Long-term outcome of anterior cruciate ligament tear without reconstruction: a longitudinal prospective study.

PURPOSE: To analyse subjective and objective long-term outcomes of patients with anterior cruciate ligament (ACL)-deficient knees and limited demands regarding sportive activities. This subgroup of patients might be well-treated without ligament reconstruction. METHODS: We included 303 patients with unilateral tears of the ACL and conservative treatment into a prospective study. Mean age at injury was 33.8 (min. 18, max. 66) years. Follow-up was 27.1 (min. 21.3, max. 31.5) years. Follow-up examinations were conducted 12 and 27 years after injury. At the last follow-up we analysed 50 patients completely. To evaluate clinical and radiological outcomes we used the Lysholm score, Tegner activity scale, visual analogue scale for pain (VAS-pain), KOOS and Sherman score. RESULTS: Subjective outcome (Lysholm score and VAS-pain scale) improved between the 12th and 27th year after anterior cruciate ligament tear. At the same time activity level (Tegner activity scale) decreased. Also, arthritis (Sherman score) worsened over time. Twenty-seven years after injury, 90 % of the patients rated their ACL-deficient knee as normal or almost normal; 10 % of the patients rated it as abnormal. The findings of this study show that there is a subgroup of patients with ACL tears who are well treated with physiotherapy alone, not reconstructing the ligament. Also, other authors found this correlation between activity level reduction and better subjective outcome. CONCLUSIONS: Conservative treatment of an ACL tear is a good treatment option for patients with limited demands regarding activity. Patient age, sportive activities and foremost subjective instability symptoms in daily life should be considered when deciding for or against ACL reconstruction.

Calcinosis Universalis of the Elbow: A Rare Case with Classical Presentation.

Juvenile Dermatomyositis (JDM) is a rare autoimmune disease in children and adolescents. In these patients calcinosis might be the most characteristic symptom. However there are only few reported cases of intramuscular calcinosis in Dermatomyositis. We report a case of calcinosis universalis (CU) of the elbow in JDM successfully treated with broaching. The patient, a 24-year-old woman, suffered from a long history of JDM. On examination she presented with a fistula lateral to the olecranon and pain of the right elbow joint. Plain X-rays displayed a diffuse pattern of multiple periarticular, subcutaneous, and intramuscular calcifications. The patient underwent surgery for histological and microbiological sampling as well as broaching. Intraoperatively sinus formation and subfascial hard calcium deposition were found. Due to the risk of collateral tissue damage, incomplete broaching was performed. A local infection with Staphylococcus was diagnosed and treated with antibiotics. On six-week and 30-month follow-up the patient was free of pain and had very good function. Calcifications on standard radiographs had almost resolved entirely. This case report gives a summary on calcinosis in Dermatomyositis and adds a new case of recalcitrant CU to the literature. Broaching surgery proved to be a reliable treatment option in symptomatic calcinosis.

Correlation between depressive symptoms and perioperative pain: a prospective cohort study of patients undergoing orthopedic surgeries.

OBJECTIVES: In previous research a close link between depression and postoperative pain has been described. However, the direction of impact remains unclear. The present longitudinal study aimed to clarify the prognostic value of depressive symptoms for perioperative pain and to explore the causal nature of the association between depressive symptoms and perioperative pain. METHODS: In this prospective cohort study, 200 patients scheduled for orthopedic surgery were enrolled. They were evaluated preoperatively (T1) and on the second postoperative day (T2) and on the day of discharge (T3). Perioperative pain was monitored using a visual analogue scale-based pain assessment protocol, and depressive symptoms were measured with the self-reported Patient Health Questionnaire. Cross-lagged multiple regression analyses were performed without and with adjusting for possible confounders (sex, American Society of Anesthesiologists physical status, type of surgery, type of anesthesia). RESULTS: We found significant and substantial links between depressive symptoms and perioperative pain, within a time point and across time intervals, showing consistency with a model of reciprocal impact of depressive symptoms and perioperative pain. No causal priority of one factor over the other was evident. However, after adjusting for possible confounders, only depressive symptoms in the early postoperative period (T2) remained predictive for pain at discharge (T3) and preoperative pain (T1) predicted postoperative depressive symptoms at both T2 and T3. CONCLUSIONS: Our results suggest that early postoperative depressive symptoms predicts pain at discharge and preoperative pain predicts postoperative depressive symptoms. In conclusion, perioperative pain therapy should include the treatment of both, pain and depressive symptoms, to achieve sufficient pain relief. The evidence regarding the causal relationships between depressive symptoms and perioperative pain, however, must be tested in future research.

Reduced postoperative pain in total hip arthroplasty after minimal-invasive anterior approach.

