A comparison between laterally wedged insoles and ankle-foot orthoses for the treatment of medial osteoarthritis of the knee: A randomized cross-over trial.

OBJECTIVE: To compare biomechanical and clinical outcome of laterally wedged insoles (LWI) and an ankle-foot orthosis (AFO) in patients with medial knee osteoarthritis. DESIGN: Single-centre, block-randomized, cross-over controlled trial. SETTING: Outpatient clinic. SUBJECTS: About 39 patients with symptomatic medial knee osteoarthritis. INTERVENTIONS: Patients started with either LWI or AFO, determined randomly, and six weeks later changed to the alternative. MAIN MEASURES: Change in the 1st maximum of external knee adduction moment (eKAM) was assessed with gait analysis. Additional outcomes were other kinetic and kinematic changes and the patient-reported outcomes EQ-5D-5L, Oxford Knee Score (OKS), American Knee Society Clinical Rating System (AKSS), Hannover Functional Ability Questionnaire - Osteoarthritis and knee pain. RESULTS: Mean age (SD) of the study population was 58 (8) years, mean BMI 30 (5). Both aids significantly improved OKS (LWI P = 0.003, AFO P = 0.001), AKSS Knee Score (LWI P = 0.01, AFO P = 0.004) and EQ-5D-5L Index (LWI P = 0.001, AFO P = 0.002). AFO reduced the 1st maximum of eKAM by 18% (P < 0.001). The LWI reduced both maxima by 6% (P = 0.02, P = 0.03). Both AFO and LWI reduced the knee adduction angular impulse (KAAI) by 11% (P < 0.001) and 5% (P = 0.05) respectively. The eKAM (1st maximum) and KAAI reduction was significantly larger with AFO than with LWI (P = 0.001, P = 0.004). CONCLUSIONS: AFO reduces medial knee load more than LWI. Nevertheless, no clinical superiority of either of the two aids could be shown.

[Intervertebral disc-related occupational diseases of the lumbar and cervical spines]. / Bandscheibenbedingte Berufskrankheiten der Lenden- und Halswirbelsäule.

Intervertebral disc-related diseases of the cervical and lumbar spine are considered to be occupational diseases, if the occupational and medical prerequisites are fulfilled and the causal connection between the prerequisites is likely. The working conditions include occupational burdens with long-term lifting and carrying of heavy loads or long-term activities in an extremely bent position of the torso, long-term carrying of heavy loads on the shoulders and long-term effects of whole-body vibration in a sitting position. A medical prerequisite is fulfilled by a damage pattern with chronic lower back or neck pain and damage of the cervical or lumbar vertebrae in a conform manner.In the legal assessment the occupational conditions are examined by the preventive services of the statutory accident insurance and the medical conditions by the medical expert. Furthermore, the medical expert examines the causal connection between the fulfilled prerequisites, whereby the temporal connection (reaching the minimum load dose before realization of the conform damage pattern) and by exclusion of other competing factors are essential. As of 1 January 2021 the necessity to quit the burdening occupation has been omitted by law.

[The sacroiliac joint and pain]. / Iliosakralgelenk und Schmerz.

Pain caused by the sacroiliac joint (SIG) makes up a relevant proportion of lumbar back pain and can have a variety of specific and non-specific causes. The SIG represents the central link between the spine and the lower extremity. It is characterized by high stability and low mobility. There are significant inter-individual differences. In addition to the possibility of asymptomatic situations, SIG dysfunction can trigger pain in the lower back with possible radiation to the lower extremity. In addition to a structured medical history, clinical examination requires an examination of the adjacent joints and the neurological status. More specifically, movement and provocation tests as well as infiltrations are carried out. General information and conservative therapeutic methods represent the first-line therapies. Interventional and surgical procedures can help in the case of chronification.

[Recommendations of the second update of the LONTS guidelines : Long-term opioid therapy for chronic noncancer pain]. / Empfehlungen der zweiten Aktualisierung der Leitlinie LONTS : Langzeitanwendung von Opioiden bei chronischen nicht-tumorbedingten Schmerzen.

