[Epidemiology, prevention and early detection of femoroacetabular impingement syndrome (FAIS)]. / Epidemiologie, Prävention und Früherkennung des Femoroazetabulären Impingement-Syndroms (FAIS).

During the last two decades femoroacetabular impingement syndrome (FAIS) has gained importance and is one of the main causes of hip pain in young adults. FAIS is a motion-related clinical pathology of the hip that represents symptomatic contact between the proximal femur and the acetabulum. Symptoms, clinical signs, and imaging findings must be present to diagnose FAIS. Especially the development of the cam-FAIS seems to be associated with an overuse of the growth plate during adolescence. Here an approach may be found for the prevention of the development of FAIS. Sufficient evidence through high-quality long-term results is yet lacking.

Improved pre-operative diagnostic accuracy for low-grade prosthetic joint infections using second-generation multiplex Polymerase chain reaction on joint fluid aspirate.

BACKGROUND: A major obstacle for the treatment of prosthetic joint infection (PJI) is the identification of the underlying causative organism. While the diagnostic criteria ruling PJI in or out have become ever more accurate, the detection of the causative pathogen(s) still relies mostly on conventional and time-consuming microbial culture. The aim of this study was to evaluate the diagnostic potential of a second-generation multiplex PCR assay (Unyvero ITI G2, Curetis AG, Holzgerlingen, Germany) used on synovial fluid specimens. Our hypothesis was that the method would yield a higher diagnostic accuracy in the pre-operative workup than synovial fluid culture. Thus, a more precise classification of septic and aseptic prosthesis failure could be achieved before revision surgery. METHODS: Prospectively collected frozen joint fluid specimens from 26 patients undergoing arthroplasty revision surgery of the hip or knee were tested as per the manufacturer's protocol. Sensitivities, specificities, positive and negative predictive values as well as positive and negative likelihood ratios with corresponding confidence intervals were estimated using the statistical software R. A combination of the serum C-reactive protein (CRP) level, leukocyte count, erythrocyte sedimentation rate, joint fluid culture, tissue biopsy culture, and tissue biopsy histology served as the gold standard. RESULTS: Of the 26 patients included in the study, 15 were infected and 11 were aseptic. Conventional joint fluid culture showed a sensitivity of 0.67 and a specificity of 0.91. Joint fluid multiplex PCR yielded a sensitivity of 0.8 and a specificity of 1.0. CONCLUSIONS: Using the second-generation Unyvero ITI cartridge on joint fluid aspirate for the detection of prosthetic joint infection, we were able to achieve a higher diagnostic accuracy than with conventional culture. We conclude that to improve pathogen detection before revision surgery, this method represents a valuable and practicable tool.

[Native joint infections]. / Native Gelenkinfektionen.

Joint infections are a great challenge for the treating physicians. Infection of a native joint can result in the rapid destruction of the joint if treatment is inadequate or delayed and is associated with severe life-threatening diseases, such as sepsis. This article presents a detailed overview of the treatment of joint infections of native joints with a focus on the diagnostic approach and treatment decisions. Infections in native joints are caused either endogenously by hematogenic spreading or are caused by exogenous factors. A relevant proportion of joint infections in native joints occur in connection with iatrogenic measures, such as operations, synovial punctures and joint infiltrations. Fundamentally, acute infections represent an orthopedic surgical emergency, which is associated with the necessity for immediate operative measures. The best possible success can only be achieved by an interaction between early diagnosis, an adequate surgical approach and a tailor-made anti-infectious treatment. This is also the case with periprosthetic infections, which will be dealt with in detail in a second article.

Mid-term outcome following revision surgery of clavicular non- and malunion using anatomic locking compression plate and iliac crest bone graft.

