[The S2k guideline: Indications for knee endoprosthesis : Evidence and consent-based indications for total knee arthroplasty]. / S2k-Leitlinie: Indikation Knieendoprothese : Evidenz- und konsensbasierte Indikationsstellung in der Knie-Endoprothetik (EKIT-Knie).

Total knee arthroplasty (TKA) is one of the most frequent surgical procedures in orthopaedic surgery. Until now there have not been any standardized indication criteria, which might contribute to the large geographical differences in the frequency of TKA. This guideline aims to consent minimal requirements (main criteria), additional important aspects (minor criteria), as well as relative and absolute contraindications for TKA. The following main criteria have been consented: knee pain, radiological confirmation of osteoarthritis or osteonecrosis, inadequate response to conservative treatment, adverse impact of knee disease on the patient's quality of life and the burden of suffering due to the knee disease. Relative contraindications have been consented as severe general disease with reduced life expectancy and a BMI ≥40; absolute contraindications are an active infection and if the patient is not able to undergo major surgery.

[Evidence-based trauma and orthopedic surgery : 20 years after Sackett]. / Evidenzbasierte Unfallchirurgie und Orthopädie : Zwanzig Jahre nach Sackett.

The article "Evidence based medicine: what it is and what it isn't" published in the BMJ in 1996, is regarded as the foundation of the evidence-based medicine (EbM) movement. Approximately 5 years later David L. Sackett, one of the leaders of the movement, requested all experts to voluntarily abandon their position to make way for young researchers and fresh ideas. Since the term was first coined and the establishment of organizations and platforms fostering the idea, EbM has polarized clinicians and scientists around the world. Clinical and methodological developments during recent years have, however, overtaken the original principles of EbM. This review highlights the core concepts of EbM which have remained unchanged and valid for the current practice of trauma and orthopedic surgery and where revision is needed.

Similar stability and range of motion between cruciate-retaining and cruciate-substituting ultracongruent insert total knee arthroplasty.

PURPOSE: The use of an ultracongruent (UC) insert with a standard femoral component for substitution of the posterior cruciate ligament (PCL) is a bone-preserving and therefore interesting alternative to the established box and cam mechanism of posterior-stabilized total knee arthroplasty (TKA). Despite the regular use of these UC inserts, there is little evidence about stability and range of motion (ROM). METHODS: The aim of this study was to evaluate the stability and ROM in standard cruciate-retaining (CR) and cruciate-substituting UC inserts of the same TKA. In 39 patients, intraoperative measurements of stability and ROM were taken (1) before soft tissue release and bone cuts, (2) after implantation of a CR TKA and (3) after resection of the PCL and substitution with an UC insert. All measurements were taken using a navigation system. RESULTS: Stability measurements demonstrated no differences between CR (PCL intact) and UC TKA (PCL resected), but significantly increased anteroposterior translation at 60° and 90° of knee flexion compared with the preoperative condition. ROM measurements demonstrated improvement of knee flexion from preoperatively mean 105° (SD 14.1°) to intraoperative 120.2° (SD 6.7°) with the CR and 121.0° (SD 7.5°) with the UC insert and 113.5° (SD 14.0°) at the 1-year follow-up. CONCLUSION: This study demonstrates similar stability of an UC insert compared with a standard CR insert. UC inserts are therefore a bone-preserving solution if the PCL needs to be substituted. ROM was not improved after resection of the PCL and substitution with the UC insert. LEVEL OF EVIDENCE: II.

[Endoprosthetic treatment of osteoporosis-related coxarthrosis : aspects of safe patient treatment]. / Endoprothetische Versorgung bei osteoporoseassoziierter Koxarthrose : Aspekte zur sicheren Patientenversorgung.

