[Hip arthroplasty after pelvic and femoral osteotomies]. / Hüftendoprothetik nach Osteotomien des Beckens und des proximalen Femurs.

Pelvic and femoral osteotomies can be a challenge even for experienced orthopedic surgeons. Residual metal may complicate the insertion of the endoprosthesis in some cases. Sometimes, the anatomical modification of the previous osteotomy complicates the total hip replacement. This may require the use of an acetabular revision system for the primary implantation. Femoral deformities can require additional osteotomies of the femur during the implantation. In every case, accurate preoperative planning should be performed. A preoperative CT with 3D reconstruction is a powerful tool for further information beyond conventional imaging.

[Joint-preserving operative treatment of avascular necrosis of the femoral head]. / Operative gelenkerhaltende Therapie der Hüftkopfnekrose.

The cause of avascular necrosis of the femoral head is multifactorial. Conservative treatment is only an option in the early stages. It is only symptomatic and not causative treatment. The implantation of an artificial hip joint should be postponed as the typically affected middle-aged males are right in the middle of their working life. Therefore, some joint-preserving operative therapies might be considered in stages ARCO I-III. Those range from core decompression to osteotomies and grafts, the advantages and disadvantages of which have to be weighted in each case. More recent therapies such as additive stem cells or platelet rich plasma (PRP) combined with core decompression have yet to prove their efficacy.

[Perthes disease-diagnosis, classification and treatment based on Aachen-Dortmund treatment algorithm]. / M. Perthes ­ Diagnostik, Klassifikation und Therapie anhand des Aachen-Dortmunder Therapiealgorithmus.

Legg-Calvé-Perthes disease is a multifactorial idiopathic necrosis of the hip that typically occurs in childhood between the ages of 3 and 12. Treatment adapted to the stadium of the disease and to the clinical findings is medical art. The treatment is focused on the preservation or recovery of the arthrogenic containment of the femoral head. Multiple treatment options are available. The indications for treatment can be derived from clinical and radiological pathology. Structuring of the therapy options is the aim of this publication. For this purpose, a clear and concise overview of relevant clinical findings and useful radiographic classifications as well as reasonable therapy is presented.

[Intertrochanteric femoral osteotomy : Indications, surgical technique, results]. / Die intertrochantäre Femurosteotomie : Indikationen, Operationstechnik, Ergebnisse.

BACKGROUND: Intertrochanteric osteotomies are part of joint-preserving hip surgery. Indications involve not only the mature but also the growing skeleton. After identification of the causative pathologies multidimensional corrections with the aim of a better joint situation and prevention of early osteoarthritis are possible. METHODS: The surgical technique of intertrochanteric osteotomies is presented. Potential indications are discussed on the basis of results in the literature. RESULTS: In the surgical treatment of developmental dysplasia of the hip intertrochanteric osteotomies are used as additional surgery. In Perthes disease the containment is improved while the onset of osteoarthritis in epiphysis capitis femoris can be decelerated. Treatment of torsion pathologies is reliable. Avascular necrosis of the femoral head and beginning osteoarthritis are critical indications. CONCLUSION: For appropriate indications intertrochanteric osteotomies are a valuable element in joint-preserving surgery with very good long-term results.

[Tönnis and Kalchschmidt triple pelvic osteotomy]. / Die 3­fache Beckenosteotomie nach Tönnis u. Kalchschmidt.

BACKGROUND: The Tönnis and Kalchschmidt triple pelvic osteotomy (TPO) has been performed at the Klinikum Dortmund for more than 30 years. In more than 5000 cases the TPO has proven its potential to deal with even severe dysplastic hips. TPO can be easily combined with other hip procedures as intertrochanteric osteotomies and even impingement treatment can easily be done. As an elaborate technique TPO respects the growth plates and can therefore also be used for treating Legg-Calve-Perthes disease. PROCEDURE: In most cases only conventional X­rays are needed for proving the indication. Further imaging like MRI or CT-scans are only needed in certain cases. In addition EOS® is becoming an increasingly useful tool in planning and performing the surgery. For adequate movement of the acetabulum, three clearly defined osteotomies are needed. Current osteosynthesis methods provide an enhanced stability due to a novel technique of screw fixation. This is in line with the general trends towards short hospitalization and early mobilization. THERAPY: A successful treatment requires not only experience in performing the surgical technique, but furthermore an experienced team, including care, physical examination and also pain management. The surgeon should be aware that he is performing highly elective surgery and complications or a poor outcome can significantly reduce the quality of life of the mainly young patients.

