[Use of an new modular revision arthroplasty system for the knee reconstruction]. / Einsatz eines neuen modularen revisionsendoprothetischen Systems zur Kniegelenksrekonstruktion.

OBJECTIVE: Reconstruction of stable knee joint kinematics using modular axis-guided revision implants after failed knee arthroplasty surgery. INDICATIONS: Revision implant for bone defects (type Anderson Orthopaedic Research Institute [AORI] III) in case of revision arthroplasty. Primary implant in case of mediolateral instability (>grade I) or multidirectional instability. CONTRAINDICATIONS: Persistent or current joint infection, general infection (e.g. pneumonia), missing metaphysis femoral and/or tibial, insufficient extensor apparatus. SURGICAL TECHNIQUE: Standard approach extending the previously used skin incision. Arthrotomy, synovectomy and collection of multiple samples for microbiological and histopathological analyses. Preparation of the femur with reamers of increasing diameter. Subsequently, a reference stem is anchored and after referencing the correct rotation and joint line height; the femoral osteotomy is performed after fixation of the 5­in­1 cutting block. Following the femoral osteotomy, the box of the femoral prosthesis is prepared. In addition, the tibia is prepared using an intramedullary reference system. Level of constraint and additional tibial augmentation is chosen according to the amount of defect bone and according to ligament stability. POSTOPERATIVE MANAGEMENT: Full load bearing; standard wound control and sterile dressings; limitation of active/passive range of motion only in case of weakened extensor apparatus. RESULTS: Between 03/2011 and 05/2018, a total of 48 patients underwent revision arthroplasty using the described system. The mean follow-up was 24 months (range 21-35 months). In 30 of the 48 cases, a rotating hinge variant was implanted, while in 18 cases a semiconstrained variant was implanted. Indications to revision arthroplasty: infection (n = 22), aseptic loosening (n = 11), instability (n = 11), periprosthetic fracture (n = 3) and PMMA allergy (n = 1). In 11 cases, revision had to be performed due to persistent infection (n = 6) and aseptic loosening (n = 5): 9 cases could be successful treated by a two-step revision procedure, while in 2 cases it was necessary to perform an arthrodesis. The 2­year implant survival rate was 77%.

[Periprosthetic Femoral Fractures: Classification and Therapy]. / Proximale periprothetische Femurfrakturen: Klassifikation und Therapie.

Periprosthetic femoral fractures can be categorized into proximal fractures around a hip stem or distally around a knee arthroplasty. This paper focuses on the proximal periprosthetic fractures. It is important to classify the fracture at diagnosis and to perform accurate planning of the surgery. Basically it is necessary to decide if the implant is fixed or loose, in the latter case a revision surgery including the change of the endoprosthesis is neccessary. If the implant is fixed an open reduction and internal fixation can be done. All implants have to be available on site because in the course of the intervention the plan could change. Due to rising numbers of primary arthroplasties and more elderly patients an increase of periprosthetic fractures can be expected. The treatment of periprosthetic fractures is an economic and surgical challenge. It is important to provide competence for these cases concerning both operative techniques and interdisciplinary treatment.

Prospective mid-term results of a consecutive series of a short stem.

A large number of short stem prostheses for hip -arthroplasty have been introduced in the past years. Although there is a large increase of publications about short stems, there is still little data available about survival and revision rates. We report prospectively on the outcome of 84 consecutive NANOS® short stem prostheses in 81 patients. We have included 37 female patients and 44 male patients with an average age of 61.6 ±â€ˆ9.2 years. The main diagnoses were osteoarthritis in 67 patients, dysplastic osteoarthritis in 8 patients and avascular necrosis of the femoral head in 6 patients. Along with demographic data and co-morbidities, the Harris Hip Score was recorded preoperatively and at follow-up. The Harris Hip Score increased from 36.6 ±â€ˆ14.5 preoperatively to 94.5 ±â€ˆ8.8 at the final follow-up. During the main follow-up time (27.7 months ±â€ˆ5.7) none of the 84 stems were revised, intraoperatively three fissure fractures occurred.

The Charcot foot: pathophysiology, diagnosis and classification.

