Alpine Skiing With total knee ArthroPlasty (ASWAP): study design and intervention.

The aim of this study was to monitor the long-term effects of skiing on health-related parameters and implant related factors like loosening and wear in patients with total knee arthroplasty. This paper describes the overall study design, general demographics, and physiological demand of the intervention phase. A control group design consisting of an intervention group (n = 14; age: 70.4 ± 4.5 years) and a control group (n = 17; age: 71.5 ± 5.1 years) was utilized in this study. Parameters of interest were measured during pre-, post-, and retention test sessions. During the 12 weeks of intervention, an average of 25.5 days of guided skiing was conducted by each patient. Daily heart rate (HR) profiles and global positioning system data throughout the ski day were recorded. The intervention group completed an average of 3393 vertical meters of downhill skiing, with a total skiing distance of 33.6 km/day. Average skiing speed was 8.2 m/s. In the skiing phase, the average physiological load was 75.9 ± 6.6% of HRmax . Further effects of the 12-week skiing intervention on the tested parameters will be reported in the following papers of this supplementum.

Alpine Skiing With total knee ArthroPlasty (ASWAP): clinical and radiographic outcomes.

The aim of the study was to assess the effect of a recreational alpine skiing intervention on implant-related factors, such as loosening and wear, in patients with total knee arthoplasty (TKA). A group of 16 TKA patients were examined 2.3 ± 0.1 years after skiing about 80 days over three seasons inclusive of a ski intervention of 2-3 times per week (25.5 days) over a 12-week period. Mean follow-up period was 5.1 ± 1 years after surgery. All patients had excellent clinical and radiological outcomes. The average flexion was 120-130°, the average Oxford Knee Score increased from 15 points pre-operatively to 47.4 points post-operatively. An average Tegner activity level of 5.5 was assessed, indicating a very high post-operative activity level. No radiolucencies or osteolyses were observed in any of the radiographs. One patient sustained a meniscal tear in the contralateral knee. Recreational alpine skiing on intermediate terrain at moderate speed can be recommended after TKA. Analysis of mid-term follow-up has not shown any negative effect on the implant loosening or additional polyethylene wear.

Alpine Skiing With total knee ArthroPlasty (ASWAP): muscular adaptations.

This study investigated the effectiveness of recreational skiing as an intervention to improve quadriceps muscle architecture, strength, and antagonistic co-activation in patients with unilateral total knee arthroplasty (TKA). Hence, patients with TKA were assigned to either an intervention group (IG) or control group (CG). The IG completed a 12-week guided skiing program whereas the CG was instructed not to change their daily routines for the same period and was not allowed to ski. Before, after the intervention/after an 8-week retention period m. rectus femoris (RF) cross-sectional area (CSA), m. vastus lateralis muscle thickness, fascicle length, and pennation angle were measured with ultrasonography, while isometric (90° knee angle) knee extension, flexion torque and m. biceps femoris co-activation were assessed on an isokinetic dynamometer in 26 patients. There were significant and stable increases in RF CSA for the operated (10%; P < 0.05) and non-operated leg (12%; P < 0.01) after the training period in the IG whereas no changes were observed for the CG (all P > 0.05). There were no significant effects for other parameters (all P > 0.05). Overall, the skiing intervention was successful in increasing muscle mass in TKA older patients.

Alpine Skiing With total knee ArthroPlasty (ASWAP): effect on tendon properties.

The aim of this study was to investigate the effect of alpine skiing on patellar tendon properties in patients with total knee arthroplasty (TKA). Thirty-one adults (70.4 ± 4.7 years) with unilateral TKA were recruited 2.7 ± 0.9 years after surgery and assigned to an intervention (IG) or a control group (CG). The IG underwent a 12-week guided skiing program. Tendon stiffness, Young's modulus, and cross-sectional area (CSA) were measured before and after the intervention. In both groups, mean tendon CSA was 28% (P < 0.001) larger in the operated (OP) than in the non-operated (NOP) leg at baseline, without any difference in other tendon properties. After training, stiffness increased in the IG by 5.8% and 15.8%, respectively, in the OP and NOP legs. Likewise, mean CSA increased in the IG by 2.9% in the OP and 3.8% in the NOP leg, whereas no significant changes were found for the Young's modulus. None of the tendon parameters changed in the CG. Results indicate that patellar tendon structure and/or loading pattern are altered following TKA, but this tissue seems to retain its adaptation capacity. Further, alpine skiing appears to offer a suitable rehabilitation strategy for TKA patients.

