[Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]. / Chirurgische Therapie fokaler Knorpelschäden am Knie : Indikationen, Techniken, Modifikationen, Ergebnisse.

The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.

[Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]. / Chirurgische Therapie fokaler Knorpelschäden am Knie : Indikationen, Techniken, Modifikationen, Ergebnisse.

The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.

[Fast track in hip and knee arthroplasty]. / Fast-Track in der Hüft- und Kniegelenkendoprothetik.

Fast-track treatment concepts were developed decades ago in general and abdominal surgery and have been adapted in recent years for the special requirements of hip and knee arthroplasty. In this field, Hendrik Husted in particular was able to demonstrate scientific evidence for the components of fast-track concepts. The primary aim is not so much to shorten the patient's hospital length of stay (LOS) but rather to effectively increase the quality of medical treatment for the patient and to reduce complications. The optimization of organizational processes as well as intraoperative and perioperative surgical approaches are essential components regarding the introduction of fast track into the clinical routine. This article gives a comprehensive overview of fast-track treatment concepts and explains the scientific principles for the approach.

[Infected endoprosthesis in patients with rheumatism]. / Infizierte Endoprothese des Rheumatikers.

Infections are a severe complication after an artificial joint replacement. The clinical symptoms are highly variable, particularly in patients with inflammatory rheumatic diseases, which often makes the diagnosis difficult. In addition to clinical and laboratory findings, joint puncture is an essential component of the diagnostics and enables the identification of pathogens. Treatment of periprosthetic infections in patients with rheumatism should be an interdisciplinary cooperation between surgeons, rheumatologists and specialists for infectious diseases. The two essential pillars of treatment are surgical intervention and antibiotics. For acute joint infections an attempt at preservation of the artificial joint can be carried out, whereas for chronic infection situations only replacement of the prosthesis is possible as a curative treatment. In order to reduce the probability of occurrence of a joint infection, modifiable risk factors should be preoperatively identified and specifically treated.

[Nerve compression syndromes of the upper extremities]. / Nervenkompressionssyndrome der oberen Extremität.

Nerve compression syndromes of the upper extremities are relatively frequent diseases, the timely detection and treatment of which can prevent irreversible damage in the sense of muscle atrophy and subsequent paresis. The medical history and clinical examination play an important role in determining the suspected diagnosis. The subsequent neurological examination then serves to confirm the suspected diagnosis. This article provides a comprehensive overview of the etiology, pathogenesis, symptoms and treatment of the disease.

[Application of image-guided injection for cervical and lumbar syndromes]. / Anwendung Bildwandler-gestützter Injektionen bei Zervikal- und Lumbalsyndromen.

The X­ray image-guided injection methods are an important tool for the treatment of cervical and lumbar pain syndromes. For the application of these methods it is necessary to have a differentiated consideration of cervical and lumbar pain syndromes. This leads to a decoding of complaints to assignable pain generators, which enables a targeted injection method. Depending on the origin of pain, injections are placed at the nerve root or the joints. Thus, the vicious cycle of pain can be stopped. A correct technical procedure is of enormous importance. Particular attention must be paid to the pharmacological effects and special complications. A monitoring and precautionary measures are mandatory.

[Discrepancy between radiographic and true cup position after total hip arthroplasty : Are we interpreting our radiographic quality indicators correctly? Video article]. / Diskrepanz zwischen radiographischer und tatsächlicher Pfannenstellung bei der Hüft-TEP-Versorgung : Interpretieren wir unsere radiologischen Qualitätsindikatoren richtig? Videobeitrag.

BACKGROUND: After total hip arthroplasty (THA), objective postoperative quality control is done via X­rays by as component position assessment. The cup position is defined by its version and inclination. However, there is a discrepancy between radiographically measured and true (anatomic) cup position, which may lead to misinterpretation. METHODS: To visualize the discrepancy between true and radiographically measured cup position, in this video, a cup holder was used to set the angular cup version and inclination. Hereby, the cup position (anteversion and inclination) can be characterized in its radiographic and anatomic definition in greater detail. The viewer of this video should receive an impression as to when radiographically measured cup angles must be considered with caution. RESULTS: In a simultaneous X­ray and image sequence, this video shows decreased radiographic inclination measurement with increasing anterior rotation of the cup exceeding 20° of anteversion, yet with unchanged true inclination on the cup holder. Isolated consideration of the radiographic angles of anteversion and inclination may cause misinterpretation of true cup position. In pectoral illustration we show that variations in cup version and inclination may remain undetected when considering isolated the radiographic cup parameters. CONCLUSION: True cup position in its anatomical definition can be calculated from the radiographically measured position. For this purpose, both cup parameters (radiographic anteversion and radiographic inclination) have to be taken into account.

[Gluteal insufficiency]. / Gluteale Insuffizienz.