BACKGROUND: The second scheduled update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the LONTS (AWMF registration number 145/003), was started in December 2018. METHODS: The guidelines were developed by 28 scientific societies and 2 patient self-help organizations under the coordination of the German Pain Society. A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Scopus databases (up until December 2018) was performed. The systematic reviews with meta-analyses of randomized controlled trials with opioids for CNCP from the previous versions of the guideline were updated. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by formal multistep procedures in order to reach a consensus according to the Association of the Medical Scientific Societies in Germany (AWMF) regulations. The guidelines were reviewed by four external pain physicians. Public comments were possible for 4 weeks. RESULTS: Opioid-based analgesics are a drug-based treatment option for short-term (4-12 weeks), intermediate-term (13-25 weeks) and long-term (≥26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. Based on a clinical consensus the guidelines list other medical conditions for which a therapy with opioids can be considered on an individual basis. Long-term therapy of CNCP with opioids is associated with relevant risks. CONCLUSION: A responsible administration of opioids requires consideration of possible indications and contraindications as well as regular assessment of efficacy and adverse effects. Opioids remain a treatment option for CNCP if nonpharmacological therapies are not effective and/or other drugs are not effective, are not tolerated or are contraindicated.

[Diagnostics and therapy of back pain: what is advisable? What should be avoided and why is it still done?] / Diagnostik und Therapie von Rückenschmerzen: Was ist empfehlenswert? Was sollte unterbleiben und warum wird es dennoch gemacht?

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X­rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

[Predictors for persistent pain and dissatisfaction after total knee arthroplasty]. / Prädiktoren für persistierende Schmerzen und Unzufriedenheit nach Kniegelenksendoprothese.

BACKGROUND: A substantial number of patients patients suffer from persistent pain or are unsatisfied after total knee arthroplasty (TKA). OBJECTIVES: This work aims to present the frequency of postoperative persistent pain and/or dissatisfaction as well as known causes and predictors. MATERIALS AND METHODS: The current literature is studied regarding the subject and is reviewed narratively. RESULTS: Most postoperative problems did not arise from operation details, but from patient-related criteria, a lack of patient education and selection. The satisfaction correlates most strongly with the reduction of preoperative pain. CONCLUSION: For a successful TKA, care should be taken that the following aspects are met preoperatively: clinically and radiologically advanced osteoarthritis, a patient age preferably older than 60 years, sufficient psychosocial resources to cope with postoperative stress, no opioid medication and realistic expectations after TKA. Postoperatively, patients with persistent pain or dissatisfaction should be checked for any prosthesis-related problems. If no prosthesis-related problems could be detected, the patients should be referred for interdisciplinary therapies.

[Disease Experience after Many Years of Orthopedic Therapy in Childhood]. / Krankheitserleben nach langjähriger orthopädischer Therapie in der Kindheit.

The orthopedic medical history of the now 56-year-old Mr. Z began immediately after his birth with an inpatient clubfoot therapy. With the onset of adolescence, multilocular pain began. The long-standing patient career was characterized by disappointment about the early onset and recurrent need for treatment. The disappointment motive is closely related to the relationship between the patient and his mother. The biography illustrates the intertwining of early (orthopedic) treatment, primary bonding and disease experiences. A multimodal pain therapy was able to target Mr. Z, create positive body experiences and finally reduce the pain.

Pain threshold correlates with functional scores in osteoarthritis patients.

BACKGROUND AND PURPOSE: Pain sensitization may be one of the reasons for persistent pain after technically successful joint replacement. We analyzed how pain sensitization, as measured by quantitative sensory testing, relates preoperatively to joint function in patients with osteoarthritis (OA) scheduled for joint replacement. PATIENTS AND METHODS: We included 50 patients with knee OA and 49 with hip OA who were scheduled for joint replacement, and 15 control participants. Hip/knee scores, thermal and pressure detection, and pain thresholds were examined. RESULTS: Median pressure pain thresholds were lower in patients than in control subjects: 4.0 (range: 0-10) vs. 7.8 (4-10) (p = 0.003) for the affected knee; 4.5 (2-10) vs. 6.8 (4-10) (p = 0.03) for the affected hip. Lower pressure pain threshold values were found at the affected joint in 26 of the 50 patients with knee OA and in 17 of the 49 patients with hip OA. The American Knee Society score 1 and 2, the Oxford knee score, and functional questionnaire of Hannover for osteoarthritis score correlated with the pressure pain thresholds in patients with knee OA. Also, Harris hip score and the functional questionnaire of Hannover for osteoarthritis score correlated with the cold detection threshold in patients with hip OA. INTERPRETATION: Quantitative sensory testing appeared to identify patients with sensory changes indicative of mechanisms of central sensitization. These patients may require additional pain treatment in order to profit fully from surgery. There were correlations between the clinical scores and the level of sensitization.

