Midterm Development of Ultrasound-unstable Hip Joints After Overhead Traction and Treatment With Tübingen Splint and Fettweis Plaster: A Radiologic Follow-up Analysis Over 5.5 Years.

PURPOSE: The aim of this study was to determine the success rate for treatment of ultrasound unstable hips (type D, III and IV) with Fettweis plaster in terms of a midterm follow-up from the very beginning in the neonatal period until the age of 4 to 8 years. METHODS: In total, 69 unstable hips, which were successfully treated with Fettweis plaster and after with a flexion-abduction splint, were included into the study. Hip delvelopment was followed by determining the acetabular index (ACI) on routine pelvic radiographs at the age of 12 to ≤24, 24 to ≤48 and 48 to ≤96 months and the center edge angle on the latter, and classifying both angles according to Tönnis. RESULTS: After initially successful treatment, the first radiograph at the age of 12 to ≤24 months showed 39.1% (n=27) hips with normal findings, 33.2% (n=23) hips with slightly dysplastic findings, and 27.5% (n=19) hips with severe dysplastic findings. Comparison between first and second radiograph showed improvement of the ACI in 9/69 hips and between the second and third time point in 20/69 hips. Overall, 20 hip joints showed deteriorations. Hereby, 16 deteriorations took place after the first radiograph and 4 after the second radiograph. Deteriorations were observed independently of the initial hip type (D, III, and IV). CONCLUSIONS: Midterm results indicate that radiologic controls should be provided to detect deteriorations after finishing treatment. ACI and center edge angle are helpful parameters in the assessment of hip joint development in the age range of 4 to 8 years. LEVEL OF EVIDENCE: Level III.

Radiological long-term follow-up up to 12 years of initially ultrasound unstable hip types D, III and IV after treatment with the Tübingen splint worn as a plaster.

INTRODUCTION: The treatment of ultrasound unstable hips with the Tübingen splint is currently under discussion. However, there is a lack of long-term follow-up data. This study presents to the best of our knowledge first radiological mid-term to long-term data of the successful initial treatment with the Tübingen splint of ultrasound unstable hips. MATERIALS AND METHODS: From 2002 to 2022 the treatment of ultrasound unstable hips type D, III and IV (age ≤ 6 weeks, no severe limitation of abduction) with the Tübingen splint worn as a plaster is evaluated. Based on data derived from routine X-rays during the follow-up period, a radiological follow-up (FU) analysis until the age of 12 years was performed. The acetabular index (ACI) and center-edge angle (CEA) were measured and classified according to Tönnis as normal findings (NF), slightly (sliD) or severely dysplastic (sevD). RESULTS: 193 of 201 (95.5%) unstable hips could be successfully treated showing normal findings with an alpha angle > 65°. The few patients showing treatment failures were successfully treated applying a Fettweis plaster (human position) under anesthesia. The radiological FU of 38 hips showed a favorable trend with increase of normal findings from 52.8% to 81.1% and decrease of 38.9% to 19.9% of sliD respectively 8.3% to 0% of sevD hips. The analysis of avascular necrosis of the femoral head showed 2 cases (5.3%) of grade 1 according to Kalamchi and McEwen, which were improving over time in the further course. CONCLUSIONS: The Tübingen splint as alternative to replace a plaster has proven a successful therapeutic option for ultrasound unstable hips type D, III and IV with favorable and over time improving radiological parameter up to the age of 12 years.

Rifampicin has - Compared to clindamycin - A dose and time dependent effect on hMSCs during osteogenic differentiation in vitro.

BACKGROUND: The effects of rifampicin and clindamycin on human mesenchymal stromal cell (hMSC) were examined. METHODS: hMSC were cultured with rifampicin and clindamycin (0.5 µg/ml, 5 µg/ml, 50 µg/ml) and examinations of proliferation (Bromodeoxyuridine), calcification (Alizarin red) and mineralization (alkaline phosphatase) were performed after 7th, 14th and 21st days. RESULTS: With rifampicin (50 µg/ml) cultured hMSC showed a significant negative effect during proliferation, mineralization (7, 14 and 21 days) and calcification (21 days). Clindamycin seems to have no effect. CONCLUSIONS: Rifampicin in a dosage of 50 µg/ml showed a negative impact on proliferation, mineralization and calcification of hMSC after 21 days.

