[Refixation of the biceps tendon onto the radial tuberosity using two suture anchors]. / Refixation der distalen Bizepssehne an der Tuberositas radii mit zwei Spreizankern.

OBJECTIVE: Reinsertion of the distal biceps tendon onto the radial tuberosity restoring full force of flexion and supination. INDICATIONS: Distal biceps tendon avulsion from the radial tuberosity. Acute and chronic tears with a tendon stump, which can be mobilized and reduced to the radial tuberosity in flexion and supination. CONTRAINDICATIONS: Tears of the musculotendinous junction. Chronic distal biceps tendon tears with wide retraction and the need for tendon graft augmentation. Severe atrophy of the biceps muscle. SURGICAL TECHNIQUE: In supination, the skin is incised longitudinally for 4 cm, centered over the medial border of the radial tuberosity. Incision starts 2 cm distal from the humeroradial joint line. Bluntly the distal biceps tendon stump is found and mobilized. Preparation and debriding of the radial tuberosity sparing neurovascular structures. Crossing vessel branches are ligated, if needed. Positioning of two spreading anchors into the radial tuberosity and reinsertion of the tendon stump. POSTOPERATIVE MANAGEMENT: Adjustable elbow movement orthosis adapted to tendon quality and tissue tension for 6 weeks without active flexion or supination. Degree of extension is gradually increased by 20° every 2 weeks. After orthosis treatment is finished after 6 weeks, flexion and supination with weights is not allowed for another 6 weeks. RESULTS: In a retrospective study of 30 patients with a mean follow-up of 45 months (range 15-80 months), the clinical outcome was good or excellent in 99% of cases. On average, a Mayo Elbow Performance Score of 93 points (range 65-100 points) and a QuickDash of 5 points (range 0-39 points) were achieved.

[Gracilis tendon augmented reconstruction of the medial patellofemoral ligament with soft tissue fixation at the patellar insertion site]. / Ersatz des medialen patellofemoralen Ligaments durch autologe Gracilissehne mit implantat- und bohrkanalfreier patellarer Fixation.

OBJECTIVE: Reconstruction of the medial patellofemoral ligament with autologous tendon augmentation and soft tissue fixation at the patellar insertion with resorbable suture material. INDICATIONS: Patellofemoral instability due to insufficiency of the medial passive stabilizers and dysplastic trochlea. CONTRAINDICATIONS: Primary traumatic dislocation of the patella without risk factors for patellar redislocation, severe osteoarthritis of the patellofemoral joint, infection. SURGICAL TECHNIQUE: Diagnostic arthroscopy to evaluate cartilage and shape of trochlea and to treat associated injuries. Harvesting of the gracilis tendon and arming with resorbable suture material. Transfer of the tendon through the medial capsule in the anatomical layer of the MPFL and weaving in u-shape through the capsule and periosteum near the patella. Soft tissue fixation with resorbable suture material. Anatomical reconstruction of the femoral insertion site. Femoral fixation with interference screw. POSTOPERATIVE TREATMENT: For 4 weeks, partial (20 kg) weight bearing with crutches; cast with physiotherapy (limited ROM extension, flexion 0-0-90°). Thereafter free range of motion and full weight bearing. RESULTS: 27 patients (age 12-45 years) with patellofemoral instability underwent reconstruction of the medial patellofemoral ligament. Clinical follow-up was assessed up to 12 months postoperatively. After 1 year, the Kujala and Flandry scores increased from preoperatively 72 points to 95 points and 65.7 points to 89.9 points, respectively. One redislocation was observed. Patient satisfaction was significantly increased at 6 months postoperatively. Reconstruction of the medial patellofemoral ligament shows good clinical results after 12 months.

[Sliding osteotomy of the tibial tuberosity in patellofemoral instability]. / Verschiebeosteotomie der Tuberositas tibiae bei patellofemoraler Instabilität.