[Anterior knee pain after total knee arthroplasty : Causes, diagnosis and treatment]. / Vorderer Knieschmerz nach Knie­TEP-Implantation : Ursachen, Diagnostik und Therapie.

BACKGROUND: Anterior knee pain is one of the most common complications after total knee arthroplasty. An incidence of up to 30 % has been reported in peer-reviewed studies. TARGET: The purpose of this study was to systematically review the literature and to identify determinants that have been analyzed with regard to anterior knee pain. CAUSES: Patient- and knee-specific characteristics, prosthetic designs and operative techniques are addressed as well as functional and neurologic determinants. Instability, increased contact pressure in the patellofemoral joint and patella maltracking due to malrotation of components, offset errors, ligament insufficiencies or patella baja are mechanical reasons for anterior knee pain. Functional causes include pathologic gait patterns, quadriceps imbalance and dynamic valgus. They have to be differentiated from infectious and inflammatory causes as well as soft tissue impingement, arthrofibrosis and neurologic diseases. TREATMENT: A differentiated treatment algorithm is recommended. Often conservative treatment options exist, however, particularly with most mechanical causes revision surgery is necessary.

[Hip arthroplasty after corrective osteotomies : Pelvis and proximal femur]. / Hüftendoprothetik nach korrigierenden Osteotomien : Becken und proximales Femur.

BACKGROUND: Pelvic and femoral osteotomies are frequently performed in patients with hip dysplasia. The aim of these surgeries are optimal biomechanical conditions of the hip joint thereby avoiding the occurrence of hip osteoarthritis or the delay of initial hip osteoarthritis progression. THERAPY: Nevertheless even with good biomechanical conditions of the hip joint, progression of hip osteoarthritis can be recognized postoperatively. A total hip arthroplasty is indicated even more after a time period with conservative treatment. In preparation for the operation, a detailed documentation of the initial clinical situation, appropriate imaging, implant selection and preoperative planning are mandatory. In addition, a biomechanical model representing the desired pre- and postoperative situation can be included in the preoperative planning. According to the previous osteotomy, the size and shape of the acetabulum after the osteotomy and the current pivot centre of the hip joint should be considered. Depending on these observations the acetabular cup can be directly inserted into the bone stock of the acetabulum or an acetabular plasty is necessary before implantation of the acetabular cup. With respect to the previous osteotomy of the femur, it needs to be clarified wether hardware removal will be necessary before total hip replacement; moreover, the anatomy of the proximal femur is critical. In addition, if necessary, a re-osteotomy of the femur is required to enable a hip stem implantation. CONCLUSION: Cementless total hip replacement should be preferred due to the younger patient age. The load of the hip replacement depends on the osseous anchoring and primary stability of the acetabular and femoral component.

[Multidisciplinary Rehabilitation and Fast-track Rehabilitation after Knee Replacement: Faster, Better, Cheaper? A Survey and Systematic Review of Literature]. / Multidisziplinäre Rehabilitation und multimodale Fast-Track-Rehabilitation in der Knieendoprothetik: Schneller, besser, günstiger? Eine Umfrage und systematische Literaturrecherche.

INTRODUCTION: The aim of multidisciplinary rehabilitation after total knee replacement (TKA) is to reduce postoperative complications and costs and enable faster convalescence. The goals of fast-track rehabilitation, as a multidisciplinary concept, are to reduce the length of hospital stay and achieve early functional improvements by optimizing the perioperative setting. METHOD: A literature review was carried out for the years 1960-2013. The search terms were: "rehabilitation", "training", "physiotherapy", "physical therapy", "recovery", "exercise program", "knee surgery", "TKA", "total knee replacement", "arthroplasty", "intensive", "multidisciplinary", "accelerated", "rapid" or "fast track". Only randomized controlled trials and metaanalyses were included. A survey was also performed to assess care as actually offered in orthopaedic rehabilitation clinics in North Rhine-Westphalia. RESULTS: A total of 729 articles were identified of which 11 studies were included. Fast-track rehabilitation can significantly reduce both the duration of hospital stay and costs after TKA. Current studies showed that a better short-/middle-term clinical outcome might be achieved with multidisciplinary rehabilitation. However, a difference in the long-term outcome could not be observed. Our survey shows that most patients are admitted to a rehabilitation clinic in a state of poor general condition as well as decreased mobility and knee range of motion. CONCLUSIONS: Fast-track rehabilitation facilitates a shortened hospital stay as well as cost saving. It probably can be used to optimize the condition of the patient before admission to a rehabilitation facility.

[Pathophysiology of traumatic bone marrow edema]. / Pathophysiologie des traumatischen Knochenmarködems.

