Anatomic ligament consolidation of the superior acromioclavicular ligament and the coracoclavicular ligament complex after acute arthroscopically assisted double coracoclavicular bundle stabilization.

PURPOSE: The consolidation of the acromioclavicular (AC) and coracoclavicular (CC) ligament complex after arthroscopically assisted stabilization of acute acromioclavicular joint (ACJ) separation is still under consideration. METHODS: Fifty-five consecutive patients after arthroscopically assisted double-CC-bundle stabilization within 14 days after acute high-grade ACJ separation were studied prospectively. All patients were clinically analysed preoperatively (FU0) and post-operatively (FU1 = 6 months; FU2 = 12 months). The structural MRI assessments were performed at FU0 (injured ACJ) and at FU2 bilateral (radiologic control group) and assessed separately the ligament thickness and length at defined regions for the conoid, trapezoid and the superior AC ligament. RESULTS: Thirty-seven patients were assessed after 6.5 months and after 16.0 months. The 16-month MRI analysis revealed for all patients continuous ligament healing for the CC-complex and the superior AC ligament with in the average hypertrophic consolidation compared to the control side. Separate conoid and trapezoid strands (double-strand configuration) were detected in 27 of 37 (73%) patients, and a single-strand configuration was detected in 10 of 37 (27%) patients; both configurations showed similar CCD data. The ligament healing was not influenced by the point of surgery, age at surgery and heterotopic ossification. The clinical outcome was increased (FU0-FU2): Rowe, 47.7-97.0 pts.; TAFT, 3.9-10.6 pts.; NAS pain, 8.9-1.4 pts. (all P < 0.05). CONCLUSION: The arthroscopically assisted double-CC-bundle stabilization within 14 days after acute high-grade ACJ separation showed 16 months after surgery sufficient consolidations of the AC and double-CC ligament complex in 73%. LEVEL OF EVIDENCE: III, Case series.

Cell-free cartilage repair in large defects of the knee: increased failure rate 5 years after implantation of a collagen type I scaffold.

INTRODUCTION: Cartilage defects of the knee remain a challenging problem in orthopedic surgery despite the ongoing improvements in regenerative procedures such as the autologous chondrocyte transplantation. Due to the lack of donor-site morbidity and the single-stage procedure cell-free scaffolds are an interesting alternative to cell-based procedures. But as currently mid- and long-term data are lacking, the aim of the present study was to present mid-term clinical, radiological and histological results of a cell-free collagen type I scaffolds for cartilage repair. MATERIALS AND METHODS: Twenty-eight patients were followed prospectively. Clinical evaluation using patient-reported outcome measures (KOOS, IKDC; VAS for pain, Tegner score for activity) as well as radiologic evaluation of the repair tissue (MOCART) was performed at 1 year, 2 years and 5 years. Histologic evaluation of the repair tissue was done in case of revision surgery using the ICRS II score for human cartilage repair. RESULTS: In these large cartilage defects with a mean defect size of 3.7 ± 1.9 cm2, clinical failure necessitating revision surgery was seen in 5 of 28 patients (18%). While the remaining patients showed good-to-excellent clinical results (KOOS, IKDC, VAS, Tegner), the radiologic appearance of the repair tissue showed a reduction of the MOCART score between the 2- and 5-year follow-up. Histologic evaluation of the repair tissue showed a cartilage-like appearance with no signs of inflammation or cell death but an overall medium tissue quality according to the ICRS II Score. CONCLUSION: The use of this cell-free collagen type I scaffold for large defects showed increased wear of the repair tissue and clinical failure in 18% of cases at 5-year follow-up.

[Influence of the trauma mechanism on cervical spine injuries]. / Einfluss des Unfallmechanismus auf die Verletzungen der Halswirbelsäule.

BACKGROUND: The influence of trauma-related kinematics on the injury pattern of the cervical spine is currently not considered in the available classification systems, only the force vector. Whether the strength of the trauma has an additional influence on the number and complexity of the injuries and whether this can be classified, has not yet been finally investigated. OBJECTIVE: What influence do different kinematics apart from the traumatic force vector have on injuries of the cervical spine? MATERIAL AND METHODS: Based on the AOSpine classification system for the upper and subaxial cervical spine, data from 134 trauma patients from a first level trauma center were retrospectively analyzed. Analogue to the S3 guidelines on polytrauma, patients were assigned to six trauma groups and the injuries were classified on the basis of computed tomography (CT) cross-sectional imaging. RESULTS: A higher trauma energy had a significant impact on the number of cervical spine injuries (p = 0.005). In low velocity accidents C2 was the most frequently injured vertebra (51%; p = 0.022) and high velocity accidents showed more C7 fractures (37%; p = 0.017). Furthermore, upper cervical spine injuries occurred more often in low energy trauma and older female patients (e.g. falling from a standing position). Subaxial cervical spine involvement was found significantly more often in high velocity accidents and younger male patients (p = 0.012). CONCLUSION: Exact knowledge of the trauma mechanism is helpful in the primary treatment of an injured person. Injury patterns can be better estimated and the appropriate diagnostics can be initiated. The results underline the importance of immediate cervical spine immobilization even after minor trauma. In high velocity trauma, patients more often suffer from lower cervical spine injuries, especially C7. Due to the accumulation of multilevel spinal injuries in high velocity trauma, radiographic imaging of the whole spine is advisable.