OBJECTIVE: The development of a stable patellofemoral joint by distal realignment with normal positioning of the patella. INDICATIONS: Patellofemoral instability with increased tibial tubercle to trochlear groove (TT-TG) distance ≥ 20 mm and higher Caton-Deschamps patellar height index ≥ 1.3. CONTRAINDICATIONS: Open epiphyseal and apophyseal plates of the proximal tibia, normal TT-TG distance with normal patellar height, and high-grade chondral lesions of the patellofemoral joint (ICRS grades 3 and 4). SURGICAL TECHNIQUE: Examination of the knee joint under anesthesia and evaluation of stability and mediolateral translation of the patella. Diagnostic knee arthroscopy and treatment of chondral or osteochondral lesions. Lateral approach to the tibial tuberosity with soft tissue mobilization and exposure of the patellar tendon. Osteotomy is performed in the frontal plane, creating a fragment at least 6 cm long. The tuberosity is slid into the desired position, medially and distally, if necessary, according to preoperative analysis and planning, followed by careful drilling of the posterior tibial cortex and lag screw osteosynthesis. POSTOPERATIVE MANAGEMENT: Partial weight-bearing of 20 kg in a MECRON knee brace for 6 weeks. Mobilization 0/0/90° from the MECRON knee brace without active knee extension. Isometric training of the thigh muscles with the knee fully extended. RESULTS: With meticulous planning and implementation, and in cases of severe trochlear dysplasia combined with medial patellofemoral ligament reconstruction, the technique of sliding osteotomy of the tibial tuberosity has a high success rate.

[Reconstruction of osteochondral defects with a collagen I hydrogel. Results of a prospective multicenter study]. / Rekonstruktion von Gelenkknorpeldefekten mit einem Kollagen-I-Hydrogel. Ergebnisse einer prospektiven Multicenterstudie.

STUDY GOALS: The aim of the study was to evaluate the therapeutic benefit of CaReS®, a type I collagen hydrogel-based autologous chondrocyte implantation technique, for the treatment of osteochondral defects of the knee (Outerbridge grades III and IV) within a prospective multicenter study. MATERIAL AND METHODS: A total of 116 patients in 9 clinical centers were treated with CaReS between 2003 and 2008. The Cartilage Injury Evaluation Package 2000 of the International Cartilage Repair Society (ICRS) was employed for data acquisition and included the subjective International Knee Documentation Committee score (IKDC score), the pain level (visual analog scale, VAS), the physical and mental SF-36 score, the overall treatment satisfaction and the functional IKDC status of the indexed knee. Follow-up evaluation was performed 3, 6 and 12 months after surgery and annually thereafter. RESULTS: The mean defect size treated was 5.4 ± 2.7 cm(2) with 30% of the cartilage defects being ≤4 cm(2) and 70% ≥4 cm(2). The mean follow-up period was 30.2 ± 17.4 months (minimum 12 months and maximum 60 months). The mean IKDC score significantly improved from 42.4 ± 13.8 preoperatively to 70.5 ± 18.7 (p < 0.01) in the mean follow-up period. Global pain level significantly decreased (p < 0.001) from 6.7 ± 2.2 preoperatively to 3.2 ± 3.1 at the latest follow-up. Both the physical and mental components of the SF-36 score significantly increased. At the latest follow-up 80% of the patients rated the overall treatment satisfaction as either good or very good. The functional IKDC knee status clearly improved from preoperative to the latest follow-up when 23.4% of the patients reported having no restriction of knee function (I), 56.3% had mild restriction (II), 17,2% had moderate restriction (III) and 3.1% revealed severe restriction (IV). CONCLUSIONS: The CaReS technique is a clinically effective and safe method for the reconstruction of isolated osteochondral defects of the knee joint and reveals promising clinical outcome up to 5 years after surgery. A longer follow-up period and larger patient cohorts are needed to evaluate the sustainability of CaReS treatment.

[Minimally invasive retrograde drilling of osteochondral lesions of the femur using an arthroscopic drill guide]. / Minimal-invasive retrograde Anbohrung der Osteochondrosis dissecans des Femurkondylus mit einem speziellen Zielinstrumentarium.