PURPOSE: The development of minimal-incision techniques for total hip replacement with preservation of soft tissue is generally associated with faster rehabilitation, reduction of postoperative pain and increased patient comfort. The aim of this study was to compare a minimal-incision anterior approach with a transgluteal lateral technique for hip replacement surgery with respect to postoperative pain, consumption of rescue medication, length of hospital stay and time to reach a defined range of motion. METHODS: In this retrospective cohort study we investigated 100 patients with a minimal-incision anterior approach (group I) and 100 patients with a transgluteal lateral approach (group II) retrospectively undergoing unilateral hip replacement. The study variables were pain at rest and during physiotherapy, amount of rescue medication, the time to reach a defined flexion and time in hospital. RESULTS: The patients of group I consumed less rescue medication (19.6 ± 6.9 mg vs. 23.6 ± 11.3 mg; p = 0.005) and experienced less pain on the day of surgery (1.3 ± 1 vs. 2.3 ± 1.3, p = 0.0001) and the first postoperative day (0.41 ± 0.8 vs. 0.66 ± 1.1, p = 0.036). The time to reach the defined range of motion (6.4 ± 2 days vs. 7.4 ± 2.1 days; p = 0.001) and the length of hospital stay were shorter (10.2 ± 1.9 days vs. 13.4 ± 1.6 days; p = 0.0001) for group I. However, pain during physiotherapy was higher on the third and sixth through ninth days after surgery in comparison to group II (p = 0.001-0.013). CONCLUSION: The implantation of a hip prosthesis through a minimal-incision anterior approach is successful in reducing postoperative pain and consumption of pain medication. Time to recovery and length of hospital stay are also influenced positively. Pain increases during physiotherapy, and may be mitigated by adopting limited weight bearing during the early postoperative period.

Interscalene brachial plexus block for open-shoulder surgery: a randomized, double-blind, placebo-controlled trial between single-shot anesthesia and patient-controlled catheter system.

INTRODUCTION: Interscalene brachial plexus block (ISB) is widely used as an adjuvant regional pain therapy in patients undergoing major shoulder surgery and has proved its effectiveness on postoperative pain reduction and opioid-sparing effect. METHOD: This single-center, prospective, double-blind, randomized and placebo-controlled study was to compare the effectiveness of a single-shot and a patient-controlled catheter insertion ISB system after major open-shoulder surgeries. Seventy patients were entered to receive an ISB and a patient-controlled interscalene catheter. The catheter was inserted under ultrasound guidance. Patients were then assigned to receive one of two different postoperative infusions, either 0.2% ropivacaine (catheter group) or normal saline solution (single-shot group) via a disposable patient-controlled infusion pump. RESULTS: The study variables were amount of rescue medication, pain at rest and during physiotherapy, patient satisfaction and incidence of unwanted side effects. The ropivacaine group revealed significantly less consumption of rescue medication within the first 24 h after surgery. Incidence of side effects did not differ between the two groups. CONCLUSION: Based on our results, we recommend the use of interscalene plexus block in combination with a patient-controlled catheter system under ultrasound guidance only for the first 24 h after major open-shoulder surgery.

Snapping elbow caused by hypertrophic synovial plica in the radiohumeral joint: a report of three cases and review of literature.

The snapping elbow caused by hypertrophic synovial radiohumeral plica is a rare form of lateral elbow impingement. In this article we report on hypertrophic radiohumeral synovial folds in three male patients, aged 54, 65 and 27 years. All three patients suffered isolated lateral elbow pain, painful snapping and unsuccessful conservative treatment over at least 5 months (range 5-9 months, mean 7.7 months) prior to surgical treatment. None of the patients had lateral epicondylitis, instability, osteochondrosis dissecans, loose bodies, arthritis or neurological disorders. Upon clinical examination the range of motion in the respective painful elbows was found to be normal in all three cases, but a painful snapping occurred between 80 degrees and 100 degrees of flexion with the forearm in pronation. While there were no pathologic findings in standard radiographs, magnetic resonance imaging (MRI) revealed hypertrophic synovial plicae in the radiohumeral joints associated with effusion in each of the diseased elbows. Arthroscopic examinations confirmed the presence of a hypertrophic synovial plica in all three radiocapitellar joints, and revealed a transient interposition and compression of the folds in the articulation from extension until 90 degrees -100 degrees elbow flexion, with replacement beyond 90 degrees elbow flexion with a visible jump. Surgical management in all three cases comprised arthroscopic diagnosis confirmation and removal of the synovial plicae, leading to excellent outcomes at 6-12 months follow-up.

FGF23 is a putative marker for bone healing and regeneration.