BACKGROUND: With increasing life expectancy the prevalence of osteoarthritis is also substantially rising. Patients aged between 65 and 75 years scheduled for total joint arthroplasty suffer from undetected osteoporosis in 20-25% of cases. OBJECTIVES: How to determine osteoporosis during preoperative workup? Which conclusions can be drawn for the operation treatment and the postoperative course? METHODS: The literature dealing with the prevalence of osteoporosis, perioperative complications of total hip arthroplasty, selected register informations, guidelines for diagnostics and treatment of osteoporosis and for the postoperative treatment are summarized and discussed. RESULTS: The fracture risk is determined according to the guidelines of the Dachverband Osteologie (DVO, Governing Body on Osteology). The implant and the anchorage are selected based on the risk of suffering from osteoporosis. An intraoperative fracture and early aseptic loosening are the main operative risk factors. For the postoperative course in addition to education about arthroplasty, adequate support for prevention of falls is mandatory. Continuous physiotherapy with muscular strengthening is advisable. The long-term medication should be checked for risks in the PRISCUS list of potentially inappropriate medication in the elderly and non-steroidal anti-inflammatory drugs (NSAIDs) should not be prescribed in patients with cardiac comorbidities. Patients with confirmed osteoporosis should be treated with antiresorptive agents.

[Complications of metal-on-metal tribological pairing]. / Komplikationen bei Metall-Metall-Gleitpaarungen.

BACKGROUND: Metal-on-metal (MoM) tribological pairing results in less volumetric abrasion than pairing with the conventionally used polyethylene and is associated with a lower risk of material failure compared to other hard-hard pairings. An increased frequency of problem cases in recent years has led to a great increase in uncertainty. Against this background in this article the current aspects of epidemiology, etiology, diagnostics and treatment of complications in MoM hip joint endoprostheses will be discussed. EPIDEMIOLOGY AND ETIOLOGY: Based on the results from national endoprosthesis registers and selected clinical studies an evaluation of the rate of local complications from MoM tribological pairings was undertaken. A differentiation was made between MoM pairings in pedicled small head prostheses (≤ 32 mm), large head (> 32 mm) and surface replacement (OFE) endoprostheses. Each year MoM endoprostheses release on average 10(12)-10(14) cobalt (Co) and chromium (Cr) nanoparticles per patient. This release of metal ions and particles can lead to a variety of tissue reactions. DIAGNOSTICS: A differentiation must be made between regular routine diagnostics within the framework of implant follow-up screening and specific investigations due to the occurrence of complaints. The diagnostics for patients treated with MoM hip endoprostheses consists of a standardized step-wise approach considering possible differential diagnoses and the utilization of modern laboratory chemical and radiological methods. When problems occur, a differentiation should preferentially be made between complaints not caused by metal and mechanical problems (e.g. prosthesis loosening and impingement) and symptoms due to periprosthetic infections. THERAPY OF COMPLICATIONS: The normal standards for hip endoprosthetics are also valid for periprosthetic infections, fractures and other general complications. Specific measures are, however, necessary for complications due to metal-specific risks.

[Femoral nerve palsy as delayed complication after total hip replacement: delayed hematoma formation in unexpected screw malpositioning]. / Femoralisparese als Spätkomplikation nach Hüftendoprothesenimplantation: Späte Hämatombildung bei unerwarteter Schraubenfehllage.

Nerve injury after total hip replacement is a rare but severe complication. If the nerve lesion becomes evident in the early postoperative phase the lesion is often due to an incorrect implant position, direct nerve injury or vascular injury with manifestation of a hematoma which results in nerve compression. Secondary nerve lesions are more often due to a chronic hematoma with nerve compression. Secondary nerve lesions in particular are often a diagnostic challenge and should lead to an early revision after comprehensive imaging diagnostics.

[Update on metal-on-metal hip joints]. / Update Metall-Metall-Gleitpaarungen.

Increasing data are available describing risk factors for the development of local and systemic adverse events following operations using metal-on-metal (MoM) hip implants. The prevalence and clinical relevance of metal-associated problems are, however, still under debate. They can be influenced by type and position of implant as well as patient-specific factors. Patients with small MoM heads (maximum diameter 32 mm) and subgroups of resurfacing arthroplasty can achieve good long-term survival. The use of large head MoM implants (diameters greater than 36 mm), however, is currently not advised due to the unsatisfactory results.