OBJECTIVE: Retrograde drilling for penetration of subchondral sclerotic bone in osteochondrosis dissecans (OCD) of the femoral condyle with preserved cartilage integrity. Hereby, revascularization of the OCD and immigration of bone marrow cells to achieve stable reintegration of the OCD into the surrounding subchondral bone. INDICATIONS: Stable juvenile and adult osteochondrosis dissecans (stage I-II of the International Cartilage Repair Society (ICRS) classification) of the medial and lateral femoral condyle with an intact articular surface and surrounding sclerosis zone, which is visible in the x-ray. CONTRAINDICATIONS: OCD stage III-IV of the ICRS grading scale. Relative contraindication: preceding retrograde drilling. SURGICAL TECHNIQUE: Arthroscopic inspection and palpation of the cartilage defect. Minimal incision over the M. vastus medialis (when the defect is located in the medial condyle) or the M. vastus lateralis (when the defect is located in the medial condyle). Preparation and dissection of the fascia of the vastus muscle. Insertion of retractors underneath the vastus muscle to expose the metaphysis of the distal femur. Intraarticular positioning of the arthroscopic drill guide, placement of the wire guide and a Kirschner(K) wire on the femur metaphysis and retrograde drilling with a 2.0-2.2 mm K wire under radiographic visualization. Length measurement of the intraosseous wire distance. Switch the guide mechanism to a multiple hole drill guide and, depending on the defect size, insertion of a further 7-10 K wires of same thickness and defined length. POSTOPERATIVE MANAGEMENT: Sterile bandage and slightly compressive dressing. Continuous active and passive knee motion. Weight bearing of 20 kg for 6 weeks, with subsequent transition to continuous weight bearing. Radiographic controls at 6 and 12 weeks postoperatively. In case of a persistent sclerosis zone in the control x-ray or clinical abnormalities, control MRI is indicated. RESULTS: A total of 55 patients with a mean age of 19.6 years were treated using the described technique: 49 patients (89.1%), and 54 knees respectively (35 juvenile OCD, 19 adult OCD), were seen with a mean follow-up of 37.9 months. An improvement was observed in 81.6% of the knees using the radiographic score, i.e., a mean improvement of 1.13 of the radiographic score published by Rodegerdts and Gleissner (preoperative 3.04 vs. postoperative 1.91). Juvenile OCD showed better radiographic results overall (88.2% healing) than adult OCD (66.7% healing).

Anterior cruciate ligament constructs fabricated from human mesenchymal stem cells in a collagen type I hydrogel.

BACKGROUND: Disruptions of the anterior cruciate ligament (ACL) of the knee joint are common and are currently treated using ligament or tendon grafts. In this study, we tested the hypothesis that it is possible to fabricate an ACL construct in vitro using mesenchymal stem cells (MSC) in combination with an optimized collagen type I hydrogel, which is in clinical use for autologous chondrocyte transplantation (ACT). METHODS: ACL constructs were molded using a collagen type I hydrogel containing 5 x 10(5) MSC/mL and non-demineralized bone cylinders at each end of the constructs. The constructs were kept in a horizontal position for 10 days to allow the cells and the gel to remodel and attach to the bone cylinders. Thereafter, cyclic stretching with 1 Hz was performed for 14 days (continuously for 8 h/day) in a specially designed bioreactor. RESULTS: Histochemical analysis for H and E, Masson-Goldner and Azan and immunohistochemical analysis for collagen types I and III, fibronectin and elastin showed elongated fibroblast-like cells embedded in a wavy orientated collagenous tissue, together with a ligament-like extracellular matrix in the cyclic stretched constructs. No orientation of collagen fibers and cells, and no formation of a ligament-like matrix, could be seen in the non-stretched control group cultured in a horizontal position without tension. RT-PCR analysis revealed an increased gene expression of collagen types I and III, fibronectin and elastin in the stretched constructs compared with the non-stretched controls. DISCUSSION: In conclusion, ACL-like constructs from a collagen type I hydrogel, optimized for the reconstruction of ligaments, and MSC have been fabricated. As shown by other investigators, who analyzed the influence of cyclic stretching on the differentiation of MSC, our results indicate a ligament-specific increased protein and gene expression and the formation of a ligament-like extracellular matrix. The fabricated constructs are still too weak for animal experiments or clinical application and current investigations are focusing on the development of a construct with an internal augmentation using biodegradable fibers.

