Ten-year follow-up and clinical outcome of a metaphyseal anchoring short hip stem prosthesis: a retrospective single-centre analysis.

PURPOSE: Short stems for total hip arthroplasty are an alternative to traditional conventional long stems. Short stems are designed to facilitate minimal-invasive surgery, improve bone-stock preservation, and mimic a physiological load distribution. However, there is little evidence of the long-term outcome of short stems. This study aims to analyze the ten year survival rates and clinical outcome of one specific metaphyseal short hip stem implant. METHODS: We retrospectively analyzed the patient records of the patients who underwent a total hip arthroplasty with a monoblock partial collum sparing metaphyseal short hip stem prosthesis in 2008 and 2009 in our clinic. Patients were contacted, and clinical follow-up was recorded using the German version of the modified Harris Hip Score. Furthermore, complications, revision surgery, and post-operative radiographs were analyzed. RESULTS: Data from 339 primary implantations in 322 patients were retrieved. The mean follow-up was 10.6 years. Seven patients underwent a revision. The ten year survival rate with any revision surgery as the endpoint was 97.5%. The mean modified Harris Hip Score was 86 points (range 30 to 91 points). Five patients had an intraoperative fracture of the femur (1.6%). Two patients (0.6%) had a dislocation of the hip. The stem tip-to-cortex distance, measured in the anterior posterior view, was 2.6 mm (range 0 to 8.3 mm). CONCLUSION: The ten year survival rate of our used monoblock partial collum sparing metaphyseal short hip stem implant is comparable to traditional stems for total hip arthroplasty.

[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.

[Causes and management of patellar instability after total knee replacement : Lateralization, subluxation and luxation]. / Ursachen und Management der Patellainstabilitäten nach künstlichem Gelenkersatz : Lateralisation, Subluxation und Luxation.

BACKGROUND: Patellofemoral complications after total knee arthroplasty are responsible for a variety of surgical revisions. OBJECTIVE: The causes of the various types of instability of the patella are listed in a differentiated way and the importance of clinical and imaging diagnostics as well as preventive strategies are elaborated. MATERIAL AND METHODS: This article is based on a selective literature search in the PubMed database and on the long-standing experience of the author. RESULTS: Besides postoperative genu valgum with malalignment of the extensor mechanisms, other risk factors for patellar maltracking are insufficiency of the medial retinaculum, weakening of the vastus medialis muscle, contracture of the quadriceps femoris or tractus iliotibialis muscle, residual valgus deformity after total knee replacement, femoral or tibial malrotation as well as malpositioning of the patella, inappropriate design of the prosthesis and asymmetrical resection of the patella. The causes with respect to incorrect component positioning, faulty preparation of the patella, leg malalignment, inappropriate design of the prosthesis and soft tissue imbalance have to be recognized in order to address the problem in a targeted way. The preferred method of choice in the case of patellofemoral instability after total knee replacement is normally surgery; however, the cause for the instability has to be identified and consequently corrected before surgery. Without a clearly identified cause surgical measures are unrewarding and almost regularly lead to an unsatisfactory outcome. CONCLUSION: Patella maltracking after total knee arthroplasty is multifactorial and requires an accurate clarification. A surgical revision is only recommended in cases of clearly defined causes of pain or a clearly defined reason for patella malpositioning.

[Revision hip arthroplastiy of the hip joint. Revision of the femur: which implant is indicated when?]. / Revisionsalloarthroplastik des Hüftgelenk. Schaftrevision: Wann ist welches Implantat indiziert?

Cementless revision hip arthroplasty is described as state of the art, especially in cases of advanced bone loss of the femur. A requirement for a good result from cement-free revision hip arthroplasty is classification of the bone defect and the presence of a mechanically stable anchorage in the area of the original implant or, in cases of bone defects, distal to the original area in stable diaphyseal bone. The possibility of the accumulation of autografts or allogeneic osseous grafts and the entire removal of the cement and debris has been postulated. The advantages of cementless revision hip arthroplasty include regeneration of the bone stock and the often available modularity of the revision hip system, which allows adaptation to different bone configurations and also allows a partial change of the prosthesis in rerevision cases, such as in cases of sintering or derotation. Cemented revision arthroplasty should be done only in special cases, such as with marginal bone defects or for older patients with a short life expectancy.