[Academic clinical medicine in orthopedic and trauma surgery: which route will the next generation choose?]. / Akademische klinische Medizin in Orthopädie und Unfallchirurgie: Welchen Weg geht der Nachwuchs?

BACKGROUND: An increasing clinical pressure forces academic surgeons in Germany to decide between private life and research activities. How do those people decide and how do they develop their individual career plan? MATERIAL AND METHODS: In an e-mail survey German orthopedic and trauma surgeons were interviewed on their way of reconciliation of private life, clinical duties and research. The survey included the same questions as the previous survey and a follow-up of 66 % was achieved. RESULTS: The number of consultants in the questioned cohort increased from 44 % to 66 %. More than 80 % reported that the workload had increased which was accompanied by a more clinical orientation of research activities. When asked about personal priorities and wishes leisure time was ranked first, surgical skills, research and income followed in that order. The majority were content with the current situation and career path. CONCLUSIONS: This is the first study on occupational conditions in orthopedic and trauma surgeons in a time-line based manner. It became evident that a more clinical orientation of research is needed to match the interests of clinically engaged surgeons in orthopedics and traumatology.

[Avoidance, diagnostics and therapy of nerve lesions after total hip arthroplasty]. / Vermeidung, Diagnostik und Therapie von Nervenläsionen nach Hüftendoprothesenimplantation.

Nerve palsy following total hip arthroplasty is a rare complication. Developmental dysplasia of the hip, previous fracture treatment and medical comorbidities are characteristic risk factors. By accurate preparation of the patient and a careful operative technique nerve palsy can be avoided in most cases. Nerve palsy following poor patient positioning during the perioperative period should be avoided by close cooperation with anesthesiologists.In cases of postoperative nerve palsy correct diagnostics should be carried out immediately. Further treatment options should be considered to minimize the damage. For patients with definite nerve palsy, devices such as a foot drop splint are often necessary and should be carried out as soon as possible.

[Templating and radiological outcome monitoring for elective total hip arthroplasty. Applied quality management principles for safe patient care]. / Operationsplanung und Ergebniskontrolle in der elektiven Hüftendoprothetik. Angewandtes Qualitätsmanagement als Grundlage einer sicheren Patientenversorgung.

Implementation of total hip arthroplasty is a successful and reliable treatment for end-stage osteoarthritis. The biomechanics and components as well as the fixation were selected with the aid of templating. Based on a cohort of 114 patients the quality of digital X-rays and the operative results were determined. There was a slight leg lengthening and a good offset reconstruction in these patients. For the patients with replacement of the second hip the leg lengthening was smaller. The cup inclination was at 43° and 44° within the desired range. The prediction of the exact component size used was 40% for the cup and 29% for the stem.Through variation in scaling of the digital X-ray a diminishing prediction accuracy was found in our study. The correction of biomechanics and position of components showed good quality in patient care. Templating and assessment of the postoperative result in total hip arthroplasty is a model for continuous quality management and can be recommended for safe patient care.

EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis.

OBJECTIVE: To develop evidence-based recommendations for the diagnosis of knee osteoarthritis (OA). METHODS: The multidisciplinary guideline development group, representing 12 European countries, generated 10 key propositions regarding diagnosis using a Delphi consensus approach. For each recommendation, research evidence was searched systematically. Whenever possible, the sensitivity, specificity and likelihood ratio were calculated for individual diagnostic indicators and a diagnostic ladder was developed using Bayes' method. Secondary analyses were undertaken to test directly the recommendations using multiple predictive models in two populations from the UK and the Netherlands. Strength of recommendation was assessed by the EULAR visual analogue scale. RESULTS: Recommendations covered the definition of knee OA and its risk factors, subsets, typical symptoms and signs, the use of imaging and laboratory tests and differential diagnosis. Three symptoms (persistent knee pain, limited morning stiffness and reduced function) and three signs (crepitus, restricted movement and bony enlargement) appeared to be the most useful. Assuming a 12.5% background prevalence of knee OA in adults aged > or =45 years, the estimated probability of having radiographic knee OA increased with increasing number of positive features, to 99% when all six symptoms and signs were present. The performance of the recommendations in the study populations varied according to the definition of knee OA, background risk and number of tests applied. CONCLUSION: 10 key recommendations for diagnosis of knee OA were developed using both research evidence and expert consensus. Although there is no agreed reference standard, thorough clinical assessment alone can provide a confident rule-in diagnosis.