[Anatomy of the glenoid labrum]. / Die Anatomie des Labrum glenoidale.

Most instabilities or pain syndromes are associated with injuries or morphologic changes in the glenoid labrum complex or long head of the biceps tendon origin. The first anatomic descriptions go back to Fick in 1910 and since then many authors have described the anatomy of these structures. It was Snyder who introduced the term SLAP lesions, classifying superior, anterior, posterior labrum changes into four grades. It is still unclear whether all of the described and arthroscopically observed changes are due to a post-traumatic, acquired lesion or whether anatomic variations can be present as well. In order to elucidate this problem, 36 cadaver shoulder joints were inspected macroscopically and sectioned for microscopic evaluation. Here the glenoid could be divided into an superior and an anterior- superior area demonstrating a wide variety of morphologic labral glenoid changes, while the dorsal and inferior sectors of the glenoid showed a relatively uniform anatomy of a firm labrum-glenoid bond. Four types of biceps tendon attachments could be identified similar to the description given by Vangsness. In addition, a variety of anterior-superior changes could be found. The sublabral hole as described by Esch in the clinical setting was found to be a physiologic variant. Precise knowledge of the anatomic morphology of the normal glenoid in its variations seems to be necessary to understand variants and allow for distinguishing between physiologic anatomic variants and pathoanatomic changes in imaging and the clinical setting.

Arthroscopic treatment of septic joints: prognostic factors.

From 1987 to 1993, 88 patients (average age 48 years, range 3 months to 83 years) with septic arthritis were treated at the orthopaedic clinic König Ludwig Haus of the University of Würzburg by arthroscopic means consisting of joint debridement and application of suction drains, combined with appropriate antibiotics and early functional treatment. The series consisted of 78 knees, 8 shoulders and 3 ankles. At the first visit to our clinic, patients typically presented with fever, leucocytosis, elevated sedimentation rate and localized findings in almost every joint involved (generalized tenderness, swelling, effusion, painful and limited range of motion). All the patients were taken to the operating room on an emergency basis. Broad-spectrum antibiotics were given before the initial culture was evaluated, and its sensitivity was determined. Recovery from arthritis by elimination of joint effusion and disappearance of the inflammatory syndrome occurred in all the joints except for 3 (1 knee joint and 2 shoulders). The number of arthroscopic procedures needed to become free from infection depended on the one hand on the time between onset of symptoms and arthroscopic surgery and on the other on the kind of microorganism discovered. At the average follow-up evaluation after 2.5 years (range 6 months to 5 years), the functional results were excellent or good in 61% of the patients, satisfactory in 20% and poor in 19% from our series. This functional outcome depends on the degenerative changes of the joint before infection, patient's age, and the time interval between onset of symptoms and surgical intervention; indirectly, the time lapse between the onset of infection and surgical intervention also had an influence on the intraoperative macroscopic appearance.

ATPase-defective derivatives of Escherichia coli DnaK that behave differently with respect to ATP-induced conformational change and peptide release.