[Diagnosis of Periprosthetic Infection - What's Obligation, What's Optional?]. / Diagnostik des periprothetischen Infekts - was ist Pflicht, was ist optional?

BACKGROUND: Periprothetic infection after primary or revision arthroplasty is of increasing importance. The incidence of infection in primary arthroplasty is approximately 1 %. Revision arthroplasty has higher infection rates, which increase with the number of revision surgeries. Aim of this Paper: An overview of the current diagnosis of periprosthetic infection. METHODS: This selective analysis is based on a lecture by the author at the DKOU 2015. RESULTS: Periprosthetic infection is taken as having been demonstrated when either two periprosthetic cultures contain the same microorganism, or if there is a fistula communicating with a joint. If only minor criteria are met, the detection of an infection is more difficult. The medical history only provides supporting evidence, especially as regards the course of the pain. Physical examination is more helpful, especially if there is redness, swelling, heat or wound dehiscence. Radiological pathologies, such as osteolysis or bone resorption can only be found in advanced infections. Nuclear medicine scans only possess acceptable sensitivity and specificity in combination with leukocyte scintigraphy. ESR, CRP and leukocyte blood count of the blood are of poor specificity. Important and targeted diagnostic steps include joint aspiration under aseptic conditions, although this exhibits a relatively high rate of false negative results. The conditions for this must be stringently observed. This is usefully complemented by cytological examinations and biopsies for tissue culture. Sensitivity and specificity are then increased. Sonication can significantly enhance the detection of an infection. The leukocyte esterase test is inexpensive and easy to perform and is therefore very much in vogue at the moment; however it is useless if there is contamination with blood. Recent studies indicate that the alpha-defensin test possesses high sensitivity and specificity, but has the disadvantage of being expensive. CONCLUSIONS: In patients with suspected periprosthetic infection, the primary aim is either to exclude an infection, or to detect a pathogen. The essential components are careful evaluation of the medical history, accompanied by imaging and laboratory tests. A critical approach is essential. Joint aspiration has become the gold standard in detecting periprosthetic infections. This should be performed in conjunction with a cytological analysis of the synovial fluid. An improvement in sensitivity and specificity can be archived by taking tissue samples. Sonication significantly improves the results. The latter method, the leukocyte esterase test and the alpha-defensin test are optional. The essential components are a rigorous evaluation, a clear algorithm and interdisciplinary collaboration with microbiologists and possibly infectiologists.

[Core decompression in Ahlbäck's disease. Follow-up and therapy control using MR tomography]. / Markraumbohrung (Core-Dekompression) bei Morbus Ahlbäck. MR-tomographische Verlaufs- und Therapiekontrolle.

Clinically suspected spontaneous osteonecrosis of the knee (Ahlbäck's disease) was confirmed by MR imaging and subsequent histology in 4 male patients with sudden onset of severe knee pain. The first typical radiological sign for osteonecrosis--flattening of the affected femoral condyle--was seen in no case. All patients were treated surgically by extraarticular drilling for core decompression and were delivered from the complained severe knee pain immediately after surgery. The healing process of early osteonecrosis could be confirmed by the normalisation of bone marrow signal in MR imaging (3 to 15 months follow-up). Core decompression seems to be an effective treatment in early osteonecrosis of femoral condyles. MR imaging is the most sensitive method for early diagnosis of osteonecrosis and for preoperative planning as well as a helpful tool for a non-invasive postoperative follow-up.

[The percutaneous CT-guided treatment of osteoid osteomas: a combined procedure with a biopsy drill and subsequent ethanol injection]. / Perkutane CT-gesteuerte Behandlung von Osteoid-osteomen: kombiniertes Vorgehen mit einem Hohlbohrer und nachfolgender Athanolinjektion.