The impact of body weight and depression on low back pain in a representative population sample.

OBJECTIVE: Low back pain (LBP), obesity, and depression are highly prevalent health conditions. We assessed the relative impact of body weight and depression on different types of LBP in a representative population sample. DESIGN: This is a cross-sectional study. SETTING AND PATIENTS: Two thousand five hundred ten subjects aged 14-90 years were randomly selected from the German general population in 2012. MEASURES: Pain sites and duration of pain were assessed by the Widespread Pain Index( WPI), depression by the Beck Depression Inventory Primary Care Questionnaire, disability by the European Organization for Research and Treatment of Cancer questionnaire, and current body mass index (BMI, kg/m(2) ) by self-reported body weight and height. Widespread pain was defined by ≥7/19 pain sites in the WPI. Hierarchical logistic regression analyses were performed with different types of LBP as the dependent variable, and age, gender, lifetime employment status as a worker, number of pain sites, BMI, and depression as independent variables. RESULTS: One thousand six hundred eighty-seven (67.1%) of participants reported no pain. Five hundred six (20.2%) reported chronic LBP and 84 (3.3%) reported disabling chronic LBP. Age (odds ratio [OR] 1.05 [95% confidence interval {CI} 1.04-1.06]), BMI (OR 1.08 [95% CI 1.05.-1.11]), and depression (OR 1.38 [95% CI 1.30-1.49]) independently predicted chronic LPB compared with persons without pain. Age (OR 1.07 [95% CI 1.05-1.09]), BMI (OR 1.07 [95% CI 1.03-1.13]), and depression (OR 1.71 [95% CI 1.55-1.88]) independently predicted disabling chronic LPB compared with persons without pain. Age (OR 1.03 [95% CI 1.01-1.05]), widespread pain (OR 5.23 [95% CI 3.04-9.00), and depression (OR 1.34 [95% CI 1.16-1.55]) independently predicted disabling chronic LPB compared with persons with nondisabling chronic LBP. CONCLUSION: BMI and depression are modifiable risk indicators for chronic disabling LBP.

Multidisciplinary treatment in patients with persistent pain following total hip and knee arthroplasty.

In a retrospective study, we evaluated the clinical outcome of multidisciplinary pain therapy (MPT) in a consecutive series of 40 patients with persistent unexplained pain following THA or TKA. Pain intensity, physical capability and psychological status were assessed before MPT (t1), after 3 weeks (t2) and at a mean follow-up of 32 months (t3). At t2, all scores demonstrated a significant improvement compared to the baseline value. At t3, pain intensity, physical capability, and depression levels deteriorated slightly but were still significantly better compared to baseline values. Anxiety scores deteriorated between t2 and t3 and showed no difference in the baseline value. The present study suggests that MPT has beneficial short-term and mid-term effects in this subgroup of patients and may avoid exploratory revision surgery.

Effects of multidisciplinary pain treatment can be predicted without elaborate questionnaires.

PURPOSE: Low back pain is one of the most common and expensive diseases of Western societies. Psychosocial factors such as low social status, depression, or work dissatisfaction are known to promote chronicity of low back pain. With a multidisciplinary approach, better outcomes can be achieved than with purely biomedical treatment. Optimal patient selection for multidisciplinary therapy reduces costs and labour. This study investigated whether elaborated questionnaires exceed simple items in predicting multimodal therapy success. METHODS: In this prospective longitudinal clinical study, 330 patients were followed up for six months after multidisciplinary therapy. We applied the patient questionnaire Heidelberg Short Early Risk Assessment Questionnaire for the Prediction of Chronicity in Low Back Pain (HKF-R10) that is approved and established for predicting chronicity in patients with acute low back pain to forecast the therapeutic outcome. Outcome criteria were QOL, pain reduction and back to work. RESULTS: With regard to outcome criteria, the HKF-R10 was unable to anticipate therapeutic success, but education level, depression, best pain condition, and helplessness predicted therapy success with an 80% probability for QOL improvement. CONCLUSIONS: It is not necessary to confront patients with an extensive and complicated questionnaire to predict the outcome of multidisciplinary therapy. In fact, assessing a few specific items allows better and easier prognosis estimation.