[Not Available]. / Gluteussehnensyndrom.

Gluteal tendinopathy as well as partial and full-thickness tears of gluteal tendons (gluteus minimus and/or medius tendon) were underestimated as a cause of chronic pain in the past, and treatment was most commonly based on the diagnosis of trochanteric bursitis. Tendinous pathologies can either stay asymptomatic or cause pain and muscular dysfunction, not necessarily being associated with osteoarthritis of the hip 1. As the terminus "rotator cuff tear of the hip" was published in 1997 2, its aetiopathogenesis was reconsidered, resulting in improvements in diagnosis and treatment. Nevertheless the adoption of those findings into clinical daily routine took time 3. Ultrasound and magnetic resonance imaging (MRI) as well as histopathologic examination questioned the relevance of acute bursitis being the only cause of greater trochanteric pain 4, 5, 6, while emphasizing degenerative tendinopathy causing those symptoms 6, 7, 8. The terminus "greater trochanteric pain syndrome" (GTPS) should hereby also include further pathologies, e.g. calcific tendinitis 1, 5. GTPS affects about 10-25 % of the adult population 5. Ultrasound and MRI are reliable, non-invasive methods for detecting tendinous and bursal pathologies 7, 8, 9; in 88 % of all patients with trochanteric pain, MRI gives pathological findings 10. Nevertheless, in 50 % of suspicious pertrochanteric pathologies, patients are free of symptoms 1, 10. In patients undergoing total hip arthroplasty, the incidence of intraoperative macroscopically identified gluteal tendon tears reaches up to 22 % 2, 11, 12, 13. Tendinous tears cause pain and constrained muscular function. Sole traumatic tears are rare, most commonly they are based on pre-existing defects. Tendinosis and partial tears are primarily treated conservatively. Hereby, therapeutic options are similar to those for rotator cuff pathologies of the shoulder. Topical infiltration of corticosteroids and physical therapy offer good results especially in early stages. The effectiveness of extracorporeal shock wave therapy has also been proven 14. Surgical intervention is necessary in case of non-responsiveness to treatment or loss of gluteal muscular function. Hereby, the open gluteal repair always represented the method of choice, whereas recently, users of endoscopic systems reported similar or even better outcomes 15, 16, 17, 18, 19, 20, 21.

Postoperative aneurysm of the popliteal artery after arthroscopic meniscectomy.

We report a case of a 14-year-old girl who underwent arthroscopic subtotal meniscectomy after a bucket-handle tear of the lateral meniscus followed by a pseudoaneurysm of the popliteal artery. A revision surgery and reconstruction of the artery with a saphena magna patch was necessary to repair the defect. At 1-year follow-up, excellent range of motion, function of the knee, and a normal quality of life was achieved.

[Initial experience using routine hip sonography in newborn infants]. / Erste Erfahrungen mit der routinemässig durchgeführten Hüftsonographie bei Neugeborenen.

933 newborn infants were subjected to routine hip screening by means of ultrasound in the first week of life, along with usual clinical investigations. The sonographic examinations were performed according to the technique and classification laid down by Graf. 68.2% of the investigated hips were of type I, 30.6% of type IIa. 20 hips (1.1%) were classified as IIg and 3 hips as type IIIa. The results of the clinical investigation during the first week were compared with the ultrasonographic findings. It is remarkable that some of the type IIg and type IIIa hips displayed no clinical signs. These hips should be controlled or treated at an early date.

[Diagnosis of tuberculosis of the spine (author's transl)]. / Zur Diagnostik der Spondylitis tuberculosa.

