Editorial Commentary: Mental Health and Tobacco Use Influence Functional Outcomes-Quod erat demonstrandum, or Not?!?

Why does one patient achieve better results than another with nonoperative orthopaedic treatment? Aside from the specific underlying pathology of knee pain, there are demographic factors, including mental health, body mass index, tobacco use, and pain perception, that influence the clinical results and should be considered as part of the equation.

Management of Pain in Elite Athletes: Identified Gaps in Knowledge and Future Research Directions.

OBJECTIVE: For elite athletes to train and compete at peak performance levels, it is necessary to manage their pain efficiently and effectively. A recent consensus meeting on the management of pain in elite athletes concluded that there are many gaps in the current knowledge and that further information and research is required. This article presents the crystallization of these acknowledged gaps in knowledge. DATA SOURCES: Information was gathered from a wide variety of published scientific sources that were reviewed at the consensus meeting and the gaps in knowledge identified. MAIN RESULTS: Gaps have been identified in the epidemiology of analgesic use, the management of pain associated with minor injuries, and the field of play management of pain for athletes with major injuries. From a pharmacological perspective, there is a lack of information on the prescribing of opioid medications in elite athletes and more data are required on the use of local anesthetics injections, corticosteroids, and nonsteroidal anti-inflammatory drugs during training and in competition. Pain management strategies for the general population are widely available, but there are few for the elite sporting population and virtually none for elite athletes with a disability. More research is also needed in assessing cognitive-behavior therapies in improving specific outcomes and also into the new process of psychologically informed physiotherapy. A key issue is the paucity of data relating to incidence or prevalence of persistent pain and how this relates to persistent dysfunction, exercise performance, and physiological function in later life. CONCLUSIONS: The identification of the gaps in knowledge in the management of pain in elite athletes will provide a unified direction for the retrieval of information and further research that will provide reassurance, speed return to active sport, and benefit performance.

[S2k-Guideline on Meniscal Disease: Non-operative and Surgical Management]. / S2k-Leitlinie Meniskuserkrankung: konservative und operative Therapie.

A meniscal injury should not automatically lead to surgery. Even in light of all the developments in arthroscopic surgery, non-operative management still has a place in the treatment algorithms for lesions around the knee. In this second publication of the German guidelines for meniscal surgery, the authors describe the various treatment possibilities, their indications and offer critical insight into the various therapeutic options. This will allow the patient and physician alike to make the proper individual decisions. Various German speaking associations addressing topics surrounding the knee have joined forces to develop these guidelines for meniscal lesions. The hope is that these two publications on the topic will shed light on the ongoing debate and offer some guidance.

[Therapeutic algorithm for traumatic cartilage injuries]. / Therapiemöglichkeiten bei traumatischen Knorpelschäden.

Reports regarding sport injuries frequently pertain to the knee. Although ligament and meniscus damage are the most common, cartilage injuries are of great interest. Even with the great variety of treatment modalities available, the healing of these cartilage injuries remains problematic. Due to the complex structure of hyaline cartilage joint surface, repair has proven to be very difficult. The conservative treatment options range from orthotic devices and physical therapy to systemic and intraarticular medication. In case of failure, a wide variety of surgical interventions exist. Among these surgical treatment forms, one must differentiate between the repair and the reconstruction of hyaline joint surfaces. In the latter group only the osteochondral autologous transplantation procedures allow for the reconstruction of a cartilaginous lesion with hyaline cartilage as part of a single procedure. This paper will provide an overview of most common therapeutic approaches to cartilage injuries available today. Even with the ongoing discussions with regard to cartilage healing, the basics such as the ligamentous stability of the affected joint, the mechanical axis of the extremity and good neuromuscular control must always be part of the algorithm.

Assessment of leech therapy for knee osteoarthritis: a randomized study.