The acromiohumeral distance in the MRI should not be used as a decision criterion to assess subacromial space width in shoulders with an intact rotator cuff.

PURPOSE: The acromiohumeral distance is in practice often evaluated on MRI by radiologists and a reduction diagnosed as subacromial impingement. However, the acromiohumeral distance as indicator for a decentered glenohumeral joint is defined on a true AP radiograph with the patient standing or sitting. The present study therefore evaluated the influence of the patient position by comparing the acromiohumeral distance in both modalities in shoulders with an intact rotator cuff. METHODS: On MRI images and true AP radiographs of patients > 20 and < 80 years with an intact rotator cuff the acromiohumeral distance was measured. The maximum cranio-caudal size of the glenoid was measured as a reference to allow a direct comparison of both modalities. RESULTS: Two-hundred and thirty-four shoulders (mean patients age 45.8 ± 14.3 years) were included. The mean acromiohumeral distance/glenoid size ratio of all shoulders was significantly larger (P < 0.0001) on the MRI with 4.6 ± 1.0 in comparison to 4.1 ± 0.9 in the radiographs indicating a smaller acromiohumeral distance on the MRI. In absolute values, a mean acromiohumeral distance of 9.2 mm ± 1.8 on MRI in comparison to 10.4 mm ± 2.4 on the radiographs was calculated. Herewith, the acromiohumeral distance in the MRI was in the average 1.2 mm ± 2.1 (13%) smaller than the in corresponding radiographs (P < 0.0001). CONCLUSION: The acromiohumeral distance is significantly smaller in the MRI in comparison to AP radiographs in shoulders with an intact rotator cuff and should not be used as a decision criterion on MRI to assess glenohumeral centering or subacromial space width. LEVEL OF EVIDENCE: IV.

Treatment of unstable hips with the Tübingen splint in early postnatal period: radiological mid-term results of 75 hips with mean follow-up of 5.5 years.

PURPOSE: For treatment of unstable hips, the Tübingen splint is a treatment option. After the initial treatment, regular radiological follow-up examinations are recommended but there is a lack of long-term outcome studies. Therefore, the further development of unstable hips treated with the Tübingen splint were evaluated. METHODS: From 2004 to 2015 116 patients with 161 unstable hips treated with the Tübingen splint were evaluated. Inclusion criteria were: 1) successfully treated unstable hip (type D, III and IV); 2) pelvic radiographs at the age of one to ≤ two, two to ≤ four and four to ≤ eight years. The acetabular index (ACI) of all and the centre-edge angle (CEA) of the third radiograph were measured and classified according to the Tönnis classification. RESULTS: A total of 53 patients with 75 unstable hips (type D 34 (45.3%), III 33 (44.0%), IV 8 (10.7%)) were included. In comparison of the first, second and third radiograph, an increase of normal findings was seen in 31 (41.3%) to 53 (70.7%) and 60 (80.0%) hips, respectively. However, a decrease of slightly dysplastic hips from 31 (41.3%) to 19 (25.3%) and 14 (18.7%) respectively and severely dysplastic hips from 13 (17.3%) to three (4.0%) and one (1.3%) hip respectively was detected. In comparison of first to second radiograph, 32 hips improved and five hips deteriorated and of second to third radiograph 16 hips improved and six hips deteriorated. The Tönnis classification of ACI compared with CEA showed no significant differences (p = 0.442). CONCLUSION: This study shows a good development of unstable hips treated with the Tübingen splint with mean follow-up 5.5 years. Nevertheless, unexpected deteriorations could be identified. The CEA is an alternative to the ACI. LEVEL OF EVIDENCE: IV.

Histologic examination of the shoulder capsule shows new layer of elastic fibres between synovial and fibrous membrane.

