-6 and IL-6/sIL-6R complex as well as neutralization of IL-6-signaling on the metabolism was analyzed. RESULTS: OA chondrocytes showed high basal IL-6 production and release, which was strongly negatively correlated with the production of cartilage-matrix-proteins. Chondrocytes produced and released sIL-6R and sgp130. The IL-6/sIL-6R complex significantly increased nitric oxide, prostaglandin E2 and matrix metalloproteinase 1 production, decreased Pro-Collagen Type II and mitochondrial ATP production, and increased glycolysis in OA chondrocytes. Neutralization of IL-6-signaling by antibodies did not significantly affect the metabolism of OA chondrocytes, but blocking of glycoprotein 130 (gp130)-signaling by SC144 significantly reduced the basal IL-6 release. CONCLUSION: Although IL-6 trans-signaling induced by IL-6/sIL-6R complex negatively affects OA chondrocytes, antibodies against IL-6 or IL-6R did not affect chondrocyte metabolism. Since inhibition of gp130-signaling reduced the enhanced basal release of IL-6, interfering with gp130-signaling may ameliorate OA progression because high cellular release of IL-6 correlates with reduced production of cartilage-matrix-proteins.

Follow-up Treatment after Cartilage Therapy of the Knee Joint - a Recommendation of the DGOU Clinical Tissue Regeneration Working Group. / Nachbehandlung nach Knorpeltherapie am Kniegelenk ­ eine Empfehlung der AG Klinische Geweberegeneration der DGOU.

The first follow-up treatment recommendation from the DGOU's Clinical Tissue Regeneration working group dates back to 2012. New scientific evidence and changed framework conditions made it necessary to update the follow-up treatment recommendations after cartilage therapy.As part of a multi-stage member survey, a consensus was reached which, together with the scientific evidence, provides the basis for the present follow-up treatment recommendation.The decisive criterion for follow-up treatment is still the defect localisation. A distinction is made between femorotibial and patellofemoral defects. In addition, further criteria regarding cartilage defects are now also taken into account (stable cartilage edge, location outside the main stress zone) and the different methods of cartilage therapy (e. g. osteochondral transplantation, minced cartilage) are discussed.The present updated recommendation includes different aspects of follow-up treatment, starting with early perioperative management through to sports clearance and resumption of contact sports after cartilage therapy has taken place.

Human AI Teaming for Coronary CT Angiography Assessment: Impact on Imaging Workflow and Diagnostic Accuracy.

As the number of coronary computed tomography angiography (CTA) examinations is expected to increase, technologies to optimize the imaging workflow are of great interest. The aim of this study was to investigate the potential of artificial intelligence (AI) to improve clinical workflow and diagnostic accuracy in high-volume cardiac imaging centers. A total of 120 patients (79 men; 62.4 (55.0-72.7) years; 26.7 (24.9-30.3) kg/m2) undergoing coronary CTA were randomly assigned to a standard or an AI-based (human AI) coronary analysis group. Severity of coronary artery disease was graded according to CAD-RADS. Initial reports were reviewed and changes were classified. Both groups were similar with regard to age, sex, body mass index, heart rate, Agatston score, and CAD-RADS. The time for coronary CTA assessment (142.5 (106.5-215.0) s vs. 195.0 (146.0-265.5) s; p < 0.002) and the total reporting time (274.0 (208.0-377.0) s vs. 350 (264.0-445.5) s; p < 0.02) were lower in the human AI than in the standard group. The number of cases with no, minor, or CAD-RADS relevant changes did not differ significantly between groups (52, 7, 1 vs. 50, 8, 2; p = 0.80). AI-based analysis significantly improves clinical workflow, even in a specialized high-volume setting, by reducing CTA analysis and overall reporting time without compromising diagnostic accuracy.

Prognosis of light chain amyloidosis: a multivariable analysis for survival prediction in patients with cardiac involvement proven by endomyocardial biopsy.