Neuropathic changes in the foot are common with a prevalence of approximately 1%. The diagnosis of neuropathic arthropathy is often delayed in diabetic patients with harmful consequences including amputation. The appropriate diagnosis and treatment can avoid an extensive programme of treatment with significant morbidity for the patient, high costs and delayed surgery. The pathogenesis of a Charcot foot involves repetitive micro-trauma in a foot with impaired sensation and neurovascular changes caused by pathological innervation of the blood vessels. In most cases, changes are due to a combination of both pathophysiological factors. The Charcot foot is triggered by a combination of mechanical, vascular and biological factors which can lead to late diagnosis and incorrect treatment and eventually to destruction of the foot. This review aims to raise awareness of the diagnosis of the Charcot foot (diabetic neuropathic osteoarthropathy and the differential diagnosis, erysipelas, peripheral arterial occlusive disease) and describe the ways in which the diagnosis may be made. The clinical diagnostic pathways based on different classifications are presented. Cite this article: Bone Joint J 2016;98-B:1155-9.

First clinical study of a novel complete metal-free ceramic total knee replacement system.

BACKGROUND: The aim of the study was to evaluate the safety and efficacy of a novel metal-free ceramic total knee replacement system. METHODS: Thirty-eight primary total knee arthroplasties (TKAs) were performed on 34 patients using the metal-free BPK-S ceramic total knee replacement system with both the femoral and tibial components of an alumina/zirconia ceramic composite. The clinical outcome was evaluated pre- and postoperatively at 3 (n = 32 TKA) and 12 months (n = 32 TKA) using the Knee Society Score (KSS), the Oxford Knee Score and the EQ-5D. Safety analysis was performed by radiological examination and assessment of adverse events. RESULTS: Postoperatively, the KSS, Oxford Knee Score and EQ-5D improved significantly at 3 and 12 months (p < 0.001). Non-progressive partial radiolucent lines were observed in six cases, but there was no osteolysis and no implant loosening. Induction or exacerbation of allergies did not occur during the follow-up. CONCLUSIONS: The metal-free BPK-S ceramic total knee replacement system proved to be a safe and clinically efficient alternative to metal implants in this short-term follow-up study.

[Patellofemoral instability in trisomy 21: MPFL-Reconstruction as a single procedure]. / Patellainstabilität bei Patienten mit Trisomie 21: Alleinige MPFL-Rekonstruktion als neue Indikation.

BACKGROUND: Patellar instability is a common orthopaedic condition which is often seen in younger individuals. Biomechanical studies have shown that the medial patellofemoral ligament (MPFL) is the most important soft tissue that restrains lateral subluxation of the patella in the beginning of flexion of the knee joint. METHODS: MPFL reconstruction is an effective procedure to treat recurrent patellar dislocation. Double-bundle and single-bundle procedures have been described. If double-bundle reconstruction is not possible, there are good postoperative outcomes with single-bundle procedure as well. DISCUSSION: This is the first report of MPFL reconstruction as a single procedure to treat patellar instability in patients with down syndrome.

[Loosening of a Calcaneo-Stop Screw after Trampolining]. / Schraubenlockerung nach Calcaneusstoppschraube bei Trampolinspringen.

Flexible flatfoot is a common malalignment in the paediatric population. Arthroereisis with a calcaneo-stop screw is an effective surgical procedure for treating juvenile flexible flatfoot after conservative measures have been fully exploited. In the present report, we describe the case of a loosening of a calcaneo-stop screw in a 12-year-old youth after excessive trampolining.

[Symptomatic os trigonum with irritation of the flexor hallucis longus tendon - arthroscopic management via a dorsal approach]. / Symptomatisches Os trigonum mit Irritation des M. flexor hallucis longus - Arthroskopische Sanierung über dorsale Zugänge.

Therapy-resistant pain in the region of the medial mallelous in the presence of an os trigonum is suggestive for irritation of the flexor hallucis longus tendon. Two patients were treated by arthroscopy in the prone position via a dorsal approach; the os trigonum was removed and the tendon released. Under the conditions of blunt dissection, dorsal arthroscopy of the os trigonum is a safe and expedient operation in our toolbox. After two weeks of partial load-bearing with 2 crutches, pain-free full load-bearing is already possible and after 3 weeks the patients can return to work.

[Complex reconstruction with internal locking plate fixation for Charcot arthropathy]. / Komplexe Rekonstruktionen mit winkelstabiler interner Plattenfixation bei Charcot-Arthropathie.