Besides numerous other factors, fibroblast growth factor receptor (FGFR) signaling is involved in fracture healing and bone remodeling. FGF23 is a phosphatonin produced by osteoblastic cells, which signals via FGFR1, thereby exerting effects in bone and kidney. We analyzed if serum FGF23 levels might be an indicator to predict fracture healing and union. FGF23 (C-Term) was elevated on day 3 postoperatively in 55 patients sustaining an exchange of total hip implants due to aseptic loosening. A prospective study of 40 patients undergoing primary hip arthroplasty also showed elevated FGF23 (C-Term) but no change in FGF23 (intact) levels on days 1, 4, and 10 postoperatively. Serum phosphate and phosphate clearance stayed within normal ranges. FGF23 mRNA expression in ovine callus was compared between a standard and delayed course of osteotomy healing. In the standard model, a marked increase in FGF23 mRNA expression compared to the delayed healing situation was observed. Immunohistochemical analysis showed FGF23 production of osteoblasts and granulation tissue in the fracture callus during bone healing. In conclusion, FGF23 is involved in bone healing, can be measured by a sensitive assay in peripheral blood, and is a promising candidate as an indicator for healing processes prone to reunion versus nonunion.

Surgical management of a double-layered patella: a case report.

The double-layered patella (DLP) is a rare intra-articular disorder that in most cases is associated with multiple epiphyseal dysplasia (MED). The DLP usually consists of an anterior and a posterior layer with a cartilaginous interface between the two parts. In this article, we present a case of bilateral DLP of a 17-year-old female adolescent with MED, suffering clinical symptoms on her left knee. Upon clinical examination, a painful "snapping" of the patella at 30-40 degrees flexion of the left knee was evident and two osseous layers could be identified in standard radiographs. Arthroscopic examination revealed a transient cranial displacement of the posterior osteochondral layer at 30-40 degrees knee flexion that replaced beyond 40 degrees knee flexion with a visible jump. Surgical management in this case of DLP comprised open debridement of the soft tissue interface and fusion of the two osseous layers using double-threaded screws leading to an excellent outcome at 12 months follow-up.

Upregulation of LITAF mRNA expression upon exposure to TiAlV and polyethylene wear particles in THP-1 macrophages.

Tumor necrosis factor alpha (TNFalpha) plays a fundamental role in the pathogenesis of wear particle-induced periprosthetic osteolysis. However, particle-induced mechanisms that control TNFalpha gene expression are not yet well characterized. LITAF [lipopolysaccharide (LPS)-induced TNFalpha factor] is a novel transcription factor that regulates expression of the TNFalpha gene, but nothing is known about its role in wear particle-induced osteolysis. We evaluated the effect of titanium aluminum vanadium (TiAlV) and polyethylene particles on mRNA expression of LITAF. A human monocytic leukemia cell line (THP-1) was used in this in vitro study. THP-1 monocytes were differentiated to macrophage-like cells and exposed to LPS-detoxified polyethylene particles and prosthesis-derived TiAlV particles. Supernatant was used for TNFalpha protein measurement and total RNA was extracted from cells. LITAF was analyzed at the mRNA level using semiquantitative RT-PCR. Both polyethylene and TiAlV particles induced significant upregulation of LITAF mRNA that was followed by a significant TNFalpha response. These effects were dependent on the particle dose. Low particle concentrations exhibited no significant effect on expression of TNFalpha and LITAF mRNA. In comparison to exposure to polyethylene and TiAlV particles, LPS stimulation exhibited similar upregulation of LITAF mRNA, but led to an overwhelming TNFalpha response. Our findings provide evidence that LITAF is implicated in the pathogenesis of wear particle-induced osteolysis.

Synergistic effects of mixed TiAlV and polyethylene wear particles on TNFalpha response in THP-1 macrophages.

TNFalpha is a potent osteoclastogenic cytokine that has a fundamental role in the pathogenesis of wear particle-induced osteolysis. Wear particles of one composition and their biological effects are well characterised. In contrast, little is known about the effects of mixed particles with respect to mix ratio and particle concentration. We evaluated the effects of different mix ratios of polyethylene and TiAlV particles on TNFalpha response. We used a human monocytic cell line (THP-1) in this in vitro study. THP-1 monocytes were differentiated to macrophage-like cells and exposed to different mixtures of lipopolysaccharide-detoxified polyethylene and TiAlV particles. TNFalpha was analysed in culture supernatants using ELISAs. Both polyethylene and TiAlV particles induced a dose- and time-related release of TNFalpha, with maximum levels after 6 h. A PE/TiAlV mix ratio of 36:1 at 10(8) particles/ml induced significantly higher TNFalpha concentrations compared to equal particle concentrations of isolated TiAlV (p=0.047) or PE (p=0.044), indicating the synergistic effect of mixed particles. These results provide evidence that TiAlV and polyethylene particles have significant synergistic effects, depending on the mix ratio and particle concentrations. This supra-additive effect can contribute substantially to the pathogenesis of implant particle-induced osteolysis.