BACKGROUND AND PURPOSE: Symptomatic treatment of osteoarthritis of the knee with leeches is presently undergoing a renaissance. Previous studies have shown methodical weaknesses. In the present study patients were blinded regarding the treatment, and a control group was included to explore possible differences in various subjective clinical scores and intake of pain medication over time between leech therapy and placebo control. PATIENTS AND METHODS: 113 patients with advanced osteoarthritis of the knee were included. The patients were randomized to a single treatment group, group I (single leech application, n = 38), a double treatment group, group II (double application, n = 35), and a control group (n = 40). The second treatment in group II took place after an interval of 4 weeks. The treatment in the control group was simulated with the help of an "artificial leech". Results were documented with the KOOS and WOMAC scores and also a visual analog scale (VAS) for pain. Changes in the use of pain medication were monitored over 26 weeks. RESULTS: An improvement in KOOS and WOMAC scores, and also in VAS, was found in all 3 groups following treatment. These improvements were statistically significant for treatment groups I and II during the complete follow-up period. The reduction in individual requirements for pain medication was also statistically significant. The greatest improvement was seen in the group treated twice with the leeches, with a long-term reduction of joint stiffness and improved function in the activities of daily living. INTERPRETATION: Leech therapy can reduce symptoms caused by osteoarthritis. Repeated use of the leeches appears to improve the long-term results. We have not determined whether the positive outcome of the leech therapy is caused by active substances released during the leeching, the placebo effect, or the high expectations placed on this unusual treatment form.

Lack of effect on bone healing of injectable BMP-2 augmented hyaluronic acid.

INTRODUCTION: Autologous bone graft is the gold standard for the filling of large osseous defects. Because of its limited supply and complications such as pain, bleeding or infection, the development of alternative bone substitutes has been the subject of several studies. In clinical practice, the most commonly used bone substitutes are calcium phosphates like hydroxyapatite or tricalcium phosphate. With the aim to improve the osseointegration of these materials, growth factors such as bone morphogenetic protein-2 (BMP-2) have been added. Preferably, an injectable bone substitute should be made available. Hyaluronic acid is a component of the extracellular matrix of many tissues, including bone. We examined the bone regenerative effect of commercially available, injectable hyaluronic acid (Hyalart) with and without addition of bone morphogenetic protein-2 (BMP-2). MATERIALS AND METHODS: Trepanation defects of 9.4 mm diameter in the intercondylar groove of sheep femora were filled with pure and augmented (200 microg BMP-2) hyaluronic acid. As controls, empty defects and defects treated with autologous bone graft harvested from the contralateral side were used. After 3 months, the defects were analysed by fluorescence microscopy after intravital fluorescence staining, contact microradiography, histology and histomorphometry. RESULTS: Treatment of the defects with loaded and unloaded hyaluronic acid resulted in a significant lack of bone formation inside the defects. Untreated defects showed an amount of 5.1% newly formed bone, and defects treated with autologous bone graft revealed a bone content of 20%. The difference between both groups was statistically significant (P < 0.05). Furthermore, there was neither a remarkable effect in the periphery of the defects nor ectopic bone formation. CONCLUSION: The application of the used injectable hyaluronic acid (Hyalart) with and without BMP-2 is not advantageous as sole bone substitute for the filling of osseous defects.

BMP-2 incorporated in a tricalcium phosphate bone substitute enhances bone remodeling in sheep.

Bone morphogenetic protein-2 (BMP-2) is a well-known osteoinductive protein, which requires a carrier for local application. As an alternative to the previously described carriers, an in situ hardening, resorbable, and osteoconductive beta-tricalcium phosphate cement (TCP) is tested. Trepanation defects in the bovine distal femoral epiphysis are filled with a composite consisting of TCP and 200 microg rhBMP-2 per cm3 TCP, autologous bone graft, pure TCP, or left empty. A radiological follow-up is performed after 7 weeks and 3 months. The sheep are euthanized and bone samples are analyzed by microradiography, histology, and histomorphometry. Microradiography and histology show similar results for pure TCP and the composite. The defects are filled with trabecular bone and newly formed bone is in close contact with the remaining TCP-particles. The majority of the cement is resorbed, in the composite group the amount of remaining cement particles is reduced. Defects treated with autologous bone graft are filled completely, while untreated defects shows only a small amount of bone originating from the rim of the defect. Histomorphometry of the defects treated with pure TCP shows a significantly increased bone content in comparison to defects treated with the composite or autologous bone graft. Analysis of the remaining cement particles shows significantly less cement in the TCP/rhBMP-2 group in comparison to pure TCP. The sum of bone and cement content in the rhBMP-2 group shows amounts comparable to the calcified structures found following autologous bone grafting. The addition of rhBMP-2 to the TCP leads to faster remodeling of the defect comparable to autologous bone graft, while defects treated with pure TCP are not completely remodeled.