PURPOSE: In the present study, a systematic histological analysis of the glenohumeral joint capsule was conducted. MATERIALS AND METHODS: 12 cadaveric shoulders were examined. Inclusion criteria were: 1) intact joint capsule and 2) fixation in neutral position. The tissue samples were Elastica Hematoxylin-van-Gieson-(ElHvG) stained and diameter, quantity, and distribution patterns were analyzed. RESULTS: We detected a new layer (elastic boundary layer, EBL) between the synovial and fibrous membrane. The elastic fibres of the EBL differ considerably in diameter, quantity, and distribution pattern. CONCLUSIONS: A previously undescribed layer was noticed, which we named elastic boundary layer for now.

Lumbar lordosis as tool to assess the level of pain in patients with low back pain after lumbar disc herniation.

BACKGROUND: It is presently unknown if lumbar lordosis (LL) might be applied to monitor low back pain (LBP) in patients with lumbar disc herniation (LDH). There is presently only conflicting data that does not show a correlation of LL with LBP: Previous studies do either include chronic LBP or do not consider that each patient has an individual value of LL that cannot be compared to other patients. METHODS: Power analysis: At least 32 patients had to be enrolled in the study. Out of 84 consecutive patients with acute onset of pain (<6 weeks) that were treated operatively from 11/2015 to 04/2017 by microscopic laminotomy for LDH, 35 were enrolled in this retrospective within - subject analysis after exclusion of patients with chronic LBP or severe disc degeneration of the lumbar spine. We recorded self - reported assessment of pain (VAS) and LL before the operation, 1 week and 6 weeks after the operation. We performed a paired - samples t - test (within - subject) to compare means of LL at admission to our institution with LL 6 weeks after surgery. Pearson's correlation was determined for LL and VAS. Significance level was set at p < 0.05. RESULTS: VAS at admission to our institution was 7.1 (0.4), VAS 6 weeks after surgery was 1.0 (0.3).LL at admission to our institution was 40.0 (2.1), LL 6 weeks after surgery was 48.0 (1.8). The difference was significant (p < 0.0005) with a high statistical power (1-ß = 0.99).Correlation of LL and VAS was significant (p < 0.01, r = -0.32). CONCLUSIONS: The increase of lumbar lordosis following surgery is significantly correlated to the decrease in the level of perceived pain in patients with a LDH and may be used as an additional tool to monitor the success of treatment in the investigated group of patients.

Position of the acromioclavicular joint and relation to the critical shoulder angle in shoulders with rotator cuff tears.

OBJECTIVE: To evaluate the position of the acromioclavicular joint (ACJ) and relation to the critical shoulder angle (CSA) in shoulders with rotator cuff tears (RCT). METHODS: In a matched pair study including 75 shoulders with arthroscopically validated RCT and 75 controls (mean age 59.4 ± 7.9 years) the position of the ACJ in relation to the glenoid and the CSA were measured on true ap radiographs. RESULTS: The CSA is larger (p = 0.0018) and the position of the ACJ is more lateral (p = 0.0016) in shoulders with RCT in comparison to matched controls. CONCLUSION: The more lateral position of the ACJ in shoulders with a large CSA might be an additional component in the multifactorial pathogenesis of RCT.

Outcome after subtalar screw arthroereisis in children with flexible flatfoot depends on time of treatment: Midterm results of 95 cases.

OBJECTIVES: The subtalar screw arthroereisis (SSA) is a treatment option for painful pediatric flexible flatfeet (PFF). Hence, the optimal time point for a SSA is discussed controversially. Therefore the present study evaluates the influence of the patient's age at surgery on the radiological outcome to provide further evidence in this matter. METHODS: From 08/2007 to 12/2015 50 patients with 95 PFF were included. Inclusion criteria were: 1) Patients with PFF under or equal 15 years of age, 2) treatment with SSA and 3) presence of pre-op, post-op and follow up (FU) routine biplane radiographs. A subdivision was made into group A: 5-8 years, group B: 9-12 years and group C: 13-15 years. The radiographs were analyzed for: 1) calcaneal-pitch (CP), 2) lateral talocalcaneal angle (lat. TCA), 3) a.p. talocalcaneal angle (a.p. TCA, kite angle) and 4) navicular-cuboidal-index (NCI) and meary angle. RESULTS: Our study showed the best deformity correction when surgery was conducted between 9 and 12 years of age (group B), with significant improvement in all measured parameters without secondary deterioration during FU. In group A, the SSA show inferior results with poorer long-term success with only an improvement in the a.p. TCA. Group C showed mixed results. While CP and NCI improved, the lat. TCA deteriorated in FU. In conclusion, the ideal age for surgical intervention by SSA is between 9 and 12 years. Surgery before the age of 8 years did not show long-term success and delayed treatment at the age of 13-15 was only partially successful with deterioration during FU period. LEVEL OF EVIDENCE: IV.