Capsule elongation occurs after first time shoulder dislocation A biomechanical in-vitro investigation on human cadaveric specimen.

Purpose: As capsule elongation is assumed to weaken the static stability of the shoulder joint, the purpose of this biomechanical study was to demonstrate that capsule elongation occurs immediately after a first-time shoulder dislocation and not just after recurrent dislocation events. We hypothesize an increment in joint clearance due to joint capsule elongation after a first-time dislocation. Methods: An experimental in-vitro study was conducted on 6 paired fresh frozen human shoulders (4 females; 2 males; 12 specimen) with a mean age of 80 (Range 67-89) years. The shoulder joint with the articular capsule was exposed and an inferior static tension force of 2.5 N was applied to the humerus prior to dislocation. Next, the humeral head was dislocated and was then immediately reduced back into the start position. The joint gap as well as joint capsule deformation was assessed using optical techniques. Results: The radiographic joint gap increased from 13.7 ± 6.9 mm (prior to dislocation) to 18.1 ± 6.5 mm (post dislocation) (p < .001). The increase in joint clearance was 4.4 mm. The joint capsule elongated from 5.9 ± 0.005 % (prior to dislocation) to 9.4 ± 0.007 % (post dislocation) (p < .001). The mean increase in joint capsule elongation was 3.5 %. Conclusions: Capsule elongation was observed immediately after a simulated first-time shoulder dislocation in an in-vitro model of elderly human cadavers. It might therefore not only be a phenomenon of recurrent dislocation events.

[What makes a good expert opinion in orthopedics and trauma surgery? : Expectations on the experts]. / Was macht ein Gutachten in der O&U gut? : Erwartungen an den Sachverständigen.

Medical assessments are aids for legal commissioning parties. Most standards are regulated by the civil legal procedure but differences between fields of law of the expert have to be considered.Professional competence, neutrality and meeting the deadlines are expected by the commissioning party. Inquiries and examinations essential for the interrogatories have to be performed by the expert personally.The interrogatories have to be answered plausibly and conclusively. The language of the legal assessment is German and technical terms are avoided.

[What makes a good expert opinion in orthopedics and trauma surgery? : Expectations on the experts]. / Was macht ein Gutachten in der O&U gut? : Erwartungen an den Sachverständigen.

Medical assessments are aids for legal commissioning parties. Most standards are regulated by the civil legal procedure but differences between fields of law of the expert have to be considered.Professional competence, neutrality and meeting the deadlines are expected by the commissioning party. Inquiries and examinations essential for the interrogatories have to be performed by the expert personally.The interrogatories have to be answered plausibly and conclusively. The language of the legal assessment is German and technical terms are avoided.

What Is the Correlation between Clinical and Radiographic Findings in Patients with Advanced Osteoarthritis of the Knee?

Knee range of motion and patient-reported outcome measures (PROMs) are often used as screening tools to assess the severity of knee osteoarthritis and guide the decision to refer patients to an arthroplasty clinic. However, there is little understanding regarding the correlation between these factors. Thus, the purpose of this study was to determine the correlation between patient-reported clinical function measured with the Oxford Knee Score (OKS), pain assessed using the visual analog scale (VAS), knee range of motion (ROM), and characteristic radiographic features in patients with advanced osteoarthritis of the knee. A prospective analysis of a consecutive series of 138 patients with advanced unilateral osteoarthritis (OA) of the knee was performed. The severity of radiographic OA was classified according to the most commonly used Kellgren and Lawrence classification (K&L). Spearman's rank correlation analysis and multiple linear regression analysis were performed. The OKS was used as a dependent variable and was adjusted for pain, ROM, and nine standardized radiographic parameters on multiple views of the tibiofemoral and patellofemoral joint. OKS and pain correlated weakly with the K&L grade (r = -0.289; p = 0.001; r = 0.258; p = 0.002). K&L grade and the degree of patellofemoral joint space narrowing were identified as independent factors being associated with a poorer OKS (coefficient -4.528, p = 0.021; coefficient -2.211, p = 0.038). Slightly worse results were identified for OKS and pain in patients with K&L grade 4 osteoarthritis compared to patients with K&L grade 3 osteoarthritis (∆OKS 5.5 points, p < 0.001; ∆VAS 1.7 points, p = 0.003). There was no significant difference for passive range of motion between patients with K&L grade 3 or 4. When counseling patients with advanced knee osteoarthritis who may be eligible for knee arthroplasty, it is essential to give primary consideration to pain levels and self-reported limitations experienced during daily activities. Relying solely on knee ROM and PROMs is not an effective screening method for guiding the decision to refer patients to an arthroplasty clinic.