[Acetabular revision arthroplasty with a novel cementless augment-and-modular-cage system (MRS-C) : Surgical technique and preliminary clinical results]. / Hüftpfannenwechsel mit einem neuartigen zementfreien "Augment-and-modular-cage"-Revisionssystem (MRS-C) : Chirurgische Technik und erste klinische Ergebnisse.

OBJECTIVE: Optimal reconstruction of acetabular anatomy and primarily stable bridging even of large bone defects in hip revision surgery by intraoperative cementless application of highly modular components of the MRS-TITAN Comfort (MRS-C) system according to the augment-and-modular-cage principle. INDICATIONS: Acetabular defect situations in hip revision surgery, hereditary/acquired acetabular deformities, severe secondary hip osteoarthritis. CONTRAINDICATIONS: Extended periacetabular defects of the dorsal pillar, pelvic discontinuities, persisting posttraumatic or periprosthetic infections, lack of intraoperative bony anchorage options. SURGICAL TECHNIQUE: Conventional positioning. Flexible selection of approach (posterolateral, anterolateral or transgluteal) to the hip joint, if possible using a previous approach. Implant removal, preparation and intraoperative acetabular defect evaluation. Optional impaction bone grafting for biological downsizing. Selection of modular components and augments depending on the defect. Preparation of the obturator foramen for anchorage of the caudal flange. Optional preparation of the os ilium for additional fixation of the cage with flanges. Fixation with polyaxial screws and selection of version/inclination of the cup component. Selection of the inlay (polyethylene/ceramic). POSTOPERATIVE MANAGEMENT: Partial weight-bearing with 20 kg body-weight for 6 weeks with crutches. Prophylaxis for deep vein thrombosis and heterotopic ossification. Additional adapted antibiotic therapy in cases of infection. RESULTS: A minimum 1­year follow-up of 42 patients showed significant improvements of Harris Hip Scores (p < 0.0001), adequate reconstruction of the physiologic center of rotation (x-ray controlled in the vertical plane, referenced to the contralateral side), and a clear reduction of preoperative leg length discrepancies. No significant changes in range of motion. No implant-associated complications noted. Based on the short follow-up results, the implant proves as suitable for reconstruction of even large acetabular bone defects.

Erratum to: Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction.

Erratum to:Oper Orthop Traumatol 2018 https://doi.org/10.1007/s00064-018-0559-3 The article was wrongly published under the article type "Review". Please note that the article is an "Original Paper".The publisher apologizes to authors and ….

Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction.

OBJECTIVE: The aim is to stabilize the thoracolumbar spine with a thoracoscopically implanted vertebral body replacement (VBR). To improve intraoperative depth perception and orientation, implantation is performed under three-dimensional (3D) thoracoscopic vision. INDICATIONS: Vertebral burst fractures at the thoracolumbar junction (A4 AOSpine classification), pseudarthrosis, and posttraumatic instability with increasing kyphosis. CONTRAINDICATIONS: Severe pulmonary dysfunctions, pulmonary or thoracic infections, previous thoracic surgery, and pulmonary adhesions. SURGICAL TECHNIQUE: The patient is lying in a right lateral decubitus position. Localization of the fractured vertebra. Minimally invasive transthoracic approach. Perform single lung ventilation and insert the 3D thoracoscope two intercostal spaces above the working portal. Utilization of special binocular glasses for 3D vision of the operation field and secure resection of the fractured vertebra. Measurement of the bony defect and insertion of the expandable cage. Control of correct cage position under fluoroscopy. Insertion of a chest tube and inflate the left lung. POSTOPERATIVE MANAGEMENT: Chestâ€¯× ray Remove chest tube when output is <500 ml/24 h Early mobilization on the ward 6 weeks no weight-bearing >5 kg RESULTS: Between 2012 and 2017, 12 patients received a VBR under 3D thoracoscopic vision. After a mean follow up of 26 months, no cage dislocation was noticed and all patients recovered from the initial back pain. Complications were notable in two cases (17%) with a small pneumothorax after removal of the chest tube and postoperative pneumonia in one patient (8%). All responded to conservative treatment. Revision surgery was not necessary.