Symptomatic medial synovial plica of the knee joint: an underestimated pathology in young patients.

INTRODUCTION: To prospectively evaluate the outcome of arthroscopic resection of a symptomatic medial plica in patients under 30 years with evaluating the influence of sports, knee trauma and plica type. METHODS: 35 consecutive patients (38 knees), mean age 16.2 ± 4.7 years (9-26 years), 28 females (73.7%) were prospectively included. Patients with any additional surgical procedures or cartilage lesions > ICRS grade I were excluded. The influence of trauma to the knee, level of sport and the morphologic plica type on the outcome was evaluated in addition to standard knee scores before and 20.1 ± 9.3 months (12-44 months) after surgery. RESULTS: The Knee Injury and Osteoarthritis Outcome Score improved significantly from 50.2 ± 19.1% (12.5-94.6) to 80.7 ± 15.3% (48.2-100; p < 0.001). The Tegner Activity Scale improved significantly from 2.2 ± 1.5 (0-6) to 4.9 ± 1.7 (3-10; p < 0.001) and the Kujala Anterior Knee Pain Scale improved significantly from 52.6 ± 16.6 (16-86) to 80.7 ± 16.5 (46-100; p < 0.001). The level of pain in the knee decreased from 7.9 ± 2.0 (1-10) to 3.1 ± 2.6 (0-9; p < 0.001) at follow-up on a numeric rating scale (0-10). Neither trauma to the knee, high impact sport, cartilage lesions to the medial femoral condyle nor the plica type or associated ICRS grade I cartilage lesion to the medial femoral condyle had a significant effect on the outcome parameters. CONCLUSION: Arthroscopic resection of a symptomatic medial plica provides excellent clinical results in young patients. Trauma, high impact sports, ICRS grade I cartilage lesions to the medial femoral condyle or the plica type are not associated with a poorer outcome. LEVEL OF EVIDENCE: Level IV, prospective case series with no control group.

The association between a low critical shoulder angle and SLAP lesions.

PURPOSE: To evaluate the critical shoulder angle (CSA), acromion index (AI) and further acromion parameters in patients with isolated SLAP lesions compared with patients without SLAP lesions. METHODS: Between 2012 and 2016, the CSA, AI, lateral acromion angle (LAA) and acromion slope (AS) were radiologically examined in consecutive patients > 18 years having had a shoulder arthroscopy with isolated SLAP lesion types II-IV. These were compared to controls without SLAP lesions and without (control group I) or with (control group II) complete supraspinatus tendon (SSP) tears. RESULTS: 75/103 patients with isolated SLAP lesion types II-IV with a mean age of 46.5 years (± 13.0, 18.1-76.3) were analyzed, 61% of them being male. For control, n = 211 consecutive patients (47% male) with an intact SSP and SLAP complex and a mean age of 52.3 years (± 15.0, 18.6-88.4) and n = 115 patients (60% male) with an intact SLAP complex but complete SSP tears, mean age 66.6 years (± 9.3, 44.7-87.9) were examined. The CSA in SLAP patients was 29.6° (± 3.5, 21.0-38.0), 33.8° (± 3.7, 25.1-46.9) in no SLAP and no SSP (p < 0.001) and 36.7° (± 3.6, 29.1-46.6) in no SLAP but SSP (p < 0.001). The area under the curve (AUC) for CSA was 0.83 for SLAP lesions resulting in a probability of 83% for patients with SLAP lesion to be associated with a specific CSA. CONCLUSIONS: Isolated SLAP lesion types II-IV are associated with a low CSA < 30°. The AI, the AS as well as the LAA showed no correlation with SLAP lesions. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Blood supply in the bicipital groove: A histological analysis.