We have characterized the effects of the T199S, T199A, and K70A mutations on the biochemical activity and in vivo functioning of Escherichia coli DnaK. Threonine-199 is the site of autophosphorylation of DnaK, and the lysine residue of bovine Hsc70 corresponding to K70 of DnaK has been shown to be essential for the hydrolysis of ATP. The dnaK alleles T199A and K70A are completely unable, and the T199S allele is only partially able, to complement the defects of a DeltadnaK mutant. The ATPase activities of the DnaK T199A and DnaK K70A proteins are nearly abolished, while the ATPase activity of the DnaK T199S protein has a steady-state rate similar to that of wild-type DnaK. The DnaK T199S protein also retains approximately 13% of the autophosphorylation activity of wild-type DnaK, while the autophosphorylation activities of the T199A and K70A derivatives are completely abolished. All four DnaK proteins bind a model peptide substrate, and the wild-type, T199A, and T199S DnaK proteins release the peptide with similar kinetics upon the addition of ATP. The DnaK K70A protein, in contrast, does not release the peptide upon the addition of ATP. ATP induces a conformational change in the wild-type, T199A, and T199S DnaK proteins but not in the DnaK K70A protein. The T199A and K70A mutations both disrupt the ATPase activity of DnaK but have profoundly different effects on the ATP-induced conformational change and peptide release activities of DnaK, implying that the two mutations affect different steps in the functional cycle of DnaK. The DnaK T199S protein represents a new class of DnaK mutant, one which has near-normal levels of ATPase activity and undergoes an ATP-induced conformational change that results in the release of peptide but which is not able to fully complement loss of DnaK function in the cell.

Primary synovial chondromatosis of the elbow.

Very few cases of primary synovial chondromatosis of the elbow have been reported in the literature. This is a study concerning the late outcome of primary synovial chondromatosis in the elbows of 12 patients, 10 men and 2 women, with a mean follow-up of 16 years 10 months. The average age at the time of the initial complaint was 29 years. The histories of 10 patients revealed elbow strain as a consequence of work-related activities. Surgery included removal of loose bodies and partial synovectomy in all patients. A moderate to severe osteoarthritis was found preoperatively in 5 of 12 patients and during follow-up in 7 of 10 patients. The degree of osteoarthritis deteriorated after surgery in 5 of these cases, depending on patient age, length of presurgical history, length of follow-up, and strenuous activities. However, the functional deficiencies were usually moderate and had little significance with respect to the activities of daily living. No recurrence of primary synovial chondromatosis was found.

Inferences concerning the ATPase properties of DnaK and other HSP70s are affected by the ADP kinase activity of copurifying nucleoside-diphosphate kinase.

Preparations of Escherichia coli DnaK from our lab as well as preparations of DnaK and other HSP70 proteins from several major labs in the field produce a stoichiometric initial burst of [alpha-(32)P]ADP when incubated with [alpha-(32)P]ATP and contain an ADP kinase activity. We determined that the initial burst activity results from the transfer of gamma-phosphate from the radiolabeled substrate [alpha-(32)P]ATP to unlabeled ADP bound by the DnaK and is the same activity that results in ADP phosphorylation. The purification of DnaK from E. coli cells that carry a disrupted ndk gene, ndk::km, results in preparations with greatly reduced ADP kinase activities compared with preparations of DnaK purified from ndk(+) cells. The reduction in the amount of ADP kinase activity in preparations of DnaK purified from ndk::km cells shows that nucleoside-diphosphate kinase (NDP kinase) is responsible for most of the ADP kinase activity present in DnaK preparations isolated from ndk(+) cells. The remaining ADP kinase activity in preparations from ndk::km cells, which varies between preparations, is also a property of NDP kinase, which is most likely expressed because of a low frequency reversion of the disrupted ndk gene. A weak, but measurable physical interaction exists between DnaK and NDP kinase and may be at least partially responsible for the co-purification of NDP kinase with DnaK. The presence of contaminating NDP kinase can explain the range of k(cat) values reported for the ATPase activity of DnaK as well as recent reports of initial burst kinetics by DnaK (Banecki, B., and Zylicz, M. (1996) J. Biol. Chem. 271, 6137-6143) and an ADP-ATP exchange activity of DnaK (Hiromura, M., Yano, M., Mori, H., Inoue, M., and Kido, H. (1998) J. Biol. Chem. 273, 5435-5438).

Preoperative irradiation versus the use of nonsteroidal anti-inflammatory drugs for prevention of heterotopic ossification following total hip replacement: the results of a randomized trial.