BACKGROUND: Treatment of clavicular non- and malunion is still challenging. Current surgical procedures often result in frustrating functional outcome along with high-grade subjective impairment and increased rates of revision surgery. However, the combination of biological augmentation with vital bone graft and a biomechanically sufficient fixation system seems to be a promising concept of treatment. METHODS: In this retrospective study, 14 patients with a mean age of 44 years (26-67 years) suffering from non-union (n = 11) and/or malunion (n = 3) of the clavicle were enrolled. All patients were surgically treated using an anatomical precontoured locking compression plate (LCP) and autologous iliac crest bone graft. Functional outcome was assessed using the age- and sex-specific relative Constant Score. RESULTS: Mean follow-up was 27 months (range 12-44 months). The relative Constant Score significantly improved from preoperative 61 ± 8 (43-72) to 82 ± 10 (65-100) points at the final follow-up examination (p < 0.05). All patients showed bony union radiographically. One patient presented with a re-fracture of the clavicle nearly 3 years after revision surgery and 5 weeks after implant removal. Secondary fractures at the donor site of the anterior superior iliac spine were recorded in two patients. CONCLUSIONS: Iliac crest bone graft and anatomic locking plate fixation allow for a safe and adequate stabilization and radiographical bony union in non- and malunions of the clavicle with a high degree of patient satisfaction. However, secondary fractures of the anterior superior iliac spine constitute relevant complications and the time of hardware removal should be considered carefully.

Results of medial patellofemoral ligament reconstruction compared with trochleoplasty plus individual extensor apparatus balancing in patellar instability caused by severe trochlear dysplasia: a systematic review and meta-analysis.

PURPOSE: Many studies have reported satisfactory clinical outcomes and low redislocation rates after reconstruction of the medial patellofemoral ligament (MPFL) for the treatment of lateral patellar instability. Despite uncorrected severe trochlear dysplasia (Dejour type B to D) being acknowledged as a major reason for less favourable clinical outcomes and a higher incidence of patellar redislocations after an isolated MPFL reconstruction, the evidence for a deepening trochleoplasty procedure remains scarce in the current literature. The hypothesis of this systematic review and meta-analysis was that a deepening trochleoplasty in combination with an a la carte extensor apparatus balancing procedure provides lower redislocation rates and superior clinical outcomes than isolated MPFL reconstruction in patients with lateral patellar instability caused by severe trochlear dysplasia. METHODS: A systematic review of the literature was conducted using specific inclusion and exclusion criteria for clinical studies reporting index operations (trochleoplasty and MPFL reconstruction) for the treatment of patellar instability caused by severe trochlear dysplasia. The Kujala score was analysed as the primary clinical outcome parameter in a random effects meta-analysis. RESULTS: Ten uncontrolled studies with a total of 407 knees (374 patients) were included in this analysis. The MPFL group comprised 4 studies with a total of 221 knees (210 patients), and the trochleoplasty group comprised 6 studies with a total of 186 knees (164 patients). The mean preoperative Kujala score ranged between 50.4 and 70.5 in the MPFL group and between 44.8 and 75.1 in the trochleoplasty group. The pooled Kujala score increased significantly by 26.4 (95% CI 21.4, 31.3; P < 0.00001) points in the MPFL group and by 26.2 (95% CI 19.8, 32.7; P < 0.00001) points in the trochleoplasty group. The post-operative patellar redislocation/subluxation rate was 7% in the MPFL group and 2.1% in the trochleoplasty group. CONCLUSION: This analysis found significant post-operative improvements in patient-reported outcomes for patients undergoing both an MPFL reconstruction and in those undergoing a trochleoplasty plus an individual extensor apparatus balancing procedure when assessed using the Kujala score. The likelihood of preventing the patella from subsequent post-operative redislocation/subluxation was, however, greater in patients who underwent trochleoplasty plus extensor balancing. LEVEL OF EVIDENCE: IV.

Bilateral diaphyseal bone cysts of the tibia mimicking shin splints in a young professional athlete--a case report and depiction of a less-invasive surgical technique.