PURPOSE: The purpose of this study was the clinical evaluation of a percutaneous treatment modality in patients with an osteoidosteoma. PATIENTS AND METHODS: 6 patients with an osteoidosteoma of the upper (n = 1) and lower (n = 5) extremity which were confirmed on plain film radiographs and computed tomography underwent CT controlled drill biopsy of the nidus with subsequent injection of 96% ethanol into the biopsy channel to sclerose probably remaining remnants of the nidus. The procedure was started under local anaesthesia, but drilling of the nidus was carried out under a short general anaesthesia using ketamine. RESULTS: The intervention was successful in all patients. No postinterventional infection occurred and no recurrence was observed in any of the patients in a follow-up time between 0.5 and 2 years. CONCLUSION: Although only 6 patients were treated until now, we conclude that this combined procedure using a bone biopsy system and the subsequent injection of alcohol is a safe and successful procedure for percutaneous treatment of osteoidosteoma.

Ipsilateral peroneus brevis tendon grafting in a complicated case of traumatic rupture of tibialis anterior tendon.

Ruptures of tibialis anterior tendon can be caused by open, closed, direct, or indirect trauma, as well as spontaneously. Sixty-three cases of tibialis anterior tendon ruptures have been reported in the international literature. The treatment of choice is the surgical end-to-end or side-to-side anastomosis after previous Z-lengthening. The case of a 28-year-old world-class female triathlete who sustained an open laceration of the tibialis anterior tendon from the bicycle chain guard is reported. The primarily applied tendon suture became infected and a wound revision with wide resection of the tendon stumps was necessary. This lead to an extensive defect of the tendon combined with a deep-seated keloidal scar reaction of the skin. The surgical closure was performed using free ipsilateral peroneus brevis tendon grafting. Four months after the operation the patient was completely rehabilitated. Eight months later she became the second European triathlon champion.

Spinal stabilization in Duchenne muscular dystrophy: principles of treatment and record of 31 operative treated cases.

The aim of this study was to report results of prophylactic spinal stabilization in patients with Duchenne muscular dystrophy. There is still debate regarding the ideal instrumentation. A prospective study of a consecutive series of 31 patients stabilized with the ISOLA system from D2 to S1 will be presented. The mean follow-up was 22 months (range, 1-60 months). The evaluation of the Cobb angle and pelvic obliquity revealed the following: 1) Cobb angle: preoperation, 48.6 degrees (range, 22-82 degrees); postoperation, 12.5 degrees (range, 0-30 degrees); follow-up, 12.5 degrees (range, 0-42 degrees); and 2) pelvic obliquity: preoperation, 18.2 degrees (range, 3-40 degrees); postoperation, 3.8 degrees (range, 0-13 degrees); follow-up, 5.1 degrees (range, 0-14 degrees). Spinal stabilization with the ISOLA system was found to be a suitable treatment for scoliosis owing to Duchenne muscular dystrophy. It should be carried out after loss of ambulation as soon as a progressive curve of more than 20 degrees is documented. The complication rate was found to be high.

Scoliosis in Duchenne muscular dystrophy: aspects of orthotic treatment.

The x-linked Duchenne muscular dystrophy (DMD) is the most frequent generalized muscle disorder arising from a lack of the sarcolemmic protein "dystrophin". Patients with DMD develop in the majority a progressive scoliosis when they cease walking and/or standing at the age of 10 years and become confined to a wheelchair. Increasing muscle weakness leads to a progression of the curvature, the pelvic tilt and problems in sitting. Together with the simultaneous progressive weakness of the respiratory muscles a restrictive pulmonary insufficiency will occur. Surgical stabilization of the spine (> 20 degrees Cobb, forced vital capacity > 35%) by an adequate multisegmental instrumentation enabling early mobilization is now the treatment of choice. However, orthotic treatment may offer an acceptable compromise in exceptional cases, if the patient rejects surgical intervention or is in the late (inoperable) stages of the disease. Such a treatment is superior to a primary sitting support provision with insufficient possibilities of correction. The authors' experiences with 48 scoliosis orthoses made for 28 patients with DMD are reported. A "double plaster" cast has emerged as the best method to optimize adaption, especially in severe curvatures and the time taken for manufacturing the orthosis. A great deal of experience, patience and the consideration of the patients' individual demands are inevitable for a successful orthotic treatment.

