Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios.

INTRODUCTION: In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. METHODS: Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°. RESULTS: No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. CONCLUSION: The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

[Orthoses and assistive devices in rheumatology : Prevention of disability, support of residual function]. / Hilfsmittel in der Rheumatologie : Einschränkungen vorbeugen, Restfunktionen unterstützen.

Due to the frequent presence of comorbidities in patients suffering from rheumatism with increased perioperative risk factors, conservative treatment is often needed. Besides pharmacological treatment, physiotherapy and occupational therapy, a variety of orthoses are available depending on the individual indications. They can be used to stabilize or support joints, limit the range of motion, prevent unphysiological movements or provide relief for affected limbs. In order to choose the right kind of orthosis, the physician should know the underlying cause of disease. Furthermore, for patients with rheumatism many devices are available for daily living that use ergonomic handles or improved leverage effects to compensate for the often severe limitations and to improve the quality of life.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Examination of the wrist and hand]. / Klinische Untersuchung des Handgelenkes und der Hand.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

[Patella navigation in computer-assisted TKA : Intraoperative measurement of patellar kinematics. Video article]. / Patellanavigation bei computerassistierter Knie-TEP-Implantation : Eine Technik zur intraoperativen Messung der Patellakinematik. Videobeitrag.

INTRODUCTION: Patellofemoral maltracking is a relevant problem after total knee arthroplasty (TKA). Patella navigation is a tool that allows real time monitoring of patella tracking. MATERIAL: This video contribution demonstrates the technique of patellofemoral navigation and a possible consequence of intraoperative monitoring. A higher postoperative lateral tilt is addressed with a widening of the lateral retinaculum in a particular manner. CONCLUSION: In selected cases of patellofemoral problems, patella navigation is a helpful tool to evaluate patellofemoral tracking intraoperatively. Modifications of implant position and soft tissue measurements can then prevent postoperative patellofemoral maltracking.

Measuring Acetabular Cup Orientation on Antero-Posterior Radiographs of the Hip after Total Hip Arthroplasty with a Vector Arithmetic Radiological Method. Is It Valid and Verified for Daily Clinical Practice?

PURPOSE: The aim of this prospective study is to validate a vector arithmetic method for measuring acetabular cup orientation after total hip arthroplasty (THA) and to verify the clinical practice. MATERIALS AND METHODS: We measured cup anteversion and inclination of 123 patients after cementless primary THA twice by two examiners on AP pelvic radiographs with a vector arithmetic method and compared with a 3D-CT based reconstruction model within the same radiographic coronal plane. RESULTS: The mean difference between the radiographic and the 3D-CT measurements was - 1.4°â€Š±â€Š3.9° for inclination and 0.8°±â€Š7.9° for anteversion with excellent correlation for inclination (r = 0.81, p < 0.001) and moderate correlation for anteversion (r = 0.65, p < 0.001). The intraclass correlation coefficient for measurements on radiographs ranged from 0.98 (95 %-CI: 0.98; 0.99) for the first observer to 0.94 (95 %-CI: 0.92; 0.96) for the second observer. The interrater reliability was 0.96 (95 %-CI: 0.93; 0.98) for inclination and 0.93 (95 %-CI: 0.85; 0.96) for anteversion. CONCLUSION: The largest errors in measurements were associated with an extraordinary pelvic tilt. In order to get a valuable measurement for measuring cup position after THA on pelvic radiographs by this vector arithmetic method, there is a need for a correct postoperative ap view, with special regards to the pelvic tilt for the future. KEY POINTS: • Measuring acetabular cup orientation on anteroposterior radiographs of the hip after THA is a helpful procedure in everyday clinical practice as a first-line imaging modality• CT remains the golden standard to accurately determine acetabular cup position.• Future measuring on radiographs for cup orientation after THA should account for integration of the pelvic tilt in order to maximize the measurement accuracy. Citation Format: • Craiovan B, Weber M, Worlicek M et al. Measuring Acetabular Cup Orientation on Antero-Posterior Radiographs of the Hip after Total Hip Arthroplasty with a Vector Arithmetic Radiological Method. Is It Valid and Verified for Daily Clinical Practice?. Fortschr Röntgenstr 2016; 188: 574 - 581.

[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.