The vascular anatomy in the closed bicipital groove with the long head of the biceps brachii muscle tendon (LHBT), its mesotenon and the transverse ligament intact has not been analyzed on a histological level yet. An anatomic dissection and histologic study was conducted by using 24 cadaveric formaldehyde fixated shoulders. The bicipital groove including the LHBT and its intact sheath was cut en-bloc, fixated, sliced in 7 µm sections, Azan stained and the vascular anatomy analyzed under light microscopy. Each sideward branch deriving from the main ascending branches of the anterior humeral circumflex artery (ACHA) in the mesotenon of the LHBT was identified and followed through multiple sections to identify its direction and area of supply. Per specimen, a mean of 2.71±1.85 branches could be identified running through the soft tissue of the mesotenon towards the osseous walls of the groove. Of the total 65 arterial branches in all specimens, 22 (33.8%) were running into the medial wall of the groove and 40 (61.5%) into the lateral wall (P<0.01). The results indicate that branches of the ACHA in the mesotenon of the LHBT provide blood supply not only to the tendon but to the osseous bicipital groove as well and here significantly more to the lateral than to the medial osseous wall. In addition, Pacini-like mechanoreceptors could be identified in the mesotenon in 9 (37.5%) of the specimens which has not been described up to now.

MRI reveals unrecognized treatment failures after application of Fettweis plaster in children with unstable hip joints.

We evaluated the success of treatment of unstable hip joints with the Fettweis plaster followed by MRI to detect potential treatment failures. A total of 132 ultrasound-detected unstable hips of type D, III, or IV according to Graf were treated with closed reduction and Fettweis plaster, followed by MRI. We examined 19 type D, 55 type III, and 58 type IV. Mean age at diagnosis was 84.5 days (SD: ± 55.4). Treatment period was 63.2 days (SD: ± 22.2). In 13 cases, the MRI showed a poor reduction. After repetition of this treatment, all 13 showed a concentric reduction. The use of MRI detects 9.8% of treatment failures. We recommend an MRI examination after each closed reduction to ensure the success of the therapy.

Osteochondritis dissecans shows a severe course and poor outcome in patients with juvenile idiopathic arthritis: a matched pair study of 22 cases.

Juvenile osteochondritis dissecans (JOCD) and juvenile idiopathic arthritis (JIA) are both common diseases which may affect joints and bony structures in pediatric patients. In some cases, JOCD and JIA occur at the same time. In this study, the course of JOCD in patients with JIA was therefore evaluated to provide possible recommendations for further treatment opportunities and control examinations. From 06/2012 to 03/2018 55 children with JOCD with or without JIA were examined. Inclusion criteria were: (1) age ≤ 16 years, (2) diagnosis of a JOCD with or without JIA and (3) two routine MRI controls. The JOCD evaluation based on the classification according to Bruns and the measurement of the largest extent via MRI. 18 of these 55 children met our criteria: 11 JOCD findings of 7 patients with JIA (group A) were matched according to age and localization of JOCD to 11 patients without JIA (group B). Mean age of disease onset of JIA was 8.2 years (oligo JIA) and of JOCD 11.6 years. The mean time follow-up was 17.7 months. At all observation time points more JOCD findings (with stage III° and IV°, respectively) along with a significant deterioration was seen in group A compared to group B. The comparison of the last MRI control between group A and group B shows a significant smaller defect size (decrease of 54.5%, p = 0.028) in group B (97.9 ± 48.9 mm2) as in group A (185.1 ± 102.9 mm2). In comparison of first (169.7 ± 84.2 mm2) and last MRI (97.9 ± 48.9 mm2) a significant decrease in lesion size of JOCD in group B was seen (decrease of 58.4%, p = 0.048). Patients with JIA show a more progressive and severe course of JOCD. Therefore, we recommend (1) the early use of MRI in patients with JIA and persistent joint pain to detect potential JOCD and (2) in presence of JIA and JOCD regular MRI follow-up controls to identify deteriorating JOCD findings and prevent early joint destruction in pediatric patients.

Development of unstable hips after treatment with the Tübingen splint: mid-term follow-up of 83 hip joints.