Bilateral total hip replacement in pseudoachondroplasia.

Pseudoachondroplasia is an inherited skeletal dysplasia with short-limbed dwarfism and early onset of osteoarthritis. A 29-year-old pseudoachondroplastic woman presented with progressively painful hips secondary to severe osteoarthritis of both joints, so that total joint replacements were necessary to restore her mobility and quality of life. The implants inserted had to be specifically manufactured in accordance with the individual geometry and reduced bone size. In addition, the implants mechanical resistance to dynamic loading conditions had to be tested prior to total hip replacement surgery.

Atraumatic recurrent posterior shoulder subluxation: review of the literature and recommendations for treatment.

Isolated atraumatic recurrent posterior subluxation of the shoulder (ARPS) constitutes 1% of all shoulder subluxations; it is therefore difficult for any single clinic to gain a large experience in treating this condition. Based on a review of the literature 83 cases of ARPS out of 237 reported cases with all types of posterior subluxation of the shoulder (185 patients) were analyzed. Most cases of ARPS occur between 11 and 20 years of age; they are frequently associated with changes such as dysplasia of the glenoid labrum or an alteration in the spinoglenoid angle. More than half of all ARPS occur bilaterally. The diagnosis is based on history, physical examination including tests of instability, or on techniques of dynamic examination (ultrasonography, arthroscopy). A plan of management related to the underlying etiology has been developed. At the first occurrence, cases of subluxation should be treated conservatively by kinesitherapy and physical therapy. Operative treatment is indicated when conservative management for at least 6 months has been unsuccessful and subluxation continues to occur during everyday activities, but it should never be instituted in patients with emotional disorders. The underlying pathologic lesion should determine the technique for shoulder reconstruction in atraumatic posterior shoulder subluxation. In cases in the atraumatic voluntary subgroup, surgery is indicated if conservative treatment fails and the voluntary component has been eliminated. In this subgroup, isolated soft tissue procedures have not been shown to produce good long-term results, and supplementary bony procedures are considered necessary. Conservative treatment exclusively is recommended in voluntary cases.

[Intraoperative damage to the medial collateral ligament (MCL) - what is to be done?]. / Intraoperative mediale Seitenbandschädigung - was tun?

BACKGROUND: Intraoperative damage to the medial collateral ligament is a rather rare condition given only scant attention in the literature. Observing international medical journals (over the recent years), one finds very few case histories. What is more, these case histories vary significantly with regards to their approaches to the problem at hand. MATERIAL AND METHODS: This survey lists essential publications and case histories in question and - following their analysis and in light of the fairly low number of respective cases - attempts to create a 'treatment algorithm'. RESULTS: Approaches to treatment vary considerably throughout the medical literature. Reasons are the localisation of the actual damage, pertaining to the medial collateral ligament as well as surgeons' aptitudes and preferences with regards to hinged or constraint implants. Eventually, there are five different treatment options: (i) solely conservative treatment by means of an orthesis; (ii) primary reconstruction of the medial collateral ligament; (iii) medial collateral ligament augmentation; (iv) inlay elevation and lateral release procedure; and (v) a higher degree of coupling regarding the TKA. CONCLUSION: It is strongly advised to refrain from conducting a release at the femoral origin of the medial collateral ligament. In stages, a tibial release should be carried out strictly subperiostally. A high expenditure of energy during tension examination needs to be utterly avoided. Reconstruction of the femoral origin/insertion can be carried out rather safely, while reconstruction of the tibial origin/insertion is more complicated due to the more complex anatomic line-up/constellation. Likewise, the reconstruction of the median ligament portion is considerably more difficult; in this case, the application of a primary suture or augmentation by use of the semitendinosus or quadriceps tendon are recommended. In addition, the temporary application of an orthesis is recommended regardless. In any case, a higher degree of coupling should be considered as a fallback. Introduced is an algorithm which differentiates the ligament damage location.