An analysis is presented of the case histories of 302 patients, admitted with tuberculosis of the spine to the Orthopaedic Department of the University Clinic, Vienna for surgical or conservative treatment. The average time between the onset of pain and the diagnosis was 13 months. Two thirds of the patients had no preceding history of healed or active tuberculosis. The average age of the patients was 40 years. Most of the patients showed tuberculous infection of only two vertebral bodies, mainly affecting the 8th thoracic to the 5th lumbar vertebrae. The diagnosis is made in most cases on the basis of the case history, clinical examination and, in particular, the radiological findings.

Ultrasonography in the diagnosis of transient synovitis of the hip and Legg-Calvé-Perthes disease.

Ultrasonography was used to establish the diagnosis of transient hip synovitis and the onset of Legg-Calvé-Perthes disease. A total of 115 patients presenting with 119 painful hips and the preliminary diagnosis of transient hip synovitis were reviewed. Hip effusion, resulting in capsular distension, was documented accurately with ultrasound. In nine patients, capsular distension persisted longer than 6 weeks and was associated with the onset of Legg-Calvé-Perthes disease.

[Hip screening in newborn infants. Clinical and ultrasound results]. / Hüftscreening bei Neugeborenen. Klinische und sonographische Ergebnisse.

A routine orthopaedic examination of each newborn was performed at the Salzburger Landesfrauenklinik (Department for gynaecology and obstetrics) since 1964. The results of these examinations were stored in an electronic database since 1978 and were now evaluated in a retrospective analysis. The examinations were performed by 8 orthopaedic surgeons between I/1978 and IX/1984. 5.9 percent of all newborns had a limited abduction and 13.2 percent a lax hip. Hips with limited abduction and lax hips were not classified as pathological but were recommended for strict observation and X-ray control at an age of four months. A similar rate of instable hips such as subluxatable (= 2.11%) and luxatable (= 0.63%) hips were also observed by other authors, whereas quite lower rates of instable hips in newborns were reported from several other European parts. Mau indicated the limited value of clinical examinations particularly when evaluating data in a multicenter study was concerned. In our study each examiner had a statistically significant variation of his results which we found by establishing an examiners ratio (Formula: see text). Since October 1984 the clinical routine newborn screening was completed by an obligatory hip sonography in the first days of life. The sonographic examination and classification was done according to Graf's method. Real-time ultrasound machines with linear 5 MHZ-transducer were used. 8.221 newborns were examined between X/1984 and XII/1988. 72.51 percent were type Ia, b. 25.63% were categorized as type IIa; 1.66 percent were classified type IIc, D; 0.16 percent were type IIIa hips. Only one hip was classified as type IV, this was a teratological dislocated hip. 1.31 percent of all hips showed a pathologic sonogram (= type IIc, D, IIIa) without having shown abnormalities, when clinically examined a few days before. In our opinion these results emphasize the value of a sonographic newborn screening. The majority of hips with distinct abnormalities only (= lax hips, limited abduction) was type Ia, b, or IIa, whereas the majority of clinical instable hips had pathologic sonograms (= IIc, D, IIIa). Newborns delivered by breech presentation had a significant higher percentage of clinically abnormal hips (= 7.48 subluxatable and luxatable hips). The percentage of pathologic sonograms (8.81%) and type IIa-hips (= 42.78%) was significantly higher compared to the normal delivered group. 336 premature newborns were found to have a statistically significant higher percentage of type Ia, b-hips (= 82.73%) and a statistically equal percentage of sonographically pathologic hips (= 0.89%) in comparison to the mature newborns.(ABSTRACT TRUNCATED AT 400 WORDS)

[Urinary bladder perforation caused by a loosened acetabular reinforcement ring]. / Harnblasenperforation durch Migration eines Burch-Schneider-Stützrings.

Reinforcement cages are widely used for the treatment of large acetabular bone defects. We report the case of a loosened Burch-Schneider reinforcement ring causing a recurrent macrohaematuria due to a perforation of the urinary bladder. After performing several diagnostic procedures, the patient underwent interdisciplinary revision surgery. Due to the severe destruction of the acetabular bone stock and an infection of the total hip prosthesis as confirmed by fresh frozen section, the hip prosthesis was explanted. At the last follow-up the patient was free of infect-related symptoms and was able to walk with one crutch.