BACKGROUND: Cardiac involvement is a main determinant of mortality in light chain (AL) amyloidosis but data on survival of patients with cardiac AL amyloidosis proven by endomyocardial biopsy (EMB) are sparse. METHODS: This study analysed clinical, laboratory, electrocardiography and echocardiographic parameters for their prognostic value in the assessment of patients with AL amyloidosis and cardiac involvement. Patients with AL amyloidosis who had their first visit to the amyloidosis centre at the University Hospital Heidelberg between 2006 and 2017 (n=1628) were filtered for cardiac involvement proven by EMB. In the final cohort, mortality-associated markers were analysed by univariate and multivariable Cox regression. Cut-off values for each parameter were calculated using the survival time. RESULTS: One-hundred and seventy-four patients could be identified. Median overall survival time was 1.5 years and median follow-up time was 5.2 years. At the end of the investigation period, 115 patients had died. In multivariable analysis, New York Heart Association-functional class >II (HR 1.65; 95% CI 1.09 to 2.50; p=0.019), left ventricular global longitudinal strain (HR 1.12; 95% CI 1.03 to 1.22; p=0.007), left ventricular end-systolic volume (HR 1.02; 95% CI 1.01 to 1.03; p=0.001), systolic pulmonary artery pressure (HR 0.98; 95% CI 0.96 to 0.99; p=0.027), N-terminal pro-B-type natriuretic peptide (HR 1.57; 95% CI 1.17 to 2.11; p=0.003) and difference in free light chains (HR 1.30; 95% CI 1.05 to 1.62; p=0.017) were independently predictive. CONCLUSION: Among all patients with AL amyloidosis those with cardiac involvement represent a high-risk population with limited therapy options. Therefore, accurate risk stratification is necessary to identify cardiac amyloidosis patients with favourable prognosis. Incorporation of modern imaging techniques into existing or newly developed scoring systems is a promising option that might enable the implementation of risk-adapted therapeutic strategies.

Wrap It! Preventive Antimicrobial Treatment Shows No Negative Effects on Tenocytes and Tendons-A Comprehensive Approach.

Although the rate of infection after the reconstruction of a ruptured anterior cruciate ligament (ACL) is low, prophylactic incubation of the graft with vancomycin (Vanco-wrap or vancomycin soaking) is routinely performed. A cytotoxic effect of vancomycin is reported for several cell types, and the prophylactic treatment might prevent infection but harm the tissue and cells. AIM: A comprehensive study was performed to investigate the effect of vancomycin on tendon tissue and isolated tenocytes using cell viability, molecular and mechanical analysis. MATERIAL AND METHODS: Rat tendons or isolated tenocytes were incubated in increasing concentrations of vancomycin (0-10 mg/mL) for different times, and cell viability, gene expression, histology and Young's modulus were analyzed. RESULTS: The clinically used concentration of vancomycin (5 mg/mL for 20 min) had no negative effect on cell viability in the tendons or the isolated tenocytes, while incubation with the toxic control significantly reduced cell viability. Increasing the concentration and prolonging the incubation time had no negative effect on the cells. The expression of Col1a1, Col3a1 and the tenocyte markers mohawk, scleraxis and tenomodulin was not affected by the various vancomycin concentrations. The structural integrity as measured through histological and mechanical testing was not compromised. CONCLUSION: The results proved the safe application of the Vanco-wrap on tendon tissue. LEVEL OF EVIDENCE: IV.

[The shoulder and elbow register of the DVSE-trend monitoring or early warning system? : A literature-based analysis]. / Das Schulter- und Ellenbogenregister der DVSE ­ Trendbeobachtung oder Frühwarnsystem? : Eine literaturbasierte Analyse.

The endoprosthesis register (SEPR) of the D­A-CH Association for Shoulder and Elbow Surgery e. V. (DVSE) collects data on the implantation of shoulder and elbow endoprostheses. The question arises as to whether the data is only used to monitor trends in arthroplasty, or whether it can also be used as an early warning system for risks and possible complications. The existing literature on the SEPR was analyzed and compared with other national endoprosthesis registries. The SEPR of the DVSE enables the collection and analysis of epidemiological data on primary implantation, follow-up and revision in shoulder and elbow endoprosthetics. It is an instrument of quality control and contributes to ensuring the greatest possible patient safety. It is used for the early detection of risks and potential requirements associated with shoulder and elbow arthroplasty.

Etiology, Classification, Diagnostics, and Conservative Management of Osteochondral Lesions of the Talus. 2023 Recommendations of the Working Group "Clinical Tissue Regeneration" of the German Society of Orthopedics and Traumatology.