[Re-evaluation of the AOK hospital navigator with a focus on total knee replacement]. / Re-Evaluation des Krankenhausnavigators der AOK für das "QSR-Verfahren" unter besonderer Berücksichtigung des Themenschwerpunkts Knieendoprothetik.

BACKGROUND: One of the biggest health insurance companies in Germany (AOK, Allgemeine Ortskrankenkasse) has published new results focussing on process quality of total knee replacement in 2010. These results were published in the online portal "Weiße Liste", which is based on health insurance routine data. The German Association of Orthopeadic Surgery questions the credibility of the rating system of the "Weiße Liste". To prove the system an interdisciplinary task force was created. MATERIAL AND METHODS: The task force identified patient-specific parameters, which influence the outcome of total knee replacement based on the literature and expert opinions. Out of 907 orthopaedic departments, 4 above average and four below average were identified. The AOK was asked to provide 80 data sets for each department. These anonymised data sets could be converted into patient-specific data sets in the identified departments. Statistical analysis was performed to answer the question of whether there are differences between the below and the above average groups. RESULTS: 625 cases could be investigated. We found an increased rate of postoperative complications in the below average group. There are differences between both groups in terms of factors influencing the procedure. In the below average group an increased rate of patients with one or more comorbidities and a preoperative extension lag of over 10° was found. The above average group has a higher rate of operations before the knee replacement. CONCLUSION: The results need to be proven on a larger scale. Further, prospective investigations are planned.

[A systemic review of the value of physical therapy in whiplash neck injury]. / Wert der Physiotherapie bei der Halswirbelsäulendistorsion: ein systematischer Uberblick.

AIM: A systematic review is performed to evaluate the clinical effects of initial immobilisation by a neck collar and physiotherapy in whiplash neck injury. METHOD: A computer aided Medline research (1985 - 2002) of randomised clinical trials concerning both rehabilitation concepts was conducted. A rating system was used to assess the methodological score of each study. Their results were analysed and a final statement for evidence according to three main parameters (neck pain, range of motion, and patients comfort) was postulated. RESULTS: Eight randomised clinical trials were identified. Six studies were determined as high-quality trials. For the neck, back immobilisation do not appear to improve the patients' conditions sufficiently. In comparison, for physiotherapy there is strong benefit for pain, range of motion and patients' comfort in comparison to no treatment and a soft collar. CONCLUSION: Principally, am early active rehabilitation with physiotherapy without initial immobilisation is highly recommended in whiplash neck injury.

[Using extracorporeal shockwave therapy in orthopedics--a meta-analysis]. / Der Einsatz der extrakorporalen Stosswellentherapie in der Orthopädie--eine Metaanalyse.

AIM: Up to now ESWT is not a standard therapeutic technique in orthopaedics. The mechanisms of the induced analgesic effect or the mechanism of shock-waves in bony defects are still unknown. By metaanalysis successrates and indications for ESWT are worked out as well as adequate impulse- and energyrates according to actual state of knowledge. Aim of this study is to rate the published cases. METHOD: 105 papers referring to ESWT of the locomotor system are rated. Validation was performed for each paper according to the international accepted system of the American Association of Spine Surgery in Type A-E. Advise for therapy is taken only from high quality publications of Type A and B. This advise should regard scientific as well as economic aspects. RESULTS: 4825 cases from 55 publications and abstracts that underwent ESWT were evaluated. 24 papers with 1585 cases (33%) live up to the standards of a scientific investigation. Numerous studies exist about therapy of calcifying tendinitis, epicondylitis humeri radialis, painful heel, pseudarthrosis and other enthesiopathies. Especially the studies concerning pseudarthosis and other enthesiopathies do hardly live up to scientific standards. In calcifying tendinitis and painful heel ESWT achieves nearly the same results than the established methods. No serious complications were observed. Because of the high complication rate in operative treatment of heel spur ESWT seems to be justifiable. The techniques of ESWT, energy density levels, impulse rates and complications will be described. CONCLUSION: The advantages of ESWT are non-invasiveness and low rate of complications. Primary aim should be to evaluate adequate energy density levels and impulse rates for specific groups of indications using high quality studies according to evidence-based-medicine. Long term results need to be awaited to be able to compare ESWT with established methods. Recent inflationary use of ESWT especially in outpatient departments has no scientific indication in numerous cases as conservative methods are not used consequently.