[Incidence of anterior intertrochanteric ossifications after total hip arthroplasty--a retrospective long-term follow-up study]. / Inzidenz von anterioren intertrochantären Ossifikationen bei Hüfttotalendoprothesen--eine retrospektive Langzeituntersuchung.

AIM: This retrospective study investigates the incidence of anterior intertrochanteric ossifications (AIO), especially in comparison with heterotopic ossifications classified according to Brooker. A classification system of AIO regarding short-term results (< 1 year after surgery) was introduced in 2003: AIO occurred solely in 13 % of all cases (ossifications according to Brooker grade 0) and would have been "overlooked" without a lateral X-ray. The incidence of AIO combined with ossifications according to Brooker > 0 was 48.8 % of all cases. Our study reports long-term results, furthermore correlations between ossifications and clinical outcome, rated by the Harris hip score (HHS) and range of motion (ROM), are evaluated. MATERIAL AND METHODS: 149 cementless total hip arthroplasties (Hofer-Imhof threaded cup, straight stem), implanted into 140 patients from November 1991 to December 1994 underwent complete clinical and radiological follow-up from December 2005 to October 2006. The average age of the 81 female and 59 male patients at the time of implantation was 64 years. Without exception, a conventional, transgluteal approach (Bauer) was performed. All patients received indomethacin prophylaxis for 8 consecutive days after surgery. Current X-rays (a.-p. and lateral view) were evaluated in comparison with the former X-rays. RESULTS: AIO were found in 77 cases (51.7 %), heterotopic ossifications corresponding to Brooker in 93 cases (62.4 %), a combination of AIO and Brooker in 58 cases (38.9 %) and solitary AIO in 19 cases (12.8 %). HHS and ROM were not significantly altered by ossifications. CONCLUSION: Our long-term findings compare with the short-term results (indicating lack of new bone formation [heterotopic ossification] after more than one year after surgery, as previously described in the literature concerning ossifications according to Brooker) and verify the incidence rate of solitary AIO. Despite a minor correlation with clinical outcome, AIO could be considered as a possible indicator for predilection of heterotopic bone formation, especially if revision arthroplasty or THA of the contralateral side is needed.

[The interesting case: schwannoma of the nervus pudendus after triple pelvic osteotomy according to toennis]. / Der interessante Fall: Schwannom des Nervus pudendus nach Triple-Osteotomie nach Tönnis.

Schwannomas (neurilemmomas) are benign neural sheath tumours which commonly arise from cranial nerves and cutaneous nerves of the head and neck. The most common site is the acoustic neuroma of the 8th cranial nerve. Pelvic schwannomas are rare and often present with non-specific symptoms leading to misdiagnosis and prolonged morbidity. Most cases of pelvic schwannoma have been reported in the gynaecological and urological literature due to their presentation as a pelvic mass or from urinary tract compression. We present a schwannoma of the nervus pudendus with clinical, radiological, MRI scan and intraoperative findings together with a description of the technique of surgical resection.

[Septic arthritis caused by erysipelotrix rhusiopathiae: case report and review of the literature]. / Kniegelenksinfekt mit Erysipelotrix rhusiopathiae: Fallbericht und Ubersicht der internationalen Fachliteratur.

A 68-year-old man presented at our department with a suspected bacterial arthritis of the left knee. All diagnostic measures confirmed this diagnosis and the detected germ was Erysipelothrix rhusiopathiae. After arthroscopic debridement of the left knee, intravenous and oral antibiotic treatment for a total of 6 weeks, the patient was treated by total knee arthroplasty 6 months after the first presentation. The postoperative follow-up was without any pathological findings. There are only 4 other case reports in the international literature of Erysipelotrix rhusiopathiae linked to septic arthritis in humans. This case report of an infected knee further illustrates the pathogenicity of Erysipelothrix rhusiopathiae in humans.

[Long-term results of the cementless Hofer-Imhof threaded titanium cup]. / Langzeitergebnisse der zementfreien Hofer-Imhof-Titan-Schraubpfanne.