PURPOSE: Previous studies showed the effectiveness of early preoperative (4 h before operation) irradiation for prevention of heterotopic ossification (HO) after total hip replacement. This procedure can result in logistic problems, if there is a great distance between the department of radiotherapy and the orthopedic clinic. To avoid these organizational problems a prospective study was undertaken to analyze the effectiveness of preoperative irradiation on the day preceding surgery (16-20 h before operation). METHODS AND MATERIALS: Between 1995 and 1996, 100 patients were randomized to receive a prophylactic therapy for prevention of heterotopic ossification. Forty-six patients were irradiated with 7 Gy single dose within 16-20 h before operation. Fifty-four patients were treated with nonsteroidal anti-inflammatory drugs (NSAID) (Voltaren resinat 2 x 75 mg/day for 2 weeks). Heterotopic ossification was scored according to the Brooker Grading system. One hundred patients receiving no prophylactic therapy after total hip arthroplasty between 1988 and 1992 were analyzed and defined as the historical control group. RESULTS: Incidence of heterotopic ossification was 47.8% in the 7 Gy preoperative group (Brooker Score I: 36.9%; II: 8.7%; III: 2.2%; IV: 0%) and 11.1% in the NSAID group (Brooker Score I: 9.3%; II: 1.8%; III: 0%; IV: 0%). Regarding overall heterotopic ossification there was a significant difference between the NSAID group and the 7 Gy group (p < 0.01). Analyzing the clinically significant heterotopic ossification (Brooker Score III and IV) there was no significant difference between the two treatment arms (p > 0.05). In the untreated historical control group the incidence of heterotopic ossification was 65% (Brooker Score I: 26%; II: 15%; III: 19%; IV: 5%). Referring to overall and to clinically relevant heterotopic ossification the incidence of HO was greater in the control group than in the prophylactically treated groups (p < 0.05). CONCLUSION: Irradiation within 16-20 h before operation and use of NSAID (Voltaren resinat) can reduce the incidence of clinically relevant heterotopic ossification after total hip replacement.

The chondrogenic potential of human bone-marrow-derived mesenchymal progenitor cells.

Mesenchymal progenitor cells provide a source of cells for the repair of musculoskeletal tissue. However, in vitro models are needed to study the mechanisms of differentiation of progenitor cells. This study demonstrated the successful induction of in vitro chondrogenesis with human bone-marrow-derived osteochondral progenitor cells in a reliable and reproducible culture system. Human bone marrow was removed and fractionated, and adherent cell cultures were established. The cells were then passaged into an aggregate culture system in a serum-free medium. Initially, the cell aggregates contained type-I collagen and neither type-II nor type-X collagen was detected. Type-II collagen was typically detected in the matrix by the fifth day, with the immunoreactivity localized in the region of metachromatic staining. By the fourteenth day, type-II and type-X collagen were detected throughout the cell aggregates, except for an outer region of flattened, perichondrial-like cells in a matrix rich in type-I collagen. Aggrecan and link protein were detected in extracts of the cell aggregates, providing evidence that large aggregating proteoglycans of the type found in cartilaginous tissues had been synthesized by the newly differentiating chondrocytic cells; the small proteoglycans, biglycan and decorin, were also detected in extracts. Immunohistochemical staining with antibodies specific for chondroitin 4-sulfate and keratan sulfate demonstrated a uniform distribution of proteoglycans throughout the extracellular matrix of the cell aggregates. When the bone-marrow-derived cell preparations were passaged in monolayer culture as many as twenty times, with cells allowed to grow to confluence at each passage, the chondrogenic potential of the cells was maintained after each passage.

Randomized trial comparing early postoperative irradiation vs. the use of nonsteroidal antiinflammatory drugs for prevention of heterotopic ossification following prosthetic total hip replacement.