Effect of upper tibial osteotomy on fibula movement and ankle joint motion.

Several techniques of upper tibial osteotomy in the treatment of unicompartmental osteoarthritis of the knee have been described. Osteotomy of the fibula is normally also carried out, or alternatively, dissection of the capsule of the proximal tibiofibular joint. There is concern, however, that this latter procedure may have an adverse effect on the mobility of the ankle joint and on fibula rotation. To investigate these suspected interactions we performed experimental studies in 14 cadaver legs. The vertical, lateral and rotational movements of the fibula were measured with the ankle in neutral (0 degrees) and maximal ankle dorsiflexion before and after performing an interligamental upper tibial osteotomy of a standardised valgus wedge. Maximal ankle dorsiflexion before the osteotomy produced external rotation of the fibula in most specimens, whereas after osteotomy this movement caused mainly internal rotation. In the neutral position of the ankle, upper tibial osteotomy lead to external rotation of the fibula. The upward movement of the fibula head after osteotomy was 0.64 cm on average. There was no measurable vertical motion of the fibula during ankle dorsiflexion either before nor after upper tibial osteotomy. Ankle dorsiflexion improved minimally after osteotomy. In conclusion, this study shows that upper tibial osteotomy with dissection of the capsule of the proximal tibiofibular joint has no adverse effect on movement of the fibula or of the ankle joint. In addition, unlike fibular osteotomy, this technique also has the advantage that the risk of common peroneal nerve injury is minimal.

Posterior dislocation of the shoulder: recommendations for a classification.

Posterior dislocation of the should is rare, constituting only 2.1% of all shoulder dislocations. The mechanisms of injury may be due to direct or indirect forces, and constitutional predisposing factors also play a role. Anatomically, 97.5% of dislocations are subacromial. Three hundred articles published in the international literature concerning posterior shoulder dislocation and subluxation were reviewed and a classification determined by the underlying aetiology was developed. On this basis dislocations and subluxations may be traumatic or atraumatic, primary and recurrent; recurrent cases of voluntary dislocation are considered separately. In addition, a follow-up assessment score weighted towards stability of the shoulder after treatment is detailed.

Complications of Chiari and Salter osteotomies: a cadaver study.

Previous investigations of the Chiari and Salter osteotomies showed that intraoperative vessel and nerve injuries are described repeatedly in the case of both pelvic osteotomies. The aim of our investigations was the exposure of each operation step in anatomic specimens to show the anatomic landmarks and potential risks. We performed nine Chiari osteotomies and five Salter osteotomies on formalin-fixed cadavers. The operation steps were made consecutively to assess the risks to the vessels and nerves as well as the determination of anatomically important reference points. In both procedures an injury of the lateral femoral cutaneous nerve at the anterior access route is feasible. By ensuring that the skin including the lateral femoral cutaneous nerve is pulled medially, injury can be avoided. Additionally, too long retraction of the tensor fasciae latae muscle injures its nutrient vessels. An inadequate subperiosteal approach during the pull on the Hohmann's retractor leads to crushing and irritation of the sciatic nerve. Moreover, there is a risk that the superior gluteal nerve as well as the superior gluteal artery may be injured. An inadequate subperiosteal application of the medial Hohmann's retractor can endanger the obturator nerve. In the Chiari osteotomy there is a risk of injury to the articular branch of the superior gluteal nerve, which supplies parts of the ventral hip joint capsule. By inserting the K-wire too far medially the internal oblique muscle is endangered. Too prolonged retraction of the iliopsoas muscle in a Salter osteotomy can lead to compression of the femoral nerve. The form of the osteotomy has an influence on the stability of the hip joint in the course of exposure of the hip joint. On account of the narrow spatial connection between the anatomic pathways and the osteotomy area, strict subperiosteal dissection and careful use of the retractor are essential to avoid nerve and vessel injuries.