The German Arthroscopy Registry DART: what has happened after 5 years?

PURPOSE: The German Arthroscopy Registry (DART) has been initiated in 2017 with the aim to collect real-life data of patients undergoing knee, shoulder, hip or ankle surgery. The purpose of this study was to present an overview of the current status and the collected data thus far. METHODS: Data entered between 11/2017 and 01/2022 were analyzed. The number of cases (each case is defined as a single operation with or without concomitant procedures) entered for each joint, follow-up rates and trends between different age groups (18-29 years, 30-44 years, 45-64 years, ≥ 65 years) and across genders, and quality of life improvement (pre- vs. 1 year postoperative EQ visual analogue scale [EQ-VAS]) for frequently performed procedures (medial meniscus repair [MMR] vs. rotator cuff repair [RCR] vs. microfracturing of the talus [MFX-T]) were investigated. RESULTS: Overall, 6651 cases were entered into DART, forming three distinct modules classified by joint (5370 knee, 1053 shoulder and 228 ankle cases). The most commonly entered procedures were: knee: partial medial meniscectomy (n = 2089), chondroplasty (n = 1389), anterior cruicate ligament reconstruction with hamstring autograft (n = 880); shoulder: sub acromial decompression (n = 631), bursectomy (n = 385), RCR (n = 359); ankle: partial synovectomy (n = 117), tibial osteophyte resection (n = 72), loose body removal (n = 48). In the knee and shoulder modules, middle-aged patients were the predominant age group, whereas in the ankle module, the youngest age group was the most frequent one. The two oldest age groups had the highest 1-year follow-up rates across all modules. In the knee and shoulder module, 1-year follow-up rates were higher in female patients, whereas follow-up rates were higher in male patients in the ankle module. From pre- to 1-year postoperative, MFX-T (EQ-VAS: 50.0 [25-75% interquartile range: 31.8-71.5] to 75.0 [54.3-84.3]; ∆ + 25.0) led to a comparably larger improvement in quality of life than did MMR (EQ-VAS: 70.0 [50.0-80.0] to 85.0 [70.0-94.0]; ∆ + 15.0) or RCR (EQ-VAS: 67.0 [50.0-80.0] to 85.0 [70.0-95.0]; ∆ + 18.0). CONCLUSION: DART has been sufficiently established and collects high-quality patient-related data with satisfactory follow-up allowing for a comprehensive analysis of the collected data. The current focus lies on improving patient enrolment and follow-up rates as well as initiating the hip module.

The German Arthroscopy Registry (DART).

In Germany, more than 400,000 arthroscopic procedures are performed each year. The DART registry is designed to study the outcome of arthroscopic procedures of the shoulder, hip, knee and ankle joint under everyday clinical circumstances using patient-reported outcome measures (PROMs). DART aims at identifying patient-specific factors correlated with therapy-associated complications and treatment failure and will help study the influence of concurrent joint diseases and procedures. To achieve these tasks, a Web-based remote data entry system will be applied and adapted to the needs of DART. DART will consist of a physician's and a patient's form to enter data on the specific disease, surgical procedure, joint-specific outcome, disability and quality of life measured by validated scores up to 5 years following surgery. The pool of data will be subjected to further clinical investigations and subgroup analysis. Individual results will be made accessible to the surgeon and the patient. Moreover, public reports will be generated to provide healthcare authorities and insurance companies with information on the effectiveness of arthroscopic surgery. The aim of this article is to present the methodology of the registry. Level of evidence V.

Intravertebral pressure gradient during vertebroplasty.

OBJECTIVE: Intravertebral pressure (IP) is considered a possible factor influencing cement leakage in vertebroplasty (VP). Reports of measuring IP during the injection of the cement reveal rather low values in the periphery of the vertebral body but fail to determine the situation in the center. Hypothesizing there is a significant IP gradient between both areas intravertebral pressure measurements were conducted in a comparative biomechanical study. METHODS: VP was performed in ten lumbar cadaveric spines. A pressure sensor was either placed in the center or in the periphery of the vertebral body, while bone cement was delivered in 1.5-cc increments. Volume flow, cement mixing time, and room temperature were standardized and kept constant during cement injection. RESULTS: During the administration of the first 1.5 cc of bone cement, the central IP (C-IP) increased to 23.6 kPa and the peripheral IP (P-IP) to 0.9 kPa on average. With the second injection, the mean C-IP was 42.8 kPa while the mean P-IP was 3.8 kPa. During the 3rd filling, C-IP averaged 69.9 kPa and P-IP 12.8 kPa, respectively. At the last increment, C-IP was at 70.7 kPa and P-IP at 24.5 kPa on average. CONCLUSIONS: A centroperipheral IP gradient (∆IP) was monitored during cement delivery in VP. ∆IP decreases with increasing bone cement charge of the vertebra, but C-IP stays significantly higher than P-IP at all times. C-IP was consistently higher than IP values reported for VP so far.

[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.

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.

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.

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.

Injury rates of the German Women's American Football National Team from 2009 to 2011.

American football is one of the leading causes of athletic-related injuries. Injury rates in female elite players are mostly unknown. We hypothesized that the injury rates of female was comparable to those in men's football during practice, as well as games. From 2009 to 2011, injury data were collected from the German female national team during training camps, World Championship 2010 and International friendly matches. The injury was categorized by location on the body and recorded as fracture/dislocation, strain, concussion, contusion or other injury. Injury rates were determined based on the exposure of an athlete to a game or practice event. The injury rate was calculated as the ratio of injuries per 1000 athlete exposures (AE). The rate of injury was significantly higher during games (58.8/1000 AE) than practices [16.3/1000 AE, (P<0.01)]. Furthermore, the injury rate in the tryouts was significantly higher (24.05/1000 AE) compared to other training sessions with the national team (11.24/1000 AE). Our findings show that the injury rates in female elite American football players can be compared to those described for male players. Higher injury rates during matches than in training should also be underlined.

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.

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.