BACKGROUND: Medial tibial stress syndrome is one of the most common causes of exertional leg pain in runners whereas musculoskeletal tumors and tumor-like lesions are rare encounters in orthopedic sports medicine practice. Unicameral (simple) bone cyst is a well-known tumor-like lesions of the bone typically affecting children and adolescents. Bilateral occurrence is very rare though and has never been reported before in both tibiae. Failing to accurately diagnose a tumorous lesion can entail far-reaching consequences for both patients and physicians. CASE PRESENTATION: We report the case of large bilateral unicameral bone cysts of the diaphyseal tibiae mimicking medial tibial stress syndrome in a 17-year old professional athlete. This is the first report of symmetric tibial unicameral bone cysts in the literature. The patient complained about persisting shin splint-like symptoms over 5 months despite comprehensive conservative treatment before MRI revealed extensive osteolytic bone lesions in both diaphyseal tibiae. The patient-tailored, less-invasive surgical procedure, allowing the patient to return to his competitive sports level symptom-free 3 months after surgery and to eventually qualify for this years Biathlon Junior World Championships, is outlined briefly. Pathogenesis and various treatment options for this entity will be discussed. CONCLUSION: This report will help to raise awareness for musculoskeletal tumors as differential diagnosis for therapy-refractory symptoms in young athletes and encourage medical staff involved in sports medicine and athlete support to perform early high quality imaging and initiate sufficient surgical treatment in similar cases. Moreover, our less-invasive surgical procedure aiming for a fast return to sports might be an optimal compromise between traditional open curettage with low risk of recurrence and a soft tissue-saving and bone-sparing minimal-invasive technique.

Clinical principles in the management of hamstring injuries.

PURPOSE: Hamstring injuries are among the most common muscle injuries seen in sports clinical practice. This narrative review covers essential knowledge of hamstring injuries, ranging from strains to total proximal three-tendon ruptures. The primary aim is to provide basic information for clinicians and sports medicine therapists dealing with hamstring problems. METHODS: In this review, existing literature of hamstring injuries was taken together. Emphasis was given to subjects less well covered in previous reviews, such as preventive measures, as well as the most relevant information needed in the treatment of these injuries. RESULTS: Occasionally, symptoms remain after hamstring injuries which can be successfully treated with surgery. Knowledge of the effectiveness of preventive measures and nonsurgical and surgical treatment is limited by small studies of low evidence level. CONCLUSIONS: Evidence-based treatment algorithms are not available. Larger studies of better quality with more concrete grading of hamstring tears are needed to improve knowledge in prevention and treatment of hamstring injuries. LEVEL OF EVIDENCE: IV.

Clinical challenge: fatal mucormycotic osteomyelitis caused by Rhizopus microsporus despite aggressive multimodal treatment.

BACKGROUND: Mucormycosis is an invasive mycotic disease caused by fungi in the zygomycetes class. Although ubiquitous in the environment, zygomycetes are rarely known to cause invasive disease in immunocompromised hosts with a high mortality even under aggressive antifungal and surgical therapy. Clinically, mucormycosis frequently affects the sinus occasionally showing pulmonary or cerebral involvement. However skeletal manifestation with Rhizopus microsporus (RM) osteomyelitis leading to emergency surgical proximal femoral resection with fatal outcome has not been described yet. CASE PRESENTATION: We report the case of a 73-year-old male suffering from myelodysplastic syndrome with precedent bone marrow transplantation. Six months after transplantation he consulted our internal medicine department in a septic condition with a four week history of painful swelling of the right hip. Radiography, computed tomography and magnetic resonance imaging revealed multiple bone infarcts in both femurs. In the right femoral head, neck and trochanteric region a recent infarct showed massive secondary osteomyelitis, breaking through the medial cortex. Emergency surgical proximal femoral resection was performed due to extensive bone and soft tissue destruction. Microbiological and basic local alignment search tool (BLAST) analysis revealed RM. Amphotericin B and posaconazole treatment with septic revision surgery was performed. However the disease ran a rapid course and was fatal two months after hospital admission. CONCLUSION: This alarming result with extensive RM osteomyelitis in the proximal femur of an immunocompromised patient may hopefully warn medical staff to perform early imaging and aggressive surgical supported multimodal treatment in similar cases.

Combined trochleoplasty and MPFL reconstruction for treatment of chronic patellofemoral instability: a prospective minimum 2-year follow-up study.