METHODS: Peer-reviewed literature was analyzed regarding different topics relevant to osteochondral lesions of the talus (OLTs) treatment. This process concluded with a statement for each topic reflecting the best scientific evidence available for a particular diagnostic or therapeutic concept, including the grade of recommendation. Besides the scientific evidence, all group members rated the statements to identify possible gaps between literature and current clinical practice. CONCLUSION: In patients with minimal symptoms, OLT progression to ankle osteoarthritis is unlikely. Risk factors for progression are the depth of the lesion on MRI, subchondral cyst formation, and the extent of bone marrow edema. Conservative management is the adaptation of activities to the performance of the ankle joint. A follow-up imaging after 12 months helps not to miss any progression. It is impossible to estimate the probability of success of conservative management from initial symptoms and imaging. Cast immobilization is an option in OLTs in children, with a success rate of approximately 50%, although complete healing, estimated from imaging, is rare. In adults, improvement by conservative management ranges between 45% and 59%. Rest and restrictions for sports activities seem to be more successful than immobilization. Intra-articular injections of hyaluronic acid and platelet-rich plasma can improve pain and functional scores for more than 6 months. If 3 months of conservative management does not improve symptoms, surgery can be recommended.

Initial experience with transcatheter tricuspid valve repair in patients with cardiac amyloidosis.

AIMS: Wildtype transthyretin amyloid cardiomyopathy is an under-recognized cause of heart failure in elderly patients. Transcatheter tricuspid valve repair is a newly emerging therapeutic option for severe tricuspid regurgitation (TR). We present first insights into safety and possible benefits of this procedure in patients with cardiac amyloidosis. METHODS AND RESULTS: Eight patients with cardiac non-hereditary (wildtype) transthyretin (ATTRwt) amyloidosis and severe to torrential TR, undergoing successful transcatheter tricuspid valve repair, were included in the analysis and compared to a control group of 21 patients without cardiac amyloidosis. All patients presented with an advanced stage of amyloid cardiomyopathy. Primary endpoint was reduction in TR at 3 months follow-up. Secondary endpoints were feasibility, safety, hospitalization or death, clinical improvement, cardiac biomarkers, and structural and functional right heart parameter obtained by echocardiography. Transcatheter tricuspid valve repair resulted in a significant reduction of TR (IV to II, P = 0.008) in all eight patients with cardiac amyloidosis (100%). Device success (amyloidosis 75% vs. control group 86%, P = 0.597) and overall probability of hospitalization or death (amyloidosis 13% vs. control group 25%, P = 0.646) were similar compared with those in the control group at 3 months follow-up. Transcatheter tricuspid valve repair led to an improvement of New York Heart Association functional class (P = 0.031) and 6 min walking distance (from 313 ± 118 to 337 ± 106, P = 0.012). TR reduction in amyloidosis patients was less extensive compared with that in control group (TR-reduction 1.6 ± 0.3, P = 0.008 vs. control group 2.3 ± 0.3, P < 0.0001). Furthermore, these patients showed no significant improvement of structural right heart parameters. CONCLUSIONS: Transcatheter tricuspid valve repair is a safe and feasible new treatment option in patients with amyloid cardiomyopathy and has the potential to improve TR-grade and clinical status. However, the benefit appears to be less pronounced compared with patients without cardiac amyloidosis.

Descriptive analysis and short-term follow-up clinical results of osteochondral lesions of the distal tibia based on data of the German Cartilage Register (Knorpelregister® DGOU).

INTRODUCTION: An increasing number of ankle injuries with osteochondral lesions (OCL) also include lesions of the distal tibia. Therefore, the German Cartilage Society database is used to describe and examine the characteristics of these lesions and, early on, the results of different surgical therapies on the clinical outcome. MATERIALS AND METHODS: Forty-seven patients out of 844 registered in the German Cartilage Society database met the inclusion criteria showing an OCL of the distal tibia (OLDT). Sixteen of them also presented a 1-year follow-up regarding the Foot and Ankle Ability Measure (FAAM). Further evaluations were included in the follow-up, such as the Foot and Ankle Outcome Score (FAOS) and the Visual Analogue Scale for pain (VAS). RESULTS: The patients' mean age was 35 ± 11 with a mean BMI in the range of overweight (26/27 ± 5 kg/m2). The lesions were equally distributed on the articular surface of the distal tibia. Most patients were operated using anterior ankle arthroscopy [nT 34 (72%); nS 13 (81%)], while some (nT 9; nS 4) converted to open procedures. Almost 90% staged III and IV in the ICRS classification. Debridement, bone marrow stimulation, solid scaffolds, and liquid filler were the treatment choices among the subgroup. All therapies led to a clinical improvement between pre-op and 1-year follow-up but not to a significant level. CONCLUSION: This study presents baseline data of OLDT based on data from a large database. BMS and scaffolds were the treatment of choice but did not present significant improvement after a 1-year follow-up.