[Operative therapy for rheumatoid arthritis of the hand]. / Operative Therapie bei rheumatoider Arthritis der Hand.

The need for operative treatment of severe rheumatic deformities of the hand and wrist is decreasing due to the increased use of disease-modifying drugs; however, some patients do not tolerate or do not sufficiently respond to these drugs, which often results in the hands being affected and in advanced stages to severe deformity and loss of function. In these cases operative surgery can help to slow the progression of rheumatic destruction and restore the function of the patient's hand. This article describes the principles of surgery for rheumatoid arthritis of the hand. A meticulous synovectomy or tenosynovectomy is the first stage of treatment. With progression of rheumatic destruction various salvage procedures are necessary to preserve the best possible functional state.

[Operative treatment of the rheumatic shoulder]. / Operative Therapie der rheumatischen Schulter.

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

Impingement-free range of movement, acetabular component cover and early clinical results comparing 'femur-first' navigation and 'conventional' minimally invasive total hip arthroplasty: a randomised controlled trial.

We report the kinematic and early clinical results of a patient- and observer-blinded randomised controlled trial in which CT scans were used to compare potential impingement-free range of movement (ROM) and acetabular component cover between patients treated with either the navigated 'femur-first' total hip arthroplasty (THA) method (n = 66; male/female 29/37, mean age 62.5 years; 50 to 74) or conventional THA (n = 69; male/female 35/34, mean age 62.9 years; 50 to 75). The Hip Osteoarthritis Outcome Score, the Harris hip score, the Euro-Qol-5D and the Mancuso THA patient expectations score were assessed at six weeks, six months and one year after surgery. A total of 48 of the patients (84%) in the navigated 'femur-first' group and 43 (65%) in the conventional group reached all the desirable potential ROM boundaries without prosthetic impingement for activities of daily living (ADL) in flexion, extension, abduction, adduction and rotation (p = 0.016). Acetabular component cover and surface contact with the host bone were > 87% in both groups. There was a significant difference between the navigated and the conventional groups' Harris hip scores six weeks after surgery (p = 0.010). There were no significant differences with respect to any clinical outcome at six months and one year of follow-up. The navigated 'femur-first' technique improves the potential ROM for ADL without prosthetic impingement, although there was no observed clinical difference between the two treatment groups.

[Prevention of periprosthetic joint infections : Not evidence-based strategies]. / Vermeidung periprothetischer Infektionen : Nicht evidenzbasierte Maßnahmen.

BACKGROUND: Surgical site infections are the most common nosocomial infections in orthopedic surgery. Strategies to prevent these infections are of enormous relevance. OBJECTIVES: Evidence-based procedures such as hand disinfection, prophylactic antibiotic application, hair removal with electric clippers, or preoperative treatment of Staphyloccus aureus are listed in national and international guidelines. Beside these measures, several scientifically not confirmed methods, e.g., the administration of antibiotic prophylaxis for several days or the usage of helmets during surgery, are still practiced. These measures are not evidence-based and should not be performed anymore. CONCLUSION: Only the consequent implementation of evidence-based procedures can help prevent surgical site infections.

[Arthrodesis for patients with rheumatic arthritis of the ankle and hindfoot. A reasonable option?]. / Arthrodesen bei Patienten mit rheumatisch bedingten Sprunggelenks- und Rückfußarthrosen. Eine sinnvolle Option?

BACKGROUND: Ankle and hindfoot deformities as well as degenerative changes are often found in patients with rheumatological diseases. They often suffer from severe pain and complain of increasing immobility. Corrective procedures with ankle or hindfoot arthrodesis are promising options. OBJECTIVES: This article presents epidemiological data and describes the clinical aspects, diagnostics and treatment options for patients with ankle and hindfoot osteoarthritis. MATERIALS AND METHODS: The retrospective results of 56 patients after ankle or hindfoot arthrodesis are presented. RESULTS: After an average follow-up of 52 months the majority of results were good or excellent with relief of pain and reconstruction of the function of the foot. CONCLUSION: Ankle or hindfoot arthrodesis represents a promising option for patients with severe osteoarthritis and can safeguard patients from increasing immobility.

[Endoprosthetic treatment of the ankle]. / Endoprothetische Versorgung des oberen Sprunggelenks.