PURPOSE: Excessive trochlear dysplasia may be responsible for recurrent patellofemoral instability (PFI) due to a missing bony guidance for the patella in early flexion. Thus, an isolated medial patellofemoral ligament reconstruction (MPFLR) can be insufficient, since it mainly addresses instability close to extension and additionally can increase patellofemoral pressure leading to pain in flat or convex trochlear dysplasia. Therefore, in combination with a trochleoplasty, an anatomical trochlear groove is created, resulting in patellofemoral stability also in flexion, while patellofemoral pressure is normalized. In this prospective study, we evaluated the outcome of open trochleoplasty in combination with MPFLR with a minimum follow-up of 2 years for treatment of excessive PFI. METHODS: In between 2007 and 2009, 18 knees of 17 consecutive patients (mean age of 22.2 ± 4.9 years) with trochlear dysplasia type B, C or D according to Dejour et al. and positive apprehension from 0 to 60° of flexion were included. Tegner, Kujala and IKDC scores, apprehension and pain, trochlear dysplasia, sulcus angle, tibial tuberosity trochlear groove, patellar tilt and shift, Caton-Deschamps index as well as patellofemoral arthrosis according to the classification of Iwano et al. were assessed pre- and postoperatively. RESULTS: At a mean of 30.5 ± 5.9 months, all but one patient were subjectively satisfied with the outcome of the procedure, all showing absence of positive apprehension or redislocation. Significant (p < 0.001) reduction in pain (5.6 to 2.5 ± 2.8 points, VAS) and increase in Tegner (2, range 0-4 points to 6, range 3-8 points), Kujala (51.1 to 87.9 ± 20.0 points) and IKDC (49.5 to 80.2 ± 21.0%) scores could be achieved. Radiologically significant (p < 0.02) improvement of patellofemoral positional parameters leading to more normal anatomy was recorded, while short-term arthrosis was absent. CONCLUSIONS: Combined treatment for trochleoplasty with MPFLR serves as a successful therapy for chronic PFI. This combinatory treatment concept is a reliable option not only as salvage therapy but also as primary procedure regarding treatment for excessive PFI. LEVEL OF EVIDENCE: Prospective case series, Level IV.

Emergency cesarean section due to acute aortic dissection type A (Debakey I) without Marfan syndrome: a case report and review of the literature.

BACKGROUND: Acute aortic dissection during pregnancy is an uncommon but important emergency due to its lethal risk to both mother and child. The dissection usually involves the ascending aorta or the aortic arch. Although additional affection of the descending aorta up to bifurcation is possible, further increasing the risk of organ malperfusion, full-length aortic dissection (DeBakey I) is known to be very rare. Dissection during pregnancy has been reported predominantly in combination with Marfan syndrome. Acute aortic dissection Stanford type A (AADA) DeBakey I during pregnancy without signs of Marfan syndrome as a warning signal is very uncommon in the current literature. OBJECTIVES: The etiology, diagnosis, differential diagnosis, and management of this rare disease are discussed in relation to the current literature. CASE REPORT: We report the case of an athletic 34-year-old woman in the third trimester of pregnancy, without history of previous diseases, who presented to our Emergency Department after collapsing. In the resuscitation department, an emergency cesarean section was performed due to the start of circulation failure in the mother. Computed tomography scan revealed a severe aortic dissection starting from 1 cm distal the aortic valve over the full length up to the iliac arteries, involving the brachiocephalic and carotid arteries up to the level of the larynx. Emergency replacement of the ascending aorta and the aortic arch was performed. Both the mother and baby survived and were doing well 1 year postoperatively. CONCLUSION: This alarming result of AADA (DeBakey I) in late pregnancy without obvious warnings such as Marfan syndrome illustrates the importance of performing early imaging in similar cases.

[Isolated Patellofemoral Osteoarthritis]. / Isolierte Patellofemoralarthrose.

Isolated patellofemoral osteoarthritis is a complex pathology. It occurs frequently in women over 40 years and leads to a high degree of suffering. The causes of femoropatellar degeneration are manifold and require stage-specific therapy. This is very challenging for the treating physician. This article is intended to provide a structured overview of the symptoms, diagnostics and stage-specific therapy of patellofemoral osteoarthritis.

Acute osteomyelitis of the humerus mimicking malignancy: Streptococcus pneumoniae as exceptional pathogen in an immunocompetent adult.

BACKGROUND: Chronic osteomyelitis due to direct bone trauma or vascular insufficiency is a frequent problem in orthopaedic surgery. In contrast, acute haematogenous osteomyelitis represents a rare entity that almost exclusively affects prepubescent children or immunodeficient adults. CASE PRESENTATION: In this article, we report the case of acute pneumococcal osteomyelitis of the humerus in an immunocompetent and otherwise healthy 44-year-old male patient presenting with minor inflammation signs and misleading clinical features. CONCLUSIONS: The diagnosis had to be confirmed by open biopsy which allowed the initiation of a targeted therapy. A case of pneumococcal osteomyelitis of a long bone, lacking predisposing factors or trauma, is unique in adults and has not been reported previously.