BACKGROUND: Morphologically, bone marrow edema (BME) is an accumulation of fluid in the bone marrow. The BME is per se non-specific but can be identified at an early stage with magnetic resonance imaging (MRI). The underlying pathomechanism remains unclear. The BME can occur as an individual entity and as an accompanying condition of many diseases. The BME can be divided into three groups, ischemic, reactive and mechanical BME. Mechanical BME occurs after trauma or repetitive strain. Typical histological changes are present and there is no clear boundary between edema and microfracture. Some forms of trauma show BME in typical localizations. Both the trauma and the possible accompanying injuries can be indirectly indicated in this way in cases with an unknown trauma mechanism. CONCLUSION: The BME can be present as an isolated entity or as a comorbidity. For initiation of therapy, a comprehensive medical history and targeted diagnostics are indispensable. In some cases BME is indicative of the trauma mechanism and possible further accompanying injuries.

[Osteochondrosis of the pediatric foot]. / Osteochondrosen des kindlichen Fußes.

Osteochondrosis is a heterogeneous group of self-limiting conditions characterized by disturbance of enchondral ossification caused by a lack of circulation. Foot pain is a relatively common problem in children and adolescents and may be due to osteochondrosis. Osteochondrosis of the growing foot shows painful radiological alterations including increased density, fragmentation and irregularity of the epiphyses, physes and apophyses. Lacking etiologic and pathophysiologic information, ostoechondroses have been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating pediatric foot pain. The most common localizations of osteochondroses of the growing foot include the navicular as Kohler's syndrome, the metatarsal as Freiberg's infraction and calcaneal apophysitis as Sever's disease. Prognosis and final outcome vary considerably between the different localizations. Physicians should therefore be informed about the etiology, clinical presentation and treatment options for osteochondroses of the growing foot.

[Vertical talus: current diagnostic and therapy options]. / Talus verticalis: Aktuelle Diagnose- und Therapieoptionen.

Congenital vertical talus is a rare condition which presents as an isolated deformity or in association with neuromuscular and/or genetic disorders. Pathoanatomically the deformity shows a dislocated talonavicular and subtalar joint. The etiology and pathogenesis are still not finally determined although in some cases a genetic basis has been identified. The clinical picture is that of a flat, convex longitudinal arch with abduction and dorsiflexion of the forefoot and an elevated heel. Clinical diagnosis is confirmed by plain radiographic imaging. Congenital vertical talus should not be confused with other deformities of the foot, such as congenital oblique talus, flexible flat feet or pes calcaneus. The object of treatment of congenital vertical talus is to restore a normal anatomical relationship between the talus, navicular and calcaneus to obtain a pain-free foot. Major reconstructive surgery has been reported to be effective but is associated with substantial complications. Good early results of a modified non-operative treatment using serial manipulation, cast treatment and minimally invasive surgery may change therapeutic concepts.

A five to seven year follow-up comparing computer-assisted vs freehand TKR with regard to clinical parameters.

PURPOSE: Computer-assisted knee surgery has become established in routine clinical practice. Still, there is no study investigating midterm clinical outcome after five to seven years postoperatively. We aimed to test the hypothesis that there is no difference either for subjective [Western Ontario and McMaster Universities (WOMAC) scores] or for objective (Knee Society Score, degree of flexion) criteria between computer-assisted total knee replacement (TKR) and freehand TKR after 5.6-7.3 years. METHODS: We performed a matched-pair analysis; 100 patients who received a primary TKR were investigated after a median follow-up of 6.25 years. Group A was operated on with the support of a computer system, while surgery on patients in group B was performed with the freehand technique. We determined WOMAC Score, Knee Society Score and degree of flexion. RESULTS: Overall we found similar results for WOMAC Score [group A: 42.98 (SD 13.80); group B: 41.54 (SD 15.01; p = 0.62)], Knee Society Score [group A: 168.20 (SD 21.94); group B: 166.60 (SD 21.44; p = 0.71)] and range of motion [group A: 106° (SD 9.19); group B 107° (SD 7.44; p = 0.62)]. CONCLUSIONS: No significant differences in midterm clinical outcome were found after TKR performed in the freehand vs computer-assisted technique.

[Treatment algorithm for periprosthetic infections of the knee joint]. / Behandlungsalgorithmus der periprothetischen Infektionen am Kniegelenk.

Periprosthetic knee joint infection is a rare complication. However, patients as well as surgeons have to deal with severe problems. The past years have brought new knowledge on periprosthetic knee joint infections which have resulted in new classifications. The present manuscript evaluates the current literature on this topic and presents a new therapeutic algorithm.