A bFGF/TCP-composite inhibits bone formation in a sheep model.

Basic fibroblast growth factor is a well known osteostimulative protein. The effects of basic fibroblast growth factor are dose-dependent and, when used with a carrier, influenced by the release kinetics. Aim of our study was to determine the effects of a composite of basic fibroblast growth factor and a newly developed, in situ setting tricalcium phosphate (TCP) cement. A trepanation defect in the distal femoral epiphysis of Merino-Mix sheep with a diameter of 9.4 mm and 10 mm depth was filled with the in situ setting TCP cement combined with 0 or 200 microg of bFGF/cm(3) TCP, autologous bone graft or left empty. The sheep were euthanized after 3 months. The defect and the periimplant area were examined by microradiography, histology, and histomorphometry. The data was analyzed with the help of the Wilcoxon and Kruskal-Wallis tests. Defects filled with TCP with or without bFGF showed a close bone-cement contact. The histomorphometric analysis revealed that the addition of bFGF inhibited the ingrowth of bone significantly, while the resorption of the cement was not influenced. In conclusion, the clinical application of this bFGF/TCP-composite does not seem promising. The reason for the inhibition of new bone formation will be discussed, but requires further investigation.

Amphiphilic bonder improves adhesion at the acrylic bone cement-bone interface of cemented acetabular components in total hip arthroplasty: in vivo tests in an ovine model.

INTRODUCTION: Even following the introduction of the "third generation" cementing technique, an improvement of the fixation of the acetabular component similar to that of the femoral has not been shown in clinical studies. The goal of the present study was to achieve a better stability with the use of an amphiphilic bonder while preserving the mechanically important subchondral sclerosis. MATERIALS AND METHODS: In a total of 20 sheep, a cemented total hip replacement was implanted. In the treatment group (n = 10), the implantation was carried out following surface conditioning of the acetabular bed with an amphiphilic bonder. All the sheep were followed for 9 months. To assess the biocompatibility, the osseous ingrowth at the cement-bone interface was depicted with the help of an in vivo fluorescent marking of the osteoblasts. Additionally, conventional radiographs were obtained over the course of treatment. Finally, the ovine pelvic regions were split following a standardized technique allowing for histological evaluation of the cement-bone interfaces. RESULTS: The acetabular components of the treatment group revealed a stable cement-bone compound. In the control group, the implants were easily dislodged from their beds. This finding was consistent with the radiological and histological results, which had revealed increased, progressive lytic radiolucent lines and the interposition of fibrous tissue at the cement-bone interface in the control group compared to the treatment group. The bonder was biocompatible. CONCLUSION: Following the application of the bonder, the cemented acetabular components revealed an improved stability without signs of inflammation or neoplasia in a viable acetabular osseous bed. With the help of this technique, the in vivo longevities of cemented acetabular components can be increased in the clinical setting without sacrificing the biomechanical relevant subchondral sclerosis.

Ingrowth of osteochondral grafts under the influence of growth factors: 6-month results of an animal study.