The antineoplastic antibiotic taurolidine promotes lung and liver metastasis in two syngeneic osteosarcoma mouse models and exhibits severe liver toxicity.

Osteosarcoma (OS) is the most frequent primary bone tumor. Despite multiagent neoadjuvant chemotherapy, patients with metastatic disease have a poor prognosis. Moreover, currently used chemotherapeutics have severe toxic side effects. Thus, novel agents with improved antimetastatic activity and reduced toxicity are needed. Taurolidine, a broad-spectrum antimicrobial, has recently been shown to have antineoplastic properties against a variety of tumors and low systemic toxicity. Consequently, we investigated in our study the antineoplastic potential of taurolidine against OS in two different mouse models. Although both OS cell lines, K7M2 and LM8, were sensitive for the compound in vitro, intraperitoneal application of taurolidine failed to inhibit primary tumor growth. Moreover, it enhanced the metastatic load in both models 1.7- to 20-fold and caused severe liver deformations and up to 40% mortality. Thus, systemic toxicity was further investigated in tumor-free mice histologically, by electron microscopy and by measurements of representative liver enzymes. Taurolidine dose-dependent fibrous thickening of the liver capsule and adhesions and atrophies of the liver lobes were comparable in healthy and tumor-bearing mice. Liver toxicity was further indicated by up to eightfold elevated levels of the liver enzymes alanine transaminase, aspartate transaminase and GLDH in the circulation. Ultrastructural analysis of affected liver tissue showed swollen mitochondria with cristolysis and numerous lipid vacuoles in the cytoplasm of hepatocytes. The findings of our study question the applicability of taurolidine for OS treatment and may suggest the need for caution regarding the widespread clinical use of taurolidine as an antineoplastic agent.

Antimetastatic activity of honokiol in osteosarcoma.

BACKGROUND: Metastasizing osteosarcoma has a mean 5-year survival rate of only 20% to 30%. Therefore, novel chemotherapeutics for more effective treatment of this disease are required. METHODS: The antineoplastic activity of honokiol, which was demonstrated previously in numerous malignancies, was studied in vivo in C3H mice subcutaneously injected with syngeneic ß-galactosidase bacterial gene (lacZ)-expressing LM8 osteosarcoma (LM8-lacZ) cells. In vitro cytotoxic effects of honokiol were investigated in 8 human and 2 murine osteosarcoma cell lines with different in vivo metastatic potential. RESULTS: Seven days after subcutaneous flank injection of LM8-lacZ cells, daily intraperitoneal treatment of mice with 150 mg/kg honokiol reduced the number of micrometastases in the lung by 41% and reduced the number of macrometastases in the lung and liver by 69% and 80%, respectively, compared with control. Primary tumor growth was not inhibited. In osteosarcoma cell lines, honokiol inhibited the metabolic activity with a half-maximal concentration (IC(50) ) between 8.0 µg/mL and 16 µg/mL. Cyclosporin A partially reversed the inhibition of metabolic activity in LM8-lacZ cells. Cell proliferation and wound healing migration of LM8-lacZ cells were inhibited by honokiol with an IC(50) between 5.0 µg/mL and 10 µg/mL. Higher concentrations caused rapid cell death, which was distinct from necrosis, apoptosis, or autophagy but was associated with swelling of the endoplasmic reticulum, cytoplasmic vacuolation, and morphologically altered mitochondria. CONCLUSIONS: Honokiol exhibited prominent antimetastatic activity in experimental osteosarcoma and caused rapid cell death in vitro that was unrelated to necrosis, apoptosis, or autophagy. The authors concluded that honokiol has considerable potential for the treatment of metastasizing osteosarcoma.

[Persistent or recurrent symptoms after surgery for femoroacetabular impingement syndrome (FAIS) : Pathology, diagnostics and therapy]. / Persistierende oder wiederkehrende Beschwerden nach femoroazetabulärer Impingement-Chirurgie : Ursachen, Diagnostik und Therapie.