BACKGROUND: Osteosynthesis and reposition of the Charcot foot is challenging with respect to choice of a proper implant. There is currently no international consensus regarding the optimal implant. OBJECTIVES: Locking plates seem to be an innovative and stable method for reconstruction. The aim of this work is to analyze bone fusion, complications, pseudoarthrosis, and patient satisfaction. METHODS: This paper presents a retrospective analysis of 63 consecutive Charcot feet treated between 2004 and 2014. The mean follow-up time was 2.4 years. RESULTS: All Charcot feet treated between 2004 and 2014 were Sanders type II or III. A bony fusion was achieved in 50 % of the cases, 26 % had a functional pseudoarthrosis with intact implants and pain-free mobility, and 22 % showed no healing with broken implants. Conclusion Internal fixation with locking plates is superior to screw fixation only with regard to biomechanics. We prefer internal fixation plates to external fixation because of stability even in the case of pseudoathrosis and because of the learning curve.

[Diabetic foot syndrome and diabetic neuropathic osteoarthropathy (DNOAP): an update of conservative and surgical therapy methods]. / Diabetisches Fußsyndrom und diabetische neuropathische Osteoarthropathie (DNOAP).

A diabetic foot or Charcot foot diagnosed in time can reduce a lot of problems for the patient, lessen high medical expense, and last but not least prevent an amputation. Good treatment options of the diabetic foot result from new technologies in wound management, angioplastic vessel improvement and optimised orthopaedic aids. Nevertheless it stays a challenging issue for practitioners and medical and health care as well as hospital owners to master this problem which will be even growing in the long run. This article intends to raise the awareness for the diabetic foot and the neuropathic osteoarthropathy, and furthermore illustrate diagnostic steps and offer therapeutic options. After distinguishing the diabetic foot from the Charcot foot a selective therapy for each entity has to be initiated. An interdisciplinary approach of specialists in dermatology, radiology, orthopaedic and internal medicine, plastic surgery and orthopaedic shoemaking is essential for a good therapeutic monitoring in order to avoid the amputation of the lower leg.

Radio-lunate arthrodesis in rheumatoid arthritis: outcome and techniques.

BACKGROUND AND PURPOSE: The wrist is one of the most affected joints in rheumatoid arthritis. The purpose of this retrospective study was to assess clinical, functional and radiographic results of radio-lunate arthrodesis. Two different operation and fixation techniques are compared and detailed outcome after this intervention is presented. METHODS: Twenty-seven patients with long-standing rheumatoid arthritis were operated on, either by stabilisation of the arthrodesis with Shapiro staples (n = 14) or by Herbert screw (n = 13) and followed for a mean of 5.4 years. RESULTS: Radio-lunate arthrodesis resulted in high overall and subjective satisfaction concerning function, grip and return to work. Grip strength was 35 kPa for the dominant and 26 kPa for the non-dominant hand. No revision, pseudoarthrosis or hardware failure was observed; only two conservatively treated wound healing problems were reported. The procedure resulted in a mean flexion of 26° and a mean extension of 24°; a clear improvement was also seen in activities of daily life. No difference between both groups was observed for pain, complication rate or functional outcome. INTERPRETATION: Due to high patient satisfaction and functional outcome, radio-lunate wrist arthrodesis can be recommended independent of fixation method.

[Proximal tibial reconstruction with gastrocnemius flap]. / Proximaler Tibiaersatz mit Transfer des M. Gastrocnemius.

OBJECTIVE: Technique for limb-salvage surgery of tumors of the proximal tibia. Endoprosthetic replacement of the tibia with a modular tumor endoprosthesis and reconstruction of the extensor mechanism with a gastrocnemius flap. INDICATIONS: Primary tumors and recurrences of semimalignant tumors of the proximal tibia. Diagnosis by biopsy and, depending on the entity, neoadjuvant chemotherapy. CONTRAINDICATIONS: Tumor infiltration of nerves or vessels, massive soft tissue infiltration, pathologic fracture, superinfection. SURGICAL TECHNIQUE: The tumor is resected en bloc with wide margins including the biopsy scar, the knee joint is resected intra-extra articular, politeal structures are exposed (anatomical border to the tumor is the popliteus muscle), osteotomy of the tibia 3-5 cm distal of the tumor. After removing the tumor, reconstruction with a modular tumor endoprosthesis is performed. The medial gastrocnemius muscle is detached and mobilized, rotated anteriorly and connected to the patella tendon. Closure of the muscle and skin. POSTOPERATIVE MANAGEMENT: Suction drainage for 48 h, extension brace for 2 weeks, followed by partial weight-bearing for 6 weeks. RESULTS: Despite technical developments over the years, a complication rate > 10% remains. Secondary amputation due to local recurrence is reported in about 10% of cases and due to infection in 6-12%. Transient or permanent palsy of the peroneal nerve is observed in 5% of cases. A quarter of all patients have full (< 20° extension lag) active extension, the mean extension lag is about 30°. The probability of a revision (including implant related) is 60-70% after 10 years. Based on the clinical results, the technical demanding resection of the proximal tibia is a recommendable procedure.