Status and future of modern technologies in arthroplasty : Results of a survey of the German Society for Orthopedics and Trauma Surgery (DGOU).

BACKGROUND: The orthopedic community is divided on the question of whether modern technologies in arthroplasty improve outcomes. Therefore, the aim of this initiative of the working group on intraoperative imaging and technology integration (Arbeitsgemeinschaft intraoperative Bildgebung und Technologieintegration, AGiTEC) is to initiate the collection of additional data for the scientific evaluation of modern technologies. QUESTION: To what extent are modern technologies currently used and which implementations are planned? Do the members of the German Society for Orthopedics and Trauma Surgery (DGOU) consider the acquisition of additional data for scientific assessment necessary? METHODS: Members of the DGOU were asked via an e­mail survey about the distribution and projected introduction of modern technologies in arthroplasty. They were also asked whether sufficient data were collected for scientific evaluation and whether acquisition of additional data in studies or arthroplasty registries were considered necessary. RESULTS: Of the 7923 probands surveyed, 428 completed the questionnaire in full (5.4%). It was found that individual implants and navigation are currently the most frequently used (31% and 29%, respectively). The largest increases in the next 2 years are projected for virtual reality and robotics (+30% and +23%, respectively), 85% of respondents indicated that insufficient data were collected for scientific evaluation, and 89% each requested initiation of multicenter studies and inclusion of technologies in the arthroplasty registry. CONCLUSION: The results of this study should motivate the scientific community, industry, and those responsible for the arthroplasty registries to collect and analyze data for the scientific assessment of modern technologies.

Fixation of revision TKA: a review of the literature.

PURPOSE: Early aseptic loosening is a major complication in revision total knee arthroplasty (TKA). It is well accepted that intramedullary stems improve the anchoring of the prosthetic components; however, controversy still exists about the optimal fixation technique of the stems (cementless, hybrid, cemented). METHODS: A literature review was carried out in the main medical databases from 1980 to 04/2010 to evaluate the available literature by evidence-based criteria and to analyse the results of the single studies regarding fixation technique in knee revision arthroplasty. RESULTS: There are four studies regarding the cementless fixation. Eight studies reported the hybrid technique and five studies the cemented technique. Hybrid and cemented techniques are comparable regarding the survival of arthroplasties, the rate of aseptic loosening and the clinical outcome. However, most studies just show a low level of evidence (LoE III and IV), a small to medium number of cases and a short follow-up. CONCLUSION: Based on the current literature, no final statement can be drawn regarding the optimal fixation technique in revision TKA. Future RCTs are needed to enable conclusive statements about the possible advantages and disadvantages of the single fixation techniques, although the clinical implementation often is critical.

[Therapy of isolated arthritis in the patellofemoral joint: are there evidence-based options?]. / Therapie der isolierten Femoropatellararthrose : Gibt es evidenzbasierte Verfahren?

BACKGROUND: Isolated osteoarthritis of the patellofemoral joint occurs in 9% of patients over 40 years of age and women are more often affected. Options of treatment are varied and not sufficiently justified by the literature. MATERIALS AND METHODS: A literature research with keywords in the field of femoropatellar osteoarthritis was carried out in the relevant databases. Studies were categorized into different treatment options and analyzed. RESULTS: There are almost no level I studies comparing the different treatment options. In the literature there are indications that relief of pain can be achieved by conservative treatment, arthroscopic surgery, cartilage conserving surgery and isolated arthroplasty. CONCLUSION: In view of the fact that there are almost no prospective randomized controlled trials, none of the options for treatment can be highly recommended. There is still no gold standard for the treatment of isolated patellofemoral osteoarthritis.

[Patellofemoral pain after total knee arthroplasty: clinical pathway and review of the literature]. / Patellofemoraler Schmerz nach primärer Knieendoprothetik : Behandlungsalgorithmus und Literaturüberblick.

Total knee arthroplasty (TKA) is an operation with a high gain in quality of life. However, some patients suffer from pain, limited range of motion, instability, infections or other postoperative complications. Patellofemoral pain (PFP) in particular is a common complication after TKA and is often responsible for revision surgery. In particular increasing and localized contact pressure and patella maltracking are held accountable for patellofemoral pain but the reasons are various. Diagnostics and therapy of patellofemoral pain is not easy to handle and should be treated following a clinical pathway. We suggest that patients with patellofemoral pain should be classified into four groups according to the suspected diagnosis after basic diagnostic measures as 1) tenidinosis, 2) mechanical reasons, 3) intraarticular non-mechanical reasons and 4) neurogenic psychogenic reasons. Efficient application of special diagnostic measures and further therapy is facilitated by this classification.