BACKGROUND: Chronic polyarthritis is the second most common cause regarding the etiology of upper ankle osteoarthritis after posttraumatic degenerative changes. Patient mobility is limited by this painful disease. Besides conservative treatment options, replacement of the upper ankle joint is an operative therapeutic option in eligible candidates which provides very good results. OBJECTIVES: Besides epidemiological data, clinic presentation, diagnostic tools, treatment options and management of postoperative complications for patients with ankle osteoarthritis, this article presents the results of midterm outcome after total ankle replacement. MATERIAL AND METHODS: The retrospective results of 44 patients after total ankle arthroplasty are presented. RESULTS: After an average follow-up of 53 months (range 20-98 months) the majority of results were good or excellent with respect to pain relief. CONCLUSION: Total ankle replacement is a good option for treating osteoarthritis of the ankle joint in rheumatoid arthritis when attention is paid to the eligibility of the patients.

[Painful total knee arthroplasty. A treatment algorithm]. / Die schmerzhafte Knieprothese. Ein Behandlungsalgorithmus.

BACKGROUND: Persisting and newly occurring complaints after implantation of a total knee endoprosthesis (TKE) are common problems for orthopaedic surgeons in clinics and private practices. The search for the cause and the diagnostics are often difficult due to the many possible influencing factors. Painful TKE requires patience from the orthopaedic surgeon as well as from the patient. THERAPY MODALITIES: The indications for surgical revision should basically be considered with caution and conservative therapeutic procedures can contribute to a considerable improvement in complaints. The treatment algorithm presented in this article helps to adopt a therapeutic direction and if necessary in assessing the indications for revision or replacement surgery. The algorithm offers the possibility of a systematic classification according to clinical, radiological and laboratory testing aspects and assists in the decision for further procedures depending on the four differential diagnoses of limitations in movement, instability, loosening and infection. CONCLUSION: Revision operations should be performed in specialized centers and should be tailored to the individual patient. A comprehensive knowledge of knee joint biomechanics and experience with the large spectrum of modular and axis-linked revision systems are essential for revision surgeons.

No difference in accuracy between pinless and conventional computer-assisted surgery in total knee arthroplasty.

PURPOSE: Many studies have demonstrated higher precision and better radiological results in Total knee arthroplasty (TKA) with computer-assisted surgery (CAS). On the other hand, studies revealed a lengthening of operation time up to 20 min for this technique and demonstrated rare additional complications as fractures and neurovascular injuries caused by the array pins and any intraoperative array dislocation leads to abortion of CAS. To combine the advantages and eliminate the disadvantages of standard CAS, we evaluated the accuracy of a so-called pinless CT-free version of knee navigation (pinless CAS) abandoning the reference pins and reducing the necessary workflow to a minimum. METHOD: The present study compares the accuracy of the reference methods of two different CT-free knee navigation software versions (Brainlab Knee 2.1 and Brainlab Knee Express 2.5). Thirty patients received TKA assisted by standard CAS. Intraoperatively, the proposed bony resections of standard CAS were matched with the new pinless CAS. Postoperatively, the results were checked by evaluating the radiographs concerning leg axis, femoral flexion and tibial slope. RESULTS: All results concerning precise cuts (femoral as well as tibial coronal/varus-valgus alignment, femoral flexion alignment and tibial slope, resection height) were comparable between both groups (n.s.). In femoral, we found a mean deviation of coronal alignment of 0.3° (SD 0.7) and flexion of 0.2° (SD 0.8). In tibial, we found a mean deviation of coronal alignment of 0.2° (SD 0.5) and slope of 0.2° (SD 0.6). The mean additional operation time for the pinless CAS was below 2 min. The postoperative mechanical leg axis was within the threshold of 3° in all patients, tibial slope and femoral flexion matched with CAS values. CONCLUSION: In clinical routine, pinless CAS can comprise the advantages of CAS leaving the disadvantages aside. It reduces surgical time and avoids complications associated with the tracking pins of conventional CAS.

Proximal interphalangeal joint replacement with an unconstrained pyrocarbon prosthesis (Ascension(R)): a long-term follow-up.