PURPOSE: A randomized trial was undertaken to assess the comparative efficacy of early postoperative irradiation with either 5 or 7 Gy vs. the use of nonsteroidal antiinflammatory drug (NSAID) for prevention of heterotopic ossification (HO) following prosthetic total hip replacement (THP). METHODS AND MATERIALS: Between 1993 and 1994, 301 patients were randomized to receive postoperative irradiation (5 or 7 Gy) or NSAID. One hundred and thirteen patients were treated with NSAID (indomethacin 2 x 50 mg/day for 1 week), 93 patients were irradiated with a single 7 Gy fraction, 95 patients with a single 5 Gy fraction. The treatment volume included the soft tissues between the periacetabular region of pelvis and the intertrochanteric portion of the femur. X-rays of treated hips were obtained immediately and 6 months after surgery. Heterotopic ossification was scored according to the Brooker Grading system. One hundred patients receiving no prophylactic therapy after total hip arthroplasty between 1988 and 1992, were analyzed and defined as historical control group. RESULTS: Incidence of heterotopic ossification was 16.0% in NSAID-group (Brooker Score I: 8.0%; II: 6.2%; III: 1.8%; IV: 0%), 30.1% in 5 Gy group (Brooker Score I: 24.7%; II: 4.3%; III: 1.1%; IV: 0%), and 11.1% in 7 Gy group (Brooker Score I: 11.6%; II: 0%; III: 0%; IV: 0%). Regarding overall heterotopic ossification there was a significant difference between the NSAID group and the 5 Gy group (p < .015), respectively, between the 7 Gy group and the 5 Gy group (p < .0001). No significant difference was noted in the influence of overall HO between the NSAID and the 7 Gy group (p > 0.3). Analyzing the clinically significant HO (Brooker Score III and IV) patients irradiated with 7 Gy developed less HO than those treated with NSAID (p = 0.003). Incidence of HO was greater in the untreated historical control group (Brooker Score I: 26%; II: 15%; III: 19%; IV: 5%) than in all three prophylacticly treated groups. CONCLUSION: Prophylactic irradiation of the operative site after hip replacement with single a 7 Gy fraction is the most effective postoperative treatment schedule in prevention of clinically significant heterotopic ossification. This therapy modality is more effective than irradiation with a single 5 Gy fraction or use of NSAID.

Prevention of heterotopic ossification after total hip replacement. A prospective, randomised study using acetylsalicylic acid, indomethacin and fractional or single-dose irradiation.

We have carried out a prospective, randomised study of prophylaxis for heterotopic ossification (HO) comparing indomethacin for 7 and 14 days, acetylsalicylic acid, and fractional (4 x 3 Gy) or single exposure of 5 or 7 Gy irradiation after operation. We initially had 723 patients (733 hip replacements), but after withdrawals there were 685 hips of which 18.4% developed HO; 14% were grade I, 2.9% grade II and 1.5% grade III of the Brooker classification. We compared the results between these groups with those of a matched control series and found that indomethacin, 2 x 50 mg for 7 and 14 days, and postoperative irradiation of 4 x 3 Gy or 1 x 7 Gy, significantly reduced the development of HO compared with the control group. Patients in the acetylsalicylic acid group and those with a single irradiation of 5 Gy after operation developed significantly more ossification than those in the indomethacin and other irradiation groups. We suggest the use of 2 x 50 mg of indomethacin with mucoprotection for seven days as prophylaxis against HO after total hip replacement for all patients. A single irradiation of 7 Gy is recommended for patients who have developed HO after previous operations or to whom administration of indomethacin is contraindicated.

Heterotopic ossification after total knee arthroplasty. 54/615 cases after 1-6 years' follow-up.

We found heterotopic ossifications in 54 (9%) of 615 cases after total knee arthroplasty. The largest ossifications were located in the anterior distal femur. In 12 cases smaller ossifications were found in other knee regions. The development of heterotopic ossification showed a positive correlation with hypertrophic arthrosis and a negative correlation with rheumatoid arthritis. We propose a new 3-grade classification which refers only to the anterior distal femoral region. Grade III heterotopic ossifications occurred in 4 patients (4 knees) who had clinical symptoms; 2 were successfully reoperated with removal of the ossifications. Prophylaxis should be considered in patients with marked hypertrophic arthrosis or marked periosteal damage to the anterior distal femur.