Social, educational, and occupational predictors of total hip replacement outcome.

OBJECTIVE: There is limited evidence on social, educational, and occupational factors as predictors of response to total hip replacement (THR). We aimed to analyze these factors in a large population-based setting. METHOD: Patients of the Dresden Hip Surgery Registry were recruited and the pre and post (6 months) operative functional status was assessed using the global Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score (0-100 points). Non-response was defined a gain of <20 points in WOMAC score over a 6 months period and was analyzed with respect to six socioeconomic parameters. Multiple logistic regression modeling was applied to adjust for age, sex, BMI, co-morbidity, and preoperative functional status. RESULTS: Data from 1007 patients (mean age 61 years, STD 13; 55% women) were included. The average preoperative WOMAC score was 45.8 which increased to 84.4 after surgery. 38.2%, 36.6%, and 25.3% of the patients attended school for 8, 9, and 12 years, respectively. 54.1% were retired, 26.9% worked full time, and 6.7% received a disability pension. A 14.8% of the patients did not achieve a gain of > or =20 points in WOMAC score and were classified as non-responders. After control for confounders, significantly increased risks of non-response were found for widowed patients compared to singles [odds ratio (OR) 4.30, 1.45-12.71], those who lived alone (OR 1.70, 1.02-2.85), and patients with a disability pension compared to those who worked full time (OR 5.81, 2.33-14.46). The risk of non-response decreased with increasing length of school education (12 vs 8 years: OR 0.49, 0.27-0.89). Compared to workers, employees (OR 0.55, 0.33-0.90) and self-employed patients (OR 0.41, 0.18-0.94) showed significantly decreased risks of non-response. CONCLUSION: Socioeconomic parameters are independent predictors of response to THR. This can help to improve the health service by identifying subgroups which need special attention in order to increase the response rate.

Precision of navigated and conventional open-wedge high tibial osteotomy in a cadaver study.

High tibial osteotomy (HTO) is an established treatment option for isolated medial osteoarthritis in young and active patients. One important factor for success of this procedure is the degree of correction of the weight-bearing line. Computer-assisted navigation systems are believed to improve the precision of axis correction through intraoperative real-time monitoring. This study investigates the precision of correction of the weight-bearing line in open-wedge HTO with and without a navigation system. Nineteen legs of well-preserved human cadaver were randomly assigned to navigated (n = 10) or conventional (n = 9) HTO. In order to achieve a sufficient amount of correction in all legs the weight-bearing line was aimed at 80 percent of the width of the tibial plateau. The mean deviation of the weight-bearing line from the desired 80 percent was 1 percent in the navigated and 8.6 percent in the conventional operated legs (p = 0.002). The weight-bearing line of all navigated but only 5 of the 9 conventional operated legs was within a +/- 5 percent tolerance level (p = 0.33). Navigated open-wedge HTO achieved better correction of the weight-bearing line than the conventional method in human cadaver legs. Future studies have to prove this advantage in a clinical setting and it's effect on patient outcome.

[Clinical pathway "total knee arthroplasty"]. / Klinischer Behandlungspfad "Knieendoprothetik"

Total knee arthroplasty is a standardized intervention in orthopedic departments. Due to the standard character of the procedure it is predestinated to be performed in a clinical pathway. We developed a clinical pathway for total knee arthroplasty and aim to show the details of it and discuss it together with the current literature. Total knee arthroplasty is a standardized procedure and is therefore predestinated to be included in a clinical pathway. The team consists of different groups which are combined in this path to work together in a very structured and standardized manner. We describe and discuss our clinical pathway for total knee arthroplasty and the initial experiences which are very promising.

[Durom™ hip resurfacing. Short- to midterm clinical and radiological outcome]. / Durom™-Hüftoberflächenersatz. Kurz- bis mittelfristiges radiologisches und klinisches Ergebnisse.