There have been limited publications that report long-term outcomes of pyrocarbon implants. This report describes both clinical and radiographic long-term results for patients who have been treated with pyrocarbon proximal interphalangeal implants. Thirteen implants in ten patients are reported for an average follow-up of 8.3 years (range 6.2-9.3). All patients were suffering from degenerative joint disease. Five of the 13 digits were free of pain, the remaining eight digits had mild to moderate pain (visual analogue scale 2-5). The average active range of motion was 58° (SD 19°) at latest examination. X-ray results were unremarkable in six digits with an acceptable position of the prosthesis. However, in seven patients significant radiolucent lines (≥ 1 mm) were observed. Three prostheses demonstrated a migration of the proximal component, and one a subsidence of the distal component. Our study does not support the use of this implant for treatment of osteoarthritis of the finger joint owing to high complication rates and limited range of motion.

[Radiological findings, evaluation and treatment of patellofemoral pain after total knee arthroplasty]. / Radiologische Diagnostik, Beurteilung und Behandlung des patellofemoralen Schmerzes nach primärer Knieendoprothetik.

Total knee arthroplasty (TKA) is one of the most successful operative procedures over the last decades in orthopedic surgery; however, some patients suffer from pain, limited range of motion, instability, infections or other complications postoperatively. Patellofemoral pain (PFP) in particular is a common problem after TKA and often necessitates revision surgery. Mainly increasing and localized contact pressure and patella maltracking are held responsible for PFP but the reasons vary. Diagnostics and therapy of PFP is not easy to manage and should be treated following a clinical pathway. The authors suggest that patients with PFP should be categorized after basic diagnostic measures according to the suspected diagnosis: (1) tendinosis, (2) mechanical reasons, (3) intra-articular non-mechanical reasons and (4) neurogenic/psychiatric reasons. Efficient application of special diagnostic measures and further therapy is facilitated by this classification.

[Orthopedic operations and postoperative treatment of rheumatic elbows]. / Orthopädische Operationen und Nachbehandlungsregimes am rheumatischen Ellenbogen.

This article gives an overview of the indications for operative treatment and the respective post-treatment of rheumatic elbows. The goal should be to preserve the function of the elbow joint and freedom from symptoms to prevent joint destruction which unfortunately can still be seen nowadays.

[Revision implants of the future: trends and new developments]. / Revisionsimplantate der Zukunft: Trends und neue Entwicklungen.

According to current prognostic studies the numbers of revision operations of hip and knee arthroplasty will increase worldwide. As many patients undergo several revisions and become older at the same time, orthopedic surgeons will have to cope with vast bony defects during operations. The introduction of highly porous metals as surface layer or metal augments has facilitated primary stabilization of prostheses. Short and mid-term results of these new products are promising. New developments in coatings, such as cationic antimicrobial peptides represent new alternatives for antibacterial therapy of periprosthetic infections and increase osteointegration of prosthesis components. Furthermore, the new revision systems have a modular design and can be individually adapted to the patient's bony conditions during operations. In most cases this can be done without cement or in a hybrid technique.

[Patient satisfaction and muscle torque after total knee replacement in dependence on body mass index]. / Patientenzufriedenheit und Muskelkraft nach Knietotalendoprothese in Abhängigkeit vom Body-Mass-Index.

AIM: In a monocentric study, we investigated patient satisfaction, clinical outcome and isokinetic muscle torque in dependence on the body mass index (BMI) in the mid-term outcome after total knee arthroplasty. PATIENTS AND METHODS: A group-matched study with two groups (each 40 knee arthroplasties in 40 patients) with a normal body mass index (BMI 20-25) and above 25 was conducted. The groups were matched for sex, diagnosis and age. Satisfaction, HSS score and isokinetic torque parameters with the Cybex 340 system were measured. RESULTS: There were no differences in the demographic data except for BMI. The HSS score was significantly lower in the overweight group (p = 0.04). Also there were more patients with an HSS score below 60 (bad result) in the group with the higher BMI (0 vs. 9, p = 0.002). Only one patient was not satisfied in the normal weight group, whereas 9 patients in the group BMI > 25 were not satisfied (p = 0.014). No differences between the groups could be found in maximum torque, work and power. CONCLUSION: The patient satisfaction was much lower in patients with BMI higher than 25. There were no differences between the groups in isokinetic torque parameters.