INTRODUCTION: In the age of growth factors and gene therapy, the induction of cartilage healing remains an unsolved problem. Even in autologous grafting, one of the preferred methods of treatment for focal osteochondral lesions, chondral integration remains difficult. This study aims to define a possible positive influence of growth factor augmentation on the ingrowth of these transplants. MATERIALS AND METHODS: In an ovine model, questions regarding the healing of osteochondral transplants under the influence of two different growth factors were to be addressed. Two osteochondral autologous transplantations (OAT), one in the weight-bearing surface of each femoral condyle, were performed on the ovine knee using the standard operative protocol. One of the grafts was bathed in augmented PBS containing 50 microg bFGF or bone morphogenetic protein (BMP)-2 directly prior to implantation, while the other condyle served as the control. Two groups, consisting of eight sheep each, were evaluated for each growth factor after 6 months. RESULTS: During the evaluation of all the specimens, neither osteophytes nor synovial changes were observed. The mechanical consistency of the cartilaginous tissue began to reach a level equivalent to the surrounding tissue at 6 months, independent of the use of growth factor. Macroscopically, the superficial border of the transplanted osteochondral plug could easily be outlined in all groups, while the cartilage interface of the bFGF specimens was determined to be less demarcated than the BMP augmented plugs or the controls. Radiographically, a solid osteointegration of the graft could be documented at 6 months in the native and augmented groups. In contrast, integration of the chondral surface of the OAT was not seen macro- or microscopically in any specimen, even though cartilage surfaces remained viable. A firm physical interdigitation of the reconstructed joint surface could not be demonstrated in either of the two augmented groups or the control population. The augmentation with bFGF and BMP-2 stimulated the osseous ingrowth and seems to expedite the remodelling process, but was not able to improve chondral healing. CONCLUSION: The lack of integration of the cartilaginous portion of the transplanted plugs into the reconstructed joint surface, even following the augmentation with bFGF and BMP-2, does not bode well for the long-term survival of the joint itself.

Evaluation of a resorbable, in situ setting bone substitute in a sheep model.

The gold standard for bone substitution is the autologous bone graft, but because of its limited supply and the associated morbidity, the search for synthetic alternatives is necessary. A new in situ setting tricalcium phosphate cement was implanted in a trepanation defect (9.4 mm diameter, 10 mm depth) in the distal femoral epiphysis of sheep. Empty cavities and autologous bone graft were used as controls. Histologic and histomorphometric examinations were carried out after 12 weeks. Nearly 90% of the implanted cement was resorbed and replaced by ingrown bone with close contact between surrounding bone, new bone, and remaining cement particles. The amount of bone in the defect area was significantly higher in defects filled with cement relative to defects filled with autologous bone graft (mean 27 vs. 21%, 95% confidence intervals 23 to 31 and 18 to 23, p = 0.026). In conclusion, this new in situ setting cement is bioactive, resorbable, and osteoconductive. It will be useful as an alternative to autologous bone graft to fill stable defects.

The effect of basic fibroblast growth factor on bone regeneration when released from a novel in situ setting tricalcium phosphate cement.

The osteostimulative effect of the basic fibroblast growth factor is well known, but it is dose dependent, and release kinetic depends on interactions with the used carrier. The aim of our study was to determine the osteostimulative effect of a composite, consisting of an in situ setting tricalcium phosphate cement and basic fibroblast growth factor. A trepanation defect of 1.5 mm in the femur diaphysis of Sprague-Dawley rats was filled with the in situ setting TCP cement combined with 0, 0.25, 2.5, or 25 microg rh bFGF, an autologous bone graft or left empty. The rats were euthanized after 1 and 3 weeks and examined by radiography, histology, histomorphometry, and bending test. The data were analyzed by the Wilcoxon and Kruskal-Wallis test. All TCP groups with or without bFGF showed a good bony ingrowth with a close bone-cement contact. Osseous ingrowth was not influenced by the addition of the different doses of bFGF as shown by histomorphometry. Also, mechanical strength was not affected. In conclusion, the combination of this in situ setting cement with bFGF is not useful for clinical application. The reason of these negative results remains unclear: the osteostimulative effect of bFGF is well known, and the TCP-cement was used as a carrier for rhBMP-2 successfully. These negative results may be due to a too slow or too fast release of bFGF from the cement.

Molecular markers in the evaluation of autologous chondrocyte implantation.