BACKGROUND: Modern hip resurfacing as an alternative for stemmed total hip replacement therapy is associated with a specific risk profile. The aim of this study was therefore to assess the short- to midterm clinical and radiological outcome after introduction of the Durom™ Hip Resurfacing prosthesis in a consecutive series. MATERIALS AND METHODS: A total of 132 hips (119 patients, 34 female, mean age 48±8,3 years) were evaluated functionally (Harris Hip Score, UCLA and Tegner activity scores) and radiologically with a mean follow-up period of 29 (6-60) months. Furthermore, preoperative ASA- and Charnley-scores, perioperative parameters as well as complications were registered. RESULTS: During the observation period the Harris Hip Score improved by a mean of 36.6 points to 92.5±11.6 points (p<0.01). ULCA and Tegner scores improved by a mean of 3.1 and 1.6 to 7.1 and 4.0 points, respectively. Three patients (2.3%) needed revision surgery due to periprosthetic fracture, prosthesis infection, and aseptic loosening of the femoral component. In four patients (3.1%) an initial migration of the acetabular component not requiring surgical revision was observed radiologically. CONCLUSION: The Durom™ Hip Resurfacing prosthesis demonstrated a low revision rate and a good mid-term functional and radiological outcome. Due to acetabular cup migrations in a small number of patients we now use an implant with modified surface design.

[Clinical pathway for total knee arthroplasty. I: Pathway conception and effect on functional quality of results]. / Klinischer Behandlungspfad zur Implantation einer Oberflächenknieendoprothese (EGON). I: Pfadkonzeption und Effekt auf funktionelle Ergebnisqualität.

PURPOSE: The aim of the current study was to evaluate patient-centred and economic outcomes after introduction of a clinical pathway for total knee arthroplasty. METHODS: In a prospective trial two sequential cohorts of patients undergoing total knee arthroplasty were recruited. Baseline treatment was surveyed in cohort I and the clinical pathway was developed and evaluated in cohort II. Data from WOMAC, EQ-5D as well as partial cost data were collected. The study design was ratified by the local Independent Ethics Committee. RESULTS: There was an increase in WOMAC score of 39% for cohort I and 35% for cohort II in 3 months follow-up. Similar results were found for ED-5D with an increase of 30% for cohort I and 25% for cohort II. Partial cost rates could be lowered from 4303 EUR to 419 EUR. Despite this significant cost saving we were not able to improve the ratio of improvement in quality of life to costs. CONCLUSION: With the aid of a clinical pathway the process for implementation of a total knee arthroplasty was improved and treatment quality assured.

[Clinical pathway for total knee arthroplasty (EGON). II. The impact of enhanced patient information]. / Klinischer Behandlungspfad zur Implantation einer Oberflächenknieendoprothese (EGON). II: Effekt einer intensivierten Patienteninformation.

PURPOSE: The effects of the introduction of a clinical pathway and enhanced patient information on patients' satisfaction were investigated in the current study. MATERIAL AND METHODS: In a prospective cohort study patients were systematically interviewed about the preparation and the clinical course during implantation of a total knee arthroplasty. The study included 132 patients before (cohort I) and 128 after (cohort II) introduction of a clinical pathway. All patients of cohort II were offered the opportunity to attend an enhanced patient information lecture. The collected data were analysed in a descriptive manner. Items with more than 10% negative answers constituted the need for improvement. RESULTS: Regarding preparation of the operation there was a need for improvement of 11 items in cohort I and 4 in cohort II. With respect to the clinical course there was a slight increase from 6 to 7 items that required improvement. The enhanced information about the treatment and the clinical course were assessed positively. Patients were unsatisfied with the individual explanation of the X-rays. Of 128 patients from cohort II, 58 decided to participate in the information session for patients. The patients who had attended were more interested in receiving additional information. The success of the operation (gain in WOMAC score of at least 20%) showed a substantial effect on patient satisfaction. CONCLUSION: With increased patient information the knowledge and patient satisfaction within clinical pathways can be improved.