Outcome of Conservative Therapy of Adolescent Idiopathic Scoliosis (AIS) with Chêneau-Brace.

Chêneau-brace (C-Brace) is a potential tool for the treatment of adolescent idiopathic scoliosis (AIS) with a Cobb angle between 20° and 45° for the primary curve. The aim of the present study was (1) to estimate study cohorts with C-brace therapy success and therapy failure and (2) to analyze possible factors that influence the therapy outcome. Seventy-eight patients with AIS were assessed before the initiation of C-brace treatment. Each patient underwent radiography examinations before the brace, in-brace, and at the therapy end. Cobb angle was considered as increased when the value at the end of therapy was increased more than 5° (Δ > 5°), unchanged-when the value was unchanged within ± 5° and decreased- when the value was decreased more than 5° (Δ < -5°). The study cohort was stratified due to curve topography in the thoracic, thoracolumbar, and lumbar scoliosis groups. Global analysis revealed no statistically significant modification of the Cobb angle (Cobb angle pre-brace vs. Cobb angle post-brace: 30.8° ± 8.2 vs. 29.3° ± 15.2, p = 0.26). However, at the end of C-brace therapy, the primary Cobb angle was decreased by more than 5° in 27 patients (35%), unchanged (Δ within the range of ±5°) in 36 patients (46%), and increased more than 5° in 15 patients (19%). Sub-group analysis due to curve topography and skeletal maturity has shown higher rates of brace therapy failure in thoracic curves and in younger patients (Risser grade 0). Patients with higher Cobb angle correction with C-brace had lower rates of therapy failure. The C-brace can be useful for the prevention of scoliotic curve progression in patients with AIS. However, many factors influence the therapy effect.

A Systematic Review and Illustrative Case Presentation of Low-Grade Myofibroblastic Sarcoma (LGMS) of the Extremities.

INTRODUCTION: Low-grade myofibroblastic sarcoma (LGMS) is a rare tumor entity which occurs in the subcutaneous and deep soft tissues; it is less common in the bone with a predilection for the extremities and the head and neck region. As confirming the diagnosis is difficult and treatment strategies are not standardized, we aimed to identify patient and tumor characteristics, and to summarize treatment strategies and their clinical outcomes to guide surgeons. METHODS: Included were full articles reporting patients with histology of LGMS in the extremities, excluding tumors of the trunk. All patients underwent surgery but with different extend, from marginal to wide resection. Included studies should inform about local recurrence, metastasis, or evidence of disease, depending on the surgical treatment. We conducted a structured search using MEDLINE (via PubMed), Web of Science, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies on low-grade myofibroblastic sarcoma of the extremities. Study designs like randomized controlled trials, systematic reviews, prospective trials, retrospective studies, and case reports were included. Prospective studies and comparative studies were not available at all. Therefore, meta-analysis was not possible and statistical analysis was purely descriptive. RESULTS: Of the 789 studies identified from our initial search, 17 studies including 59 cases reported LGMS of the extremities with the surgical treatment and clinical outcome and were therefore analyzed. In addition, we present the rare case and surgical management of a 28-year-old male patient with residual LGMS of the thumb after an initial incomplete resection. The current literature suggests that a wide excision with R0 margins should be considered the standard treatment for LGMS. In cases where surgery leads to significant functional impairment, individual options like free tissue transfer from a donor site have to be considered. Therefore, we also present an illustrative case. For all selected case series and case reports, a high risk of confounding, selection bias, information bias, and reporting bias must be anticipated. Nevertheless, this systematic review provides a comprehensive overview on surgical treatment and clinical outcomes in LGMS surgery of the extremities.