PURPOSE: With the help of molecular markers, it has become possible to quantify cartilage repair and degradation in joints. In this study, we attempt to determine whether or not molecular markers in synovial fluid can be helpful in defining the repair process following autologous chondrocyte implantation (ACI). TYPE OF STUDY: As part of a prospective clinical pilot study, 17 patients were evaluated before, as well as 6 weeks, 3, 6, and 12 months after the ACI. A synovial analysis was performed and molecular markers for bone and cartilage metabolism were determined. METHODS: A number of parameters, including pyridinium crosslink (PY), deoxypyridinolin (DPD), n-telopeptide (NTX) from type I collagen, MMP-1, MMP-3; TIMP-1, PICP, proteoglycan, and YKL-40 were analyzed. The levels were referenced to the total protein concentration of the synovial fluid. The synovial analyses were compared with clinical parameters (Larson score) and magnetic resonance imaging (MRI) examinations. RESULTS: The analysis of the data revealed differing trends for the various synovial markers over time. The most remarkable marker was found to be DPD, which increased continuously between surgery and week 12, only to disappear after the repair process had ceased 1 year after surgery. All molecular markers for cartilage degradation increased initially after surgery and dropped off below the original levels 3 to 6 months later. CONCLUSIONS: The evaluation revealed that the determination of marker levels can provide valuable information regarding the metabolism of bone and cartilage in a joint. They seem to provide a method for monitoring the repair process associated with the various treatment forms for chondral lesions.

Stimulation of bone formation with an in situ setting tricalcium phosphate/rhBMP-2 composite in rats.

The aim of the study was to determine bone-regenerative effects of an in situ setting tricalcium phosphate (TCP) cement combined with rhBMP-2 and to compare it with autologous bone graft. A trepanation defect of 1.5 mm in the femur diaphysis of Sprague-Dawley rats was filled with an in situ setting TCP cement combined with 0, 0.25, 2.5, or 25 microg of rhBMP-2, an autologous bone graft, or left empty. The rats were euthanized after 1 and 3 weeks and examined by radiography, histology, histomorphometry, and bending tests. All TCP groups with or without BMP-2 showed a good bony ingrowth with a close bone-cement contact. Histomorphometric analysis showed no increase of new bone formation in the defect, but a dose-dependent increase in callus formation with a maximum at 25 microg of rhBMP-2. As shown with intravital fluorochrome staining, new bone formation started earlier using rhBMP-2. Bone strength, measured in a three-point bending test and expressed in percentage of the contralateral healthy femur, was 75% for TCP + 25 microg rhBMP-2, 44% for TCP + 2.5 microg rhBMP-2, and 34% for autologous bone graft. TCP particles were detectable in all groups after 3 weeks. Callus formation and bending strength of the TCP + 25 microg rhBMP-2 group was superior to autologous bone graft. So TCP/rhBMP-2 composites may prove to be an effective substitute for autologous bone grafts.

Healing of osteochondral grafts in an ovine model under the influence of bFGF.

PURPOSE: The well-recognized limitations in cartilage healing have lead to the development of a number of resurfacing techniques for defects of joint surfaces. Autologous grafting has developed into 1 of the preferred methods of treatment for focal osteochondral lesions, although basic research on this topic remains sparse. TYPE OF STUDY: In an animal study, questions regarding the healing of osteochondral transplants under the influence of basic fibroblast growth factor (bFGF) were addressed. METHODS: Two osteochondral autologous transplantations (OAT), 1 in the weight-bearing surface of each femoral condyle, were performed on the ovine knee using a standard operative protocol. One of the grafts was bathed in phosphate buffered sulfate (PBS) containing 50 microgram of recombinant human bFGF (rh-bFGF) directly before implantation. Two groups consisting of 10 sheep each were evaluated after 3 and 6 months, respectively. RESULTS: During the evaluation of the specimens, neither osteophytes nor synovial changes were observed. Macroscopically, the superficial border of the transplanted osteochondral plug could easily be outlined at both time periods, even though the cartilage interface of the rh-bFGF specimens was less demarcated. Radiographically, a solid osteointegration of the graft could already be documented at 3 months in the control group. In contrast, integration of the chondral surface of the OAT was not seen macroscopically or microscopically at any point. A firm physical interdigitation of the reconstructed joint surface could not be demonstrated in either of the 2 groups. The augmentation with rh-bFGF stimulated the osseous ingrowth, but was not able to improve chondral healing. CONCLUSIONS: The lack of integration of the cartilaginous portion of the transplanted plugs into the reconstructed joint surface, even following augmentation with bFGF, leads to questions regarding the long-term survival of the joint itself.

Polysegmental spondylodiscitis and concomitant aortic aneurysm rupture: case report with 3-year follow-up period.