[Deformity-associated treatment of the hallux valgus complex]. / Deformitätsassoziierte Behandlung des Hallux-valgus-Komplexes.

Hallux valgus represents a combined deformity with malpositioning of the big toe in the metatarsophalangeal joint and metatarsal splaying due to metatarsus primus varus formation. It is defined on the basis of joint condition of the metatarsophalangeal and tarsometatarsal (TMT) joints, the extent and congruence or incongruence of malposition, mobility of the metatarsophalangeal joint and TMT stability. Basic resection appears to be indicated only in exceptional cases. Depending on the degree of severity, deformities can be corrected by means of distal, diaphyseal or proximal osteotomies and TMT arthrodeses. Any correction requires the use of subtle soft tissue surgery with recentering of the tendon, tightening of the medial capsule and abductor hallucis and releasing the lateral capsule. A check-list-like analysis of hallux valgus deformity helps determine the ideal procedure and avoid over- or under-treatment.

[Comparison of different cup revision systems]. / Unterschiedliche Pfannenrevisionsimplantate im Vergleich.

Aseptic loosening of hip cups results in cranial and medial migration, which induces bone resorption and defects. Despite these defects, it is the aim in cup revision arthroplasty to get a stable fixation and a restoration of the hip center. Depending on the size of the defect, which can be classified by different scoring systems, various strategies requiring an experienced surgeon can be used to reach this aim. If defects are localized, bigger primary cemented or cement-free cups can be used. Larger defects may need bone transplantation or special designs such as oval cups or reinforcement rings. They can be used with or without plates in combination with cement for inlay fixation. In the case of bigger defects or pelvic discontinuity, modular systems or a socket cup may be necessary.

Livin and Bcl-2 expression in high-grade osteosarcoma.

AIMS: The evaluation of prognosis in patients with osteosarcoma is limited to clinical parameters. Although numerous molecular markers have been studied, none are currently in routine clinical use. The aim of this study was to determine if Livin and Bcl-2, acting as antiapoptotic proteins through different mechanisms, are expressed in osteosarcoma, and whether they can be used as prognostic markers in human osteosarcoma. METHODS: Tumor specimens of 29 patients with high-grade central osteosarcoma, with complete clinical follow-up for a minimum of 5 years, were studied. The localization and distribution of Livin and Bcl-2 were investigated using immunohistochemistry. Results were correlated with the histological response to chemotherapy, 5-year disease-free and 5-year overall survival. RESULTS: Bcl-2 was expressed only in the cytoplasm of 16/29 cases and there was no statistically significant correlation between expression and any of the studied parameters. Livin was detected in 17/29 cases, in the cytoplasm of all 17 and in the nucleus of only 3 cases. Nuclear expression was significantly correlated with a decreased overall survival (P < 0.0002) compared with those patients without nuclear expression. CONCLUSIONS: The results of this study indicate that Bc1-2 and Livin are highly expressed in osteosarcoma cells and that possibly, the evaluation of nuclear Livin expression might be a useful prognostic marker in osteosarcoma.

Fusion of the wrist in rheumatoid arthritis: a clinical and functional evaluation of two surgical techniques.

We retrospectively compared wrist arthrodesis using the Mannerfelt technique in 19 or an AO-plate in 23 patients with long-standing rheumatoid arthritis. The mean follow-up was for 76 months. Compared with the Mannerfelt fusion group, patients in the AO-plate group reported greater satisfaction with their wrist function (74% vs 37%, p = 0.015). Complications were reported in six wrists in the AO-plate group and two wrists in the Mannerfelt fusion group (p = 0.258). At final follow-up, 95% of patients (41) reported either no pain or only mild pain. There was improvement in flexion of the finger joints in both groups but no significant improvement in the extension lag in either group. Both methods relieve pain and improve function. Overall, the activities of daily living scores and the patients' subjective assessment of outcome tended to be higher in the AO-plate group than in the Mannerfelt fusion group, although the difference was not statistically significant. Similarly, although more postoperative complications occurred in the AO-plate group, the difference between the two groups was not statistically significant.