The QuickLine IL-6 lateral flow immunoassay improves the rapid intraoperative diagnosis of suspected periprosthetic joint infections.

BACKGROUND: When deciding upon the best treatment strategy in revision arthroplasty, it is absolutely crucial to use the best possible preoperative detection whether a periprosthetic joint infection (PJI) is present or not. New molecular markers investigated in serum samples and synovial fluid can help to improve the preoperative diagnosis. In 2001, a novel IL-6 lateral flow immunoassay testing device was introduced which has never been tested in synovial fluid so far. OBJECTIVE: For our study we investigated whether the test can be used safely, feasibly and time effectively with synovial fluid gathered from potentially infected THAs or TKAs and whether the already published cutoff for IL-6 in synovial fluid predicting a PJI can be reproduced using the QuickLine IL-6 immunoassay. METHODS: After ethic approval and within the scope of a prospective controlled trial we investigated 26 patients (m = 9, 34.6%; f= 17, 65.4%) with n = 13 (50%) potentially infected total hip arthroplasties (THAs) and n = 13 (50%) suspected PJIs of total knee arthroplasties (TKAs). Sterile aspirated synovial fluid was examined for total leukocyte count and cell differentiation by a blood count analyzer in body fluid mode as well as for IL-6 (Immulite, Siemens Medical Solutions Diagnostics GmbH, Eschborn, Germany). Another part of the joint aspirate was tested using the QuickLine IL-6 Test by Milenia Biotec (Milenia Biotec, Gießen, Germany). RESULTS: The mean concentration of IL-6 as determined from our reference laboratory testing (Siemens Immulight) for aseptic cases was 1,219 pg/mL (SD 1,369 pg/mL, min 134 pg/mL-max 4,214 pg/mL). The mean IL-6 concentration measured via the IL-6 QuickLine for aseptic cases was 410 pg/mL (SD 371 pg/mL, min 100 pg/mL-max 1562 pg/mL). The test showed no false negative or false positive results in the cases tested. In six patients, PJI was considered proven. The QuickLine Test indicated IL 6 concentrations > 10,000 pg/mL in these cases without further quantification above this maximum detection threshold. Results from the QuickLine Test and the laboratory tests were matched and a non-linear best fit curve (log-log-curve) was applied. The subsequent Spearman correlation showed a correlation coefficient of r = 0.92 (95% CI 0.81-0.97) which corresponds to a two-tailed p-value of < 0.0001, respectively. As a primary finding we were able to show that the Milenia QuickLine IL-6 Test can be used safely, feasibly and time effectively with synovial fluid gathered intraoperatively from potentially infected THAs or TKAs. The test as provided worked well in 84.6% of the samples tested and failed only due to very viscous synovial fluid. As a secondary result we found that the previously published cut-off for IL-6 in synovial fluid predicting a PJI with a sensitivity of 46.88% and a specificity of 97.62% can be reproduced using the QuickLine IL-6 immunoassay. CONCLUSION: Taking the limitations of the low sample size as a given this relatively simple point of care (POC) assay showed promising results in our pilot trial and may help diagnosing PJI. It may help physicians and surgeons to choose the best and least invasive treatment strategy for patients presenting with painful arthroplasty.

Complications and failure of MPFL reconstruction with free tendon grafts in cases of patellofemoral instability.

BACKGROUND: Reconstruction of the medial patellofemoral ligament (MPFL) using free tendon grafts has become a widespread treatment option for patellofemoral instability. As the numbers of cases gradually grow, so do the reports of possible peri- and postoperative complications following this procedure. OBJECTIVE: The present review summarizes all known complications of MPFL reconstruction with regard to postoperative outcome and seeks to highlight possible pitfalls that may occur during treatment. CONCLUSIONS: MPFL reconstruction generally has to be regarded as a safe procedure today due to low patellar re-dislocation rates. Complication rates however are not trivial owing to the complexity of the underlying pathology. Complications can arise from graft fixation or femoral tunnel placement. Postoperative flexion deficits and medial knee pain have been described as predominant complaints. Anatomical preconditions as the grade of trochlear dysplasia, axis or torsion of the lower extremity have to be considered in search of causes for possible graft failure as well as in the thorough preoperative planning of the procedure.