Gluteal insufficiency or hip abductor mechanism deficiency mainly following (revision) total hip replacement is associated with highly painful complaints and severe suffering of patients. It represents a great diagnostic and therapeutic challenge. Differentiated conservative treatment pathways, open surgical and endoscopic anatomic repair techniques with intact gluteal musculature and muscle transfer are available as salvage procedures for chronic not anatomically reconstructable mass ruptures. A stepwise diagnostic and therapeutic approach is required for restoration of the quality of life and painless or almost painless mobility of affected patients in occupation and daily life.

[Biomechanical aspects of preoperative planning: What is really important?] / Biomechanische Aspekte der präoperativen Planung: Was ist wirklich wichtig?

BACKGROUND: Sagittal balance is dependent on a complex interplay of the spinal curves, shape and setting of the pelvis, but also the position of the joints of the lower limb. Degenerative processes such as stiffening of the spine, aging of musculature, or reduction of the range of motion of the joints lead to imbalance of the spine after all compensatory mechanisms have been exhausted. OBJECTIVES: Based on standardized imaging, compensation mechanisms must be identified within a biomechanical analysis of the spine, the original sagittal spine profile anticipated and included in the planning of the corrective intervention. RESULTS: This review presents the most important global and spinopelvic parameters for the biomechanical analysis of the spine. In addition, normal variations of the sagittal alignment are discussed, compensation mechanisms are shown, and the planning of the rebalancing of the sagittal alignment is shown according to the full balance integrated model.

[Lumbar spinal stenosis : From the diagnosis to the correct treatment]. / Lumbale Spinalkanalstenose : Von der Diagnose bis zur richtigen Therapie.

The number of patients with the diagnosis of lumbar spinal stenosis (LSS) is steadily increasing and simultaneously, the patients' expectations are also increasing. Nevertheless, evidence from studies for the appropriate treatment is still lacking. Treatment options mainly result from the practitioner 's experience and the clinical focus. The findings described in magnetic resonance imaging (MRI) often do not correlate with the patient's symptoms. Basically, the treatment should be started with a conservative treatment and preferably with a multimodal approach. Severe pain with extensive neurogenic claudication symptoms and unsuccessful conservative treatment should be treated surgically. Absolute indications for surgery, such as a conus-cauda syndrome are rare. The goal of all surgical procedures is to decompress the spinal canal without compromising the stability of the motion segment. Instability can also make an additional fusion necessary.

[Clinical examination of the foot]. / Klinische Untersuchung des Fußes.

A systematic clinical examination of the foot, including a structured medical history, is essential for the diagnostics of foot disorders. The foot and ankle, with a total of 28 bones and numerous joints, require a variety of musculotendinous and neuromuscular structures for stabilization and faultless gait. Almost all anatomical structures of the foot are easily accessible for a manual clinical examination due to the sparse soft tissue covering. This requires differentiated and well-founded anatomical knowledge as well as examination experience to be able to distinguish a normal finding from a pathological abnormality. The examination of the contralateral foot is always necessary. A targeted supplementary imaging examination completes the diagnosis.

[Degenerative forefoot : Diagnostics and treatment]. / Degenerativer Vorfuß : Diagnostik und Therapie.

The hallux valgus deformity is the most common toe deformity of the forefoot and is often associated with a splayfoot. Malpositioning of the small toes may be isolated but are more common in other foot deformities. The understanding of the complex pathoanatomy of the foot is necessary for orthopedic treatment. Conservative treatment is reserved for the early stages. The indications for surgery should be based on clinical and radiographic findings. Countless surgical procedures are available and minimally invasive surgical techniques are also increasingly being used.

Regarding loads after spinal fusion, every level should be seen separately: a musculoskeletal analysis.

INTRODUCTION: The number of spinal fusion surgeries is steadily increasing and biomechanical consequences are still in debate. The aim of this study is to provide biomechanical insights into the sagittal balance of the spine and to compare spinal load before and after spinal fusion. METHOD: The joint reaction forces of 52 patients were analyzed in proximo-distal and antero-posterior direction from the levels T12-L1 to L5-S1 using musculoskeletal simulations. RESULTS: In 104 simulations, pre-surgical forces were equal to post-surgical. The levels L4-L5 and T12-L1, however, showed increased spinal forces compression forces with higher sagittal displacement. Improved restauration of sagittal balance was accompanied by lower spinal load. AP shear stress, interestingly decreased with sagittal imbalance. CONCLUSION: Imbalanced spines have a risk of increased compression forces at Th12-L1. L4-L5 always has increased spinal loads. These slides can be retrieved under Electronic Supplementary Material.

[The application of different injection methods for cervical and lumbar syndromes]. / Anwendung unterschiedlicher Injektionstherapien bei Zervikal- und Lumbalsyndromen.

The differentiated consideration of cervical and lumbar pain syndromes leads to a decoding of complaints to assignable pain generators which enables a targeted injection method. Depending on the origin of pain injections are placed at the nerve root or the joints. Thus, the vicious cycle can be stopped. A correct technical procedure is of enormous importance. Because pharmacological effects and special complications are possible, monitoring and precautions are mandatory.

Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios.

INTRODUCTION: In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. METHODS: Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°. RESULTS: No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. CONCLUSION: The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

[The knee joint in rheumatoid arthritis-current orthopaedic surgical treatment options]. / Kniegelenk bei rheumatoider Arthritis ­ aktuelle orthopädisch-chirurgische Therapieoptionen.