The synthesis of brominated-boron-doped PAHs by alkyne 1,1-bromoboration: mechanistic and functionalisation studies.

The synthesis of a range of brominated-B n -containing (n = 1, 2) polycyclic aromatic hydrocarbons (PAHs) is achieved simply by reacting BBr3 with appropriately substituted alkynes via a bromoboration/electrophilic C-H borylation sequence. The brominated-B n -PAHs were isolated as either the borinic acids or B-mesityl-protected derivatives, with the latter having extremely deep LUMOs for the B2-doped PAHs (with one example having a reduction potential of E 1/2 = -0.96 V versus Fc+/Fc, Fc = ferrocene). Mechanistic studies revealed the reaction sequence proceeds by initial alkyne 1,1-bromoboration. 1,1-Bromoboration also was applied to access a number of unprecedented 1-bromo-2,2-diaryl substituted vinylboronate esters directly from internal alkynes. Bromoboration/C-H borylation installs useful C-Br units onto the B n -PAHs, which were utilised in Negishi coupling reactions, including for the installation of two triarylamine donor (D) groups onto a B2-PAH. The resultant D-A-D molecule has a low optical gap with an absorption onset at 750 nm and emission centered at 810 nm in the solid state.

Allergenicity of wine containing processing aids: a double-blind, placebo-controlled food challenge.

BACKGROUND: The European Union requires allergenic food ingredients to appear on labels in order to protect allergic consumers. OBJECTIVE: To determine whether traces of egg-, milk-, and fish-derived processing aids used in winemaking might elicit clinical reactions in food-allergic patients. METHODS: Five German wines were fined with a high dose of egg albumin, lysozyme, milk casein, fish gelatin, or isinglass, and filtered. Fourteen adults with allergy to egg (n = 5), milk (n = 5), or fish (n = 4) were included. Skin prick tests were performed with fining agents, and fined and unfined wines. All patients underwent double-blind placebo-controlled food challenges with fined and unfined wines. RESULTS: Skin prick tests were positive to hen's egg (n = 5), ovalbumin (n = 5), lysozyme (n = 4), cow's milk (n = 5), casein (n = 4), and cod (n = 3), but not to isinglass or fish gelatin (n = 0). Positive skin prick test results were observed for wines fined with albumin (n = 3), lysozyme (n = 2), casein (n = 1), gelatin (n = 0), and isinglass (n = 3), and for unfined wines (n = 1-2 in each patient group), with no significant differences between groups. Seventy-five percent of skin test-positive patients had specific immunoglobulin E to other allergens present in wine (eg, carbohydrates). The provocation test revealed no reactions to fined or unfined wines. CONCLUSIONS: Although concentrated fining agents containing ovalbumin, lysozyme, and casein were allergenic in the skin prick test, no patient reacted adversely in the provocation test to fined wine. Wines treated with fining agents at commercial concentrations appear not to present a risk to allergic individuals when filtered,

Reliability of limb alignment measurement for high tibial osteotomy with a navigation system.

OBJECTIVE: High tibial osteotomy (HTO) is one treatment option for young and active patients with unicompartmental osteoarthritis. The success of this procedure substantially depends on the degree of correction of the mechanical axis. Computer-assisted navigation systems are believed to improve the precision of axis correction through intraoperative real-time monitoring. This study investigates the accuracy of limb alignment measurements with a navigation system on a cadaver specimen. MATERIALS AND METHODS: The measurements were performed on a well-preserved cadaver specimen with a mechanical leg axis of 4 degrees varus. Data was collected during the HTO workflow. Repeated serial measurements were undertaken by four different surgeons. After these measurements, different landmarks were deliberately set at the wrong place to examine the influence of mistakes during registration. RESULTS: There was a high intra- and interobserver reliability with a mean mechanical leg axis of 3.9 degrees +/- 0.7 degrees and a mean error of 0.6 degrees. The grossly incorrect placement of landmarks for knee and ankle center resulted in an incorrect mechanical leg axis of 1 degrees valgus up to 10 degrees varus. CONCLUSION: The computer-assisted navigation system provided precise information about the mechanical leg axis, irrespective of the observer's experience.