AIM: This retrospective monocentre study investigates long-term results of the cementless parabolic-shaped HI threaded cup. MATERIAL AND METHODS: 678 threaded cups made of titanium were implanted into 641 patients from November 1991 to May 1995. Mean age was 67 years, 65 % female, 35 % male. From December 2005 until October 2006, 165 patients (168 hips) underwent complete clinical and radiological follow-up, data of the remaining group were taken from the files. Using the Kaplan-Meier method, survival rates of the threaded cup were calculated. RESULTS: For all patients the average survival time of the cup was 14.2 years, the corresponding survival probability was 93 % (+/- 3.7 %) after 14.5 years. For the patients with complete follow-up, average survival time of the cup was 14.0 years, the corresponding survival probability was 93 % (+/- 5.2 %) after 14.5 years. CONCLUSION: Our results are comparable to those of threaded cups with a conical design (Zweymüller), the HI threaded cup can thus be recommended for primary implantation.

[CT scans increase rotational accuracy in total knee arthroplasty]. / Computertomografie erhöht die Rotationsgenauigkeit der Knie-Totalendoprothesenimplantation.

AIM: Several studies have shown that the rotation of the femoral component is an essential factor in total knee replacement. Consequently, different intra-operative landmarks for femoral implantation were established but most of them are either hard to define or have a high variance, so reducing their utility value. The aim of this randomised, prospective study was to prove that a preoperative CT scan is a usable help for femoral orientation. METHOD: In 2006, 57 consecutive patients designated for implantation of a knee arthroplasty were split up in two groups (a and b) corresponding to a randomisation scheme. The implantation of the femoral component in group a) was done with a posterior condylar angle of three degrees of external rotation as invariable determined by the resection guide. In addition the surgeon could correct the rotation following any other landmarks (surgeon's own method). In group b) the posterior condylar angle was measured preoperatively with the help of a CT scan and transferred on a resection guide allowing variation of the posterior condylar angle in single degree steps. In this case variation of femoral rotation (surgeon's own method) was not possible. The rotation of all knee replacements (groups a and b) was measured postoperatively with a CT scan following the technique of Berger et al. The implantation with the femoral component lying parallel to the transepicondylar axis was regarded as correct. Differences were measured in degrees. RESULTS: Regarding the degree of femoral malrotation without consideration of the direction (external/internal rotation) the difference between group a) and group b) was highly statistically significant (p < 0.000001). The highest range of malrotation in group b) was two degrees versus six degrees in group a). In group b) 19 of 30 (= 63.3 %) femoral components showed no malrotation at all, in group a) only 5 of 27 (= 18.5 %) components were implanted completely correctly. CONCLUSION: Preoperative measurement of the posterior condylar angle was proven to be a simple, reproducible examination method which increases the rotational accuracy of total knee replacement.

[The interesting case: Nora's lesion of the big toe]. / Der interessante Fall: Nora-Läsion der Grosszehe.

"Bizarre parosteal osteochondromatous proliferations" are extremely rare manifestations first described by Nora and only a few more than 100 cases have been described in the international literature. In spite of clinically resembling an osteochondroma, a subungual exostosis or a parosteal osteosarcoma, the lesion is characterised by distinct radiological and histological findings. The lesion is defined as a reactive heterotopic ossification and is mostly found in the hands and feet of adults in the third decade of life. A high rate of local recurrence of up to 50% has been described, but since it is defined as a benign lesion no metastases can be found. We report the instructive case of a BPOP ("Nora's lesion") in the area of the proximal phalanx of the big toe in which, after performing a biopsy, a resection of the lesion under preservation of the big toe was performed. At the last follow-up examination (4 years postoperatively) the patient showed no sign of recurrence of the lesion. The clinical, radiological and MRI appearance of the lesion are described together with the distinct clinical findings.

[Total hip replacement in high total hip dislocation by performing a Z-shaped shortening osteotomy]. / Die endoprothetische Versorgung der Koxarthrose bei kongenitaler Hüftgelenksluxation: Implantation einer Hüfttotalendoprothese kombiniert mit Z-förmiger Verkürzungsosteotomie des Femurs.