Empfehlungen der AG Klinische Geweberegeneration zur Behandlung von Knorpelschäden am Kniegelenk. / Empfehlungen der AG Klinische Geweberegeneration zur Behandlung von Knorpelschäden am Kniegelenk.

The Working Group of the German Orthopedic and Trauma Society (DGOU) on Tissue Regeneration has published recommendations on the indication of different surgical approaches for treatment of full-thickness cartilage defects in the knee joint in 2004, 2013 and 2016. Based upon new scientific knowledge and new developments, this recommendation is an update based upon the best clinical evidence available. In addition to prospective randomised controlled clinical trials, this also includes studies with a lower level of evidence. In the absence of evidence, the decision is based on a consensus process within the members of the working group.The principle of making decision dependent on defect size has not been changed in the new recommendation either. The indication for arthroscopic microfracturing has been reduced up to a defect size of 2 cm2 maximum, while autologous chondrocyte implantation is the method of choice for larger cartilage defects. Additionally, matrix-augmented bone marrow stimulation (mBMS) has been included in the recommendation for defects ranging from 1 to 4.5 cm2. For the treatment of smaller osteochondral defects, in addition to osteochondral transplantation (OCT), mBMS is also recommended. For larger defects, matrix-augmented autologous chondrocyte implantation (mACI/mACT) in combination with augmentation of the subchondral bone is recommended.

Osteoarthritis-Induced Metabolic Alterations of Human Hip Chondrocytes.

Osteoarthritis (OA) alters chondrocyte metabolism and mitochondrial biology. We explored whether OA and non-OA chondrocytes show persistent differences in metabolism and mitochondrial function and different responsiveness to cytokines and cAMP modulators. Hip chondrocytes from patients with OA or femoral neck fracture (non-OA) were stimulated with IL-1ß, TNF, forskolin and opioid peptides. Mediators released from chondrocytes were measured, and mitochondrial functions and glycolysis were determined (Seahorse Analyzer). Unstimulated OA chondrocytes exhibited significantly higher release of IL-6, PGE2 and MMP1 and lower production of glycosaminoglycan than non-OA chondrocytes. Oxygen consumption rates (OCR) and mitochondrial ATP production were comparable in unstimulated non-OA and OA chondrocytes, although the non-mitochondrial OCR was higher in OA chondrocytes. Compared to OA chondrocytes, non-OA chondrocytes showed stronger responses to IL-1ß/TNF stimulation, consisting of a larger decrease in mitochondrial ATP production and larger increases in non-mitochondrial OCR and NO production. Enhancement of cAMP by forskolin prevented IL-1ß-induced mitochondrial dysfunction in OA chondrocytes but not in non-OA chondrocytes. Endogenous opioids, present in OA joints, influenced neither cytokine-induced mitochondrial dysfunction nor NO upregulation. Glycolysis was not different in non-OA and OA chondrocytes, independent of stimulation. OA induces persistent metabolic alterations, but the results suggest upregulation of cellular mechanisms protecting mitochondrial function in OA.

The Correction Potential of the Lateral Release of the Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Technique Using a Dorsal Approach.

Background: Lateral release (LR) is an integral part of surgical correction of hallux valgus. A comparison was made between the open and minimally invasive LR techniques using a dorsal approach. The reliability and safety of the two methods were compared. Besides, the release of specific structures was investigated with special emphasis on ascertaining if the release was partial or a total one. Methods: In this study on cadavers, LR was performed on nine pairs of foot and ankle specimens. The group assignments were randomized for each case. The operations were followed by anatomical preparation, data collection, photo documentation, and statistical analysis. Results: A statistically significant advantage was observed with the open dorsal approach as there was a complete release of the adductor hallucis muscle from the lateral sesamoid and the lateral metatarsosesamoid ligament (p = 0.015 in each case). In terms of releasing the adductor hallucis muscle from the proximal phalanx, the lateral joint capsule, and the lateral collateral ligament, none of the investigated procedures showed better performance. However, open dorsal access tends to show a higher degree of release more frequently. Conclusions: Splitting of the lateral joint capsule, including the lateral collateral ligament and lateral metatarsosesamoid ligament via the dorsal approach can be performed reliably and completely using the open surgical technique. The open dorsal technique shows better rates of detachment when the adductor hallucis muscle is released from the lateral sesamoid. Both techniques resulted in incomplete release of the adductor hallucis muscle from the proximal phalanx. Study Type: Therapeutic-investigating the results of a treatment. Level of Evidence: II (Prospective cohort study). Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00575-3.