INTRODUCTION: Early diagnosis and treatment of hip dysplasia are widely accepted as major factors for beneficial outcome. However, modalities for reduction and retention as well as for imaging are currently under clinical investigation. Local and general risk factors, e.g., breech presentation and the family's desire to avoid in-hospital treatment are major concerns in the decision-making process and consultation. For treatment of unstable hips in newborns the treatment with the Tübingen splint has proven good results in recent studies. However, mid- and long-term outcome studies are missing. We report on clinical results and X-ray parameter of initially unstable hips after treatment with the Tübingen splint at two time points: 12-24 and 24-48 months of age. MATERIALS AND METHODS: Included were newborns with 83 unstable hips (type D, III, IV according to Graf) which were successfully treated with the Tübingen splint-used as reduction splint 24 h per day/7 days per week-until type I hips were documented by ultrasound examination. Measurments are based on routine pelvic X-ray control at the age of 12-24 and 24-48 months. The acetabular angle was determined and according to the Tönnis-Classification evaluated into: normal findings (< 1 s), slightly dysplastic findings (1-2 s) and severely dysplastic findings (> 2 s). Children with secondary hip dysplasia were not included in this series. RESULTS: In 2nd year of life, 45 hips (54.2%; initial hip type D: 47.4%, III: 63.2%, IV: 42.9%) of the formerly unstable hips show normal X-ray findings. Although final ultrasound showed normal findings, at this time point 28 hips (33.7%; initial hip type D: 34.2%, III: 31.6%, IV: 42.9%) were slightly dysplastic and 10 (12.0%%; initial hip type D: 18.4%, III: 5.3%, IV: 14.3%) still severely dysplastic. At the age of 24-48 months, the percentage of radiologic normal hips had increased to 61 hips (73.5%; initial hip type D: 68.4%, III: 81.6%, IV: 57.1%), the number of slightly (19 hips) and severely dysplastic (3 hips) hips had decreased 22.9% (initial hip type D: 28.9%, III: 15.8%, IV: 28.6%) respectively 3.6% (initial hip type D: 2.6%, III: 2.6%, IV: 14.3%). At this time no operative intervention was neccessary. CONCLUSIONS: Our mid-term data show on the one hand a good development of unstable hips after successful treatment with the Tübingen splint. On the other hand despite successful therapy and normal ultrasound findings at the end of treatment further imaging by X-ray are mandatory to close follow-up and to detect those which might need surgical correction of residual dysplasia.

Use of the Tübingen splint for the initial management of severely dysplastic and unstable hips in newborns with DDH: an alternative to Fettweis plaster and Pavlik harness.

AIM: Hip dysplasia is one of the most common skeletal disorders. As a late consequence 20-25% of the patients are at risk to develop secondary osteoarthritis and may require total hip replacement early in life. The treatment principles of hip dislocation are (1) concentric reposition, (2) retention, i.e., plaster in human post or Pavlik harness and (3) maturation in abduction flexion orthesis. The Tübingen splint was introduced as a further development of abduction devices for the treatment of (residual) hip dysplasia with stable hips. The advantages are easy handling, adjustment according to growth and safe limitation of abduction. The aim of this study was to determine the success of treatment of unstable hips with use of the Tübingen splint from early diagnosis until final end of therapy hence normal ultrasound findings. METHODS: From January 2003 to August 2016 79 children with 109 sonographic unstable hips were treated with the Tübingen splint initially consequently 24 h/day. Inclusion criteria were diagnosis of type D, type III a/b or type IV hips according to Graf and beginning of treatment at an age of less or equal 6 weeks, without limitation of abduction on clinical examination. RESULTS: At the time of diagnosis 51 type D (46.8%), 46 type III (42.2%) and 12 type IV (11.0%) hips were noticed. In 30 patients (38.0%) bilateral hip dysplasia (type D-IV) was diagnosed. 104 of 109 hips (95.4%) treated with the Tübingen splint could be transferred in a type I hip after a mean treatment period of 88.9 days (SD ± 26.0). In 5 cases (4.6%, 1 type III and 4 type IV hips) the treatment failed. CONCLUSION: Our data show, that successful treatment of unstable hips in neonates with the Tübingen splint is a comparably successful treatment modality relative to the Pavlik harness and Fettweis plaster.