Effects of hyperthermia on heat shock protein expression, alkaline phosphatase activity and proliferation in human osteosarcoma cells.

Hyperthermia can be used as a possible adjuvant therapy in treatment of cancer patients. In this study, the direct effect of hyperthermia on osteosarcoma derived cell lines HOS85, MG-63 and SaOS-2 was investigated. Heat shock at 42 degrees C inhibited proliferation significantly in all three cell lines tested. Furthermore a sub-lethal heat shock (42 degrees C, 1 h) decreases alkaline phosphatase activity, the absolute marker for osteoblast-like cells, in all of the three cell lines. Hsp70 was expressed constitutively and was found to be upregulated in a time-dependent manner; by up to 150% in Western blot analysis. The results of this study indicate that heat shock has an inhibitory effect on human osteosarcoma cells. These data suggest that hyperthermia has an anti-tumour effect on cancers of the bone and might, therefore, become an adjuvant treatment option.

[A postoperative infectious complication in a patient with rheumatoid arthritis treated with adalimumab]. / Postoperative Infektion unter Adalimumab.

Tumor necrosis factor (TNF) blocking agents, such as adalimumab, are well tolerated and provide improvement in the symptoms and signs of rheumatoid arthritis (RA). Due to its immunosuppressive effect, an increased risk of infection has been suggested, but so far no differences between adalimumab and placebo groups have been found in pivotal trials. Patients with RA succumb to postoperative complications because they have a systemic disease and use medication with immunosuppressive effects. We report on a patient with longstanding, active RA who had received adalimumab 40 mg every other week with prolonged infection, wound dehiscence and pseudoarthrosis following reconstructive forefoot surgery due to deformities secondary to RA. The postoperative infection occurred although adalimumab therapy had been stopped 8 days before surgery. The half-life of adalimumab is 10.0-13.6 days following a single intravenous dose. Whether patients under therapy with adalimumab are at an increased risk of developing postoperative complications is unclear, a retrospective analysis of the pivotal studies would be helpful in estimating the risk of perioperative (wound) infections in patients receiving anti-TNF. Moreover, it is not clear when therapy should be stopped prior to surgical intervention. Obviously prospective clinical trials would be more convincing.

[Planning of orthopedic surgery for rheumatoid arthritis]. / Rheumaorthopädische Therapieplanung.

The inflammatory process in rheumatoid arthritis is progressive and ends in destruction of the cartilage. Subsequent instability and mutilation of the joint might happen. The classification of destruction can be done by X-rays and assessment of the clinical picture. Depending on the radiologic stage different therapy concepts, ranging from conservative to operative, are established. It is the aim of surgery to restore motion and function in a painless joint. Surgery can be done to prevent the joint from further destruction or to replace the joint after resection. Different concepts based on radiologic findings are presented in this review.

Anticancer effects of zoledronic acid against human osteosarcoma cells.

Based on neoadjuvant chemotherapy, the prognosis of osteosarcoma patients has improved dramatically. However, due to therapy resistance in patient subgroups, the development of new treatment strategies is still of utmost importance. The aim of our study was to test the effects of the nitrogen-containing bisphosphonate zoledronic acid (ZOL) on osteosarcoma cell lines (N = 9). Exposure to ZOL at low micromolar concentrations induced a dose- and time-dependent block of DNA synthesis and cell cycle progression followed by microfilament breakdown and apoptosis induction. The ZOL-induced cell cycle accumulation in S phase was accompanied by significant changes in the expression of cyclins and cyclin-dependent kinase inhibitors with a prominent loss of cyclin E and D1. ZOL not only inhibited growth but also migration of osteosarcoma cells. The mevalonate pathway intermediary geranyl-geraniol (GGOH) but not farnesol (FOH) significantly inhibited the anticancer effects of ZOL against osteosarcoma cells. Correspondingly, ZOL sensitivity correlated with the blockade of protein geranylgeranylation indicated by unprenylated Rap1. Overexpression of even high levels of P-glycoprotein, as frequently present in therapy-resistant osteosarcomas, did not impair the anticancer activity of ZOL. Summarizing, our data suggest that ZOL, which selectively accumulates in the bone, represents a promising agent to improve osteosarcoma therapy.