BACKGROUND: Femoroacetabular impingement syndrome (FAIS) has gained vast importance in the last two decades. Multiple studies have shown that if untreated, early osteoarthritis of the hip joint may result. Hip arthroscopy is one of the fastest growing procedures in the orthopedic cosmos, having already replaced the majority of (mini) open techniques in FAIS surgery. However, with the recent remarkable increase in the volume of hip arthroscopies performed worldwide, the number of patients with persistent or recurrent symptoms after FAIS surgery is also growing. PATHOLOGY: Potential underlying pathologies are misresection of the bony deformity, insufficiency fracture of the femoral head neck junction or the femoral subchondral head itself (SIFFH), adhesions, failed chondrolabral or capsular treatment, septic arthritis, heterotopic ossification or a wrong indication in the case of osteoarthritis that is already too advanced. Most of these occur more often during the extensive learning curve for hip arthroscopy. DIAGNOSTICS: High-quality imaging plays a key role in determining the need for revision surgery vs. further conservative treatment. Therapeutical avenues are shown with the common goal of proper detection and correction of the underlying pathology to address unsatisfactory FAIS treatment outcomes and ensure long-term survival of the native hip joint.

Patients with Small Acetabular Cartilage Defects Caused by Femoroacetabular Impingement Do Not Benefit from Microfracture.

OBJECTIVE: According to current recommendations, large cartilage defects of the hip over 2 cm2 are suggested to undergo autologous chondrocyte transplantation (ACT), while small defects should be treated with microfracture. We investigated if patients with small chondral defects of the hip joint (≤100 mm2) actually benefit from microfracture. DESIGN: In this retrospective multicenter cohort study 40 patients with focal acetabular cartilage defects smaller than 100 mm2 and of ICRS grade ≥2 caused by femoroacetabular impingement were included. Twenty-six unrandomized patients underwent microfracture besides treatment of the underlying pathology; in 14 patients cartilage lesions were left untreated during arthroscopy. Over a mean follow-up of 28.8 months patient-reported outcome was determined using the iHOT33 (international hip outcome tool) and the VAS (visual analog scale) for pain. RESULTS: The untreated group showed a statistically significant improvement of the iHOT33 after 12 (p = 0.005), 24 (p = 0.019), and 36 months (p = 0.002) compared to the preoperative score, whereas iHOT33 in the microfracture group did not reveal statistically significant changes over time. There was no significant difference between both groups on any time point. Regarding pain both groups did not show a significant improvement over time in the VAS. CONCLUSION: The subjective outcome of patients with small cartilage defects of the hip (≤100 mm2) improves 12 months after arthroscopic FAIS surgery without any cartilage treatment. However, no improvement could be seen after microfracture. Therefore, a reserved surgical treatment for small cartilage defects of the hip under preservation of the subchondral bone is recommended especially if a simultaneous impingement correction is performed.

Outcome-Affecting Parameters of Hip Arthroscopy for Femoroacetabular Impingement with Concomitant Cartilage Damage-Data Analysis from the German Cartilage Registry.

This study aims to report on a prospectively collected, multicenter database of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAI) and concomitant cartilage damage (according to the International Cartilage Repair Society) and to assess the outcome-affecting parameters. In the study, 353 hips with up to 24 months' follow-up were assessed by iHOT-33 scoring and achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) levels. Multiple and binary regression analyses were performed to identify factors related to (un-) favorable outcomes and to assess their clinical relevance with regard to achieving the MCID and PASS. Multiple regression yielded the parameters of male sex (p = 0.022) and lower body mass index (BMI) (p = 0.019) at 6 months, lower BMI (p = 0.022) and younger age (p = 0.022) at 12 months, and younger age at 24 months (p = 0.039) to be significantly associated with higher iHOT scoring. Male sex (p = 0.019) and lower BMI (p = 0.018) were significantly correlated with achievement of the PASS in binary regression at 6 months, whereas at 12 (p = 0.010) and at 24 (p = 0.003) only younger age was shown to be significantly correlated. None of the parameters was statistically associated with achievement of the MCID. As the parameters of younger age, male sex, and lower BMI were identified as temporarily correlated with a preferable outcome in general and with achievement of the PASS in particular, these findings help to preoperatively identify factors associated with (un-) favorable therapy results.