AIM: Total hip arthroplasty for severe chronic proximal femoral migration, most commonly seen in congenital dislocation of the hip, has been associated with high rates of complications. Placement of the acetabular component in the true acetabulum has yielded the most durable results, but leads to significant limb lengthening. In this paper six cases of a total hip arthroplasty combined with a Z-shaped osteotomy of the proximal femur are described. METHOD: All patients presented with a complete congenital dislocation of the hip. In all procedures the acetabular component was placed in the true acetabulum and the proximal femur was shortened according to a preoperative drawing in a Z-shaped manner. RESULTS: The clinical and radiological results of the patient collective are presented in this study, the mean follow-up period was 60 months. At the last follow-up no nerve palsy, osteotomy pseudarthrosis or dislocation were detected objectively. CONCLUSION: The performed procedure seems to be a viable technique in the treatment of coxarthritis in high total hip dislocation.

Contribution of anti-cyclic citrullinated peptide antibody and rheumatoid factor to the diagnosis of arthropathy in haemochromatosis.

OBJECTIVE: To investigate the prevalence of antibodies to cyclic citrullinated peptide (anti-CCP) and rheumatoid factor in patients with hereditary haemochromatosis (HHC) and to evaluate their diagnostic reliability in distinguishing HHC-associated arthropathy from rheumatoid arthritis. METHODS: Anti-CCP antibodies and rheumatoid factor levels were determined by ELISA in sera from 87 patients with HHC homozygous for the C282Y mutation of the HFE gene, 31 patients with rheumatoid arthritis and 162 healthy controls. RESULTS: Of the 87 patients with HHC, 32 (36.8%) had joint involvement. Anti-CCP antibodies were detected in only 1 patient (1.1%) with HHC, who had no joint disease, and in (1.2%) healthy controls. In total, 18 (58.1%) patients with rheumatoid arthritis displayed anti-CCP reactivity (p<0.001). Rheumatoid factor was detected in 10 (11.5%) patients with HHC compared with 7 (4.3%) healthy control subjects (p = 0.03) and 21 of 31 (65.6%) patients with rheumatoid arthritis. CONCLUSIONS: Testing for anti-CCP antibodies discriminates HHC arthropathy from rheumatoid arthritis, as these patients were consistently anti-CCP negative. Thus, HHC arthropathy should be considered in the differential diagnosis of CCP-negative arthritis.

[Polyethylene liner dislocation in Harris Galante acetabular components]. / Polyäthylen-Inlay-Dislokation des Harris-Galante-Pfannensystems.

AIM: Dislocation and subsequent dissociation of the polyethylene liner as a result of failure of the acetabular locking mechanism is a potential source of failure in the Harris-Galante acetabular component. The purposes of this study are to present seven cases with a liner dislocation due to failure of the liner locking mechanism. METHOD: Between March 1997 and December 2001, seven patients who had had a total hip arthroplasty presented with clinical and radiologic signs of liner dislocation and signs of polyethylene wear of the liner from a Harris Galante acetabular shell. In all cases the intraoperative findings showed evidence of failure of the liner locking mechanism and subsequent dislocation. The medical records, radiographs, operative notes and explanted retrieved components were reviewed. RESULTS: The components had been in situ for an average of 5.3 years (range 1-9 years). Two components were first generation, five were second generation. The symptoms developed spontaneously in five patients, the other two patients described a minor trauma. Radiographs showed eccentric position of the head in all cases. All acetabular components showed an excellent stability intraoperatively, nevertheless we had to remove the well fixed acetabular shell due to complete destruction of the liner locking mechanism in two cases. Treatment consisted of revision of the shell in two patients and exchange of the liner in five patients. All retrieved liners showed severe deformation and/or fracture of the rim. CONCLUSION: Harris Galante modular acetabular components have been used widely for primary and revision arthroplasty. The survival of this implant has been well documented in the literature. Failure of the liner locking mechanism and following dislocation or fracture of the polyethylene liner is a potential cause of failure which may possibly occur more often than the literature to date has documented. We report seven cases of liner dislocation, in which two acetabular components had to be removed completely due to destruction of the liner locking mechanism. In the other five cases exchange of the liner was possible thanks to well timed revision. We believe that, as the liner wears and becomes loose due to an inefficient locking mechanism, the load increases on the polyethylene rim until it deforms or fractures. As a consequence of the prosthetic design at that stage nothing can prevent the liner from rotating out of the shell.