[Prospective study on the prevention of heterotopic ossification after total hip replacement. Non-steroidal anti-inflammatory agents versus radiation therapy]. / Prospektive Studie zur Vermeidung heterotoper Ossifikationen nach Hüftgelenksersatz. Nichtsteroidales Antirheumatikum versus Strahlentherapie.

PURPOSE: Two prospective trials were undertaken to assess the comparative efficacy of early postoperative irradiation with different radiation doses versus the postoperative use of nonsteroidal antiinflammatory drugs (NSAID) for prevention of heterotopic ossification (HO) following prothetic total hip replacement (THP). PATIENTS AND METHOD: Between 1992 and 1994 585 patients received THP. These patients were randomed in two longitudinal studies each with 3 treatment arms comparing postoperative irradiation with 4 x 3 Gy (101 patients), 1 x 5 Gy (93 patients), 1 x 7 Gy (95 patients) and the postoperative use of the NSAID indometacin for 7 days (113 patients) respectively for 14 days (90 patients) und acetyl salicyl acid (ASS) for 14 days (93 patients). Heterotopic ossification was scored according to the Brooker grading system. One hundred patients receiving no prophylactic therapy after total hip arthroplasty between 1988 and 1992 were analysed and defined as historical control group. RESULTS: Incidence of heterotopic ossification was 5% in the 4 x 3 Gy group (Brooker grade I 5%, grade II 0%, grade III 0%), 30.5% in the 1 x 5 Gy group (Brooker grade I 24.7%, grade II 4.1%, grade III 1.0%) and 10.5% in the 1 x 7 Gy group (Brooker grade I 10.5%, grade II 0%, grade III 0%). 15.9% of the indometacin-7 days-group developed heterotopic ossification (Brooker grade I 8%, grade II 6.2%, grade III 1.7%, grade IV 0%), 12.2% of the indometacin-14 days-group (Brooker grade I 8.9%, grade II 2.2%, grade III 1.1%) and 37.5% of the ASS-group (Brooker grade I 27.9%, grade II 4.3%, grade III 5.3%). The lowest incidence of heterotopic ossification was found for the 4 xx 3 Gy and the 1 x 7 Gy group, but no significant difference between these two different treatments was observed. CONCLUSION: Prophylactic irradiation of the operative site after hip replacement is more effective than the use of NSAID. Because no significant difference between the fractionated ingle dose irradiation was found and the latter is more comfortable for patients and more economical, irradiation with single 7 Gy fraction should be preferred.

[Pigmented villonodular synovitis of the knee joint--long-term follow-up and therapeutic concept]. / Die pigmentierte villonoduläre Synovialitis am Kniegelenk--Langzeitergebnisse und Therapiekonzept.

Because of pigmented villonodular synovitis (PVS) 17 of 14,500 knee operations were accomplished at our institute between 1975 and 1993. Diffuse PVS (DPVS) was observed in 7 patients, local PVS (LPVS) in 9 patients; in 1 case LPVS was diagnosed on both joints. 15 knees could be examined 4.8 years after first surgery. 3 recurrences (42.9%) were found in the group of DPVS. In the group of LPVS no recurrent tumor growing was observed. It is demonstrated that partial arthroscopic synovectomy is a sufficient therapy in LPVS. The recurrence rate of DPVS ranges from 8 to 50%, the mean recurrence rate described in literature is 31.3%. Neither arthroscopic nor open synovectomy lead to a complete healing of DPVS. Recurrent arthroscopic synovectomy and regular clinical examination using sonography and particular MRI are the best therapeutical concepts in DPVS.

[Nail-patella syndrome. A 4-generation family study]. / Das Nail-Patella-Syndrom. Eine Familienstudie über 4 Generationen.

Five cases of hereditary onycho-osteodysplasie are reported. All of the family members presented dysplastic nails. Hypoplastic patella, elbow dysplasia or iliac horns were shown in variable expression. We've seen no other anomalies especially nephropathy did not occur.