The knee joint is often involved in rheumatoid arthritis. Despite ever-improving medical antirheumatic therapies, surgical treatment continues to play an important role in optimal multidisciplinary care. The aim of the present work is to process current orthopedic surgical therapy procedures on the knee joint according to disease stage. In the early phase, joint-preserving arthroscopic procedures for synovectomy are used. In advanced joint destruction, joint function can be restored by total knee arthroplasty. Of central importance for optimal patient care are individual treatment and good interdisciplinary coordination of all involved specialist groups.

[Rheumatism operations in a state of flux-"Foot"]. / Rheumaoperationen im Wandel ­ "Fuß".

Surgical management of rheumatic feet has dramatically changed over the last decades influenced by the development of new pharmacological drugs and tissue-preserving surgical procedures. It has switched from joint resection to joint-sparing procedures as the method of choice. Nevertheless, the surgical interventions commonly used for non-rheumatic patients cannot be applied to rheumatic patients without reflection: in addition to the basic treatment, comorbidities, degree of mobilization of the patient, orthopedic shoe engineering and orthotic treatment play a major role. Due to the decreasing incidence of the classical rheumatic foot, it has become even more important for physicians, physiotherapists and ergotherapists to recognize the development of such a disease as early as possible and immediately start the appropriate treatment.

[Hand surgery in the rheumatic hand-novel and established aspects]. / Handchirurgie an der Rheumahand ­ Neues und Bewährtes.

BACKGROUND: Hand surgery of the rheumatoid hand has undergone significant changes mostly as a result of biologicals and biosimilars. OBJECTIVE: The significance of established and innovative operative procedures in the modern treatment of the rheumatoid hand is elaborated and a subsumption of local interventional options in this context is carried out. METHODS: The analysis, evaluation and discussion of the literature and expert recommendations are presented. RESULTS: With the consistent use of modern antirheumatic drugs the destruction and deformation of the wrist and hand occur more slowly and less severely. The hand surgeon can therefore operate more selectively and focus on less pathologies at the same time. Up to the present many of the operative techniques described by the pioneers of modern hand surgery are still powerful tools. Most of the considerations about the correction of the disturbed biomechanics and about the reconstitution of stability and the range of motion are still valid. The combination of arthroscopic synovectomy and radiosynoviorthesis of the wrist seems to show promising results. CONCLUSION: Modern treatment of the rheumatoid hand is a multidisciplinary challenge. Rheumatologists, nuclear medicine physicians and hand surgeons together can achieve excellent results. A consistent medication, an early operative intervention if necessary and systematic integration of nuclear medicine physicians into the therapeutic process enable preservation of the long-term function of the hand as the main tool in daily life.

What is the optimal valgus pre-set for intramedullary femoral alignment rods in total knee arthroplasty?

PURPOSE: In total knee arthroplasty (TKA), intramedullary guides are often used for aligning the distal femoral cutting block. Because of the highly varying angles between the mechanical axis and the anatomical femoral axis (AMA), different valgus pre-sets have been recommended. The present study investigated the optimal valgus pre-set (measuring the AMA in long-leg radiographs or at 5°, 6°, 7° or 8° valgus) to align the cutting block perpendicularly to the mechanical axis. METHODS: The AMA was preoperatively measured in weight-bearing long-leg radiographs. After alignment of the cutting block by means of an intramedullary rod, deviation of the block from the mechanical femoral axis was measured with a pinless navigation device. The true AMA (tAMA) was calculated by adding the valgus pre-set of the alignment rod to the deviation measured with the navigation device. Mean deviations between the tAMA and (a) the AMA measured by the surgeon, (b) the AMA calculated with the computer software, (c) 5°, (d) 6°, (e) 7° and (f) 8° valgus pre-sets were measured for each patient. The lowest mean differences were determined. RESULTS: The 40 knees measured showed a mean tAMA of 7.2° valgus (1.7 SD) (range 4°-11.5°). The following mean differences and 95 % limits of agreement were calculated: 2.2 (-1.2, 5.5) to the tAMA for the 5° valgus pre-set, 1.2 (-2.2, 4.5) for 6°, 0.2 (-3.2, 3.5) for 7° and -0.8 (-4.2, 2.5) for 8°. AMA measurements by the surgeon and with the digital medical planning software yielded mean differences of 0.6 (-3.1, 4.3) and 0.4 (-4.1, 4.8), respectively. CONCLUSION: In the present setting, the best mean distal femoral cutting block alignment perpendicular to the mechanical femoral axis could be achieved with a valgus pre-set of 7° and not by measuring the AMA. Nevertheless, we recommend conducting weight-bearing radiographs of the entire leg prior to TKA for easy detection of any anatomical varieties, old fractures, long stems of total hip arthroplasties or cement. However, surgeons must be aware that exact coronal component alignment can only be achieved by navigational devices. LEVEL OF EVIDENCE: Diagnostic study, Level II.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.