STUDY DESIGN: A case report describing a patient with spondylodiscitis of the thoracic and lumbar spine complicated by rupture of an abdominal aortic aneurysm and aggravation of neurologic symptoms is presented. OBJECTIVE: To present a cardiovascular complication worsening the clinical condition during conservative spondylodiscitis therapy, and to describe a minimally invasive treatment regimen for both spondylodiscitis and aortic aneurysm rupture in multimorbid patients at high risk for complications or refusal of surgery. SUMMARY OF BACKGROUND DATA: Few articles describe minimally invasive treatment of spondylodiscitis. Some available reports describe neurologic symptoms resulting from spinal cord ischemia in aortic aneurysm rupture. No data were found describing simultaneous therapy for spondylodiscitis and rupture of aortic aneurysm. METHODS: Therapy consisted of CT-guided percutaneous drainage of the spondylodiscitis and parenteral antibiotic treatment combined with immobilization and minimally invasive endoluminal exclusion of the aortic aneurysm with a bifurcated stent graft. RESULTS: Effective therapy for polysegmental spondylodiscitis on the one hand and contained rupture of aortic aneurysm on the other are presented. The successful clinical outcome after conservative orthopedic therapy and vascular intervention has been followed for 3 years. CONCLUSIONS: In older patients, spondylodiscitis may be complicated by other underlying diseases. Pain and neurologic symptoms may occur secondarily to concomitant illnesses instead of being caused by the inflammation itself. Minimally invasive therapy is shown to be an effective alternative to surgery in older and multimorbid patients with spondylodiscitis and contained aortic aneurysm rupture.

Malleolus externus plasty for joint reconstruction in fibular aplasia: preliminary report of a new technique.

The instability of the upper and the lower ankle joint represents a serious problem in patients with fibular aplasia. None of the previous techniques demonstrated at least sufficient results. In this report we present a new technique of malleolus externus plasty applied in a 5 1/2-year-old boy with fibular aplasia (type II according to Coventry and Johnson or type Ib according to Achtermann and Kalamchi) with a 6 cm length deficiency of the lower leg and 1 cm of the upper leg. Furthermore, he showed a tibial antecurvation deformity of 20 degrees, a fourth ray foot with adduction deformity of the hindfoot, cutane syndactyly D 2-4, and a hallux varus. This new technique works on the following principle. A triangular iliac crest transplant is implanted with an apophysis and the annexing fascia glutealis, including the osseous part of the transplant, in the lateral distal tibia in a way that the growing apophyseal part lays distally covering the lateral talus. Gluteal fascia annexed to the apophysis was used for the reconstruction of a lateral tendon. Using a ring fixator the transplant is fixed and coincidentally the lower leg lengthened and the axis corrected. The axis deformity and the leg-length deficiency of 7 cm were equalized. The fixator could be removed after 6 months. Radiologically, an entire integration of the iliac crest transplant was found. Magnetic resonance imaging showed it had sufficient circulation. The reexamination 2.5 years later demonstrated a simultaneous growth of the malleolus externus and the distal tibia and stable ankle joints with sufficient mobility and full weight-bearing capability. For support of the foot the boy uses ready-made shoes with curved arch supports. In conclusion, using this new technique an individually adapted lateral malleolus with growth-potential can be constructed that stabilizes the foot and the ankle joints. Thus, reluxations of the foot specifically in relation to lengthening of lower legs can be avoided with concurrent preservation of the range of movement of the ankle joint.

Tibio-calcaneo-naviculo-cuboidale arthrodesis: 6 patients followed for 1-8 years.

As a salvage procedure for patients with irreparable damage to the peritalar anatomy, we used a new method, the Ilizarov ring fixator, to stabilize a tibio-calcaneo-naviculo-cuboideal (TCNC) arthrodesis after resecting the talus in 6 patients with an average follow-up of 3 years. The tibia was lengthened by callus distraction, mean 6 (3.5-10) cm. Patients with exacerbation of a chronic talar osteomyelitis, symptomatic posttraumatic changes, and those with extremely unstable club feet and talar deformity preventing an adequate reduction of the joint, were successfully treated with the TCNC-fusion. The method permits early weight bearing, while providing stability and compression of the fusion, thereby avoiding further loss of bone stock.