Good short- to medium-term results after osteochondral autograft transplantation (OAT) in middle-aged patients with focal, non-traumatic osteochondral lesions of the knee.

BACKGROUND: Osteochondral autograft transplantation (OAT) offers the opportunity to repair cartilaginous defects by restoring hyaline cartilage anatomy. Encouraging results have been reported in patients suffering from acute knee trauma or osteochondritis dissecans. Patients with focal chronic, non-traumatic osteochondral (FCNO) lesions of the knee, however, have rarely been the subject of investigation. Some authors even consider higher age as contraindications to OAT. OBJECTIVES: To assess the short- to medium-term outcomes of OAT in middle-aged patients with FCNO lesions of the knee and to identify predictors of clinical outcome. HYPOTHESIS: Filling FCNO defects with autologous osteochondral grafts should restore the congruency of the middle-aged knee joint and thereby reduce pain and loss of function on the one hand, and increase quality of life on the other hand. METHODS: One hundred and twelve patients (48.01±1.12yrs) with FCNO of the knee were assessed before OAT and 26.2±0.24 months after surgery. Clinical outcome was measured by WOMAC Index and the Visual Analogue Scale (VAS) for pain. RESULTS: Pain (pre-OAT VAS vs. post-OAT VAS: 7.14±0.19 vs. 3.74±0.26, P<0.001) was reduced and quality of life (pre-OAT WOMAC vs. post-OAT WOMAC: 134.88±5.84 vs. 65.92±5.34, P<0.001) improved. Retropatellar defects were associated with poor outcome, while overall surface and number of cylinders were not. DISCUSSION: Middle-aged patients with FCNO of the knee also profit from OAT at a short follow-up. LEVEL OF EVIDENCE: IV. Mono-centric, prospective clinical series.

A conceptual model of compensation/decompensation in lumbar segmental instability.

Lumbar spinal instability (LSI) is a common spinal disorder and can be associated with substantial disability. The concept of defining clinically relevant classifications of disease or 'target condition' is used in diagnostic research. Applying this concept to LSI we hypothesize that a set of clinical and radiological criteria can be developed to identify patients with this target condition who are at high risk of 'irreversible' decompensated LSI for whom surgery becomes the treatment of choice. In LSI, structural deterioration of the lumbar disc initiates a degenerative cascade of segmental instability. Over time, radiographic signs become visible: traction spurs, facet joint degeneration, misalignment, stenosis, olisthesis and de novo scoliosis. Ligaments, joint capsules, local and distant musculature are the functional elements of the lumbar motion segment. Influenced by non-functional factors, these functional elements allow a compensation of degeneration of the motion segment. Compensation may happen on each step of the degenerative cascade but cannot reverse it. However, compensation of LSI may lead to an alleviation or resolution of clinical symptoms. In return, the target condition of decompensation of LSI may cause the new occurrence of symptoms and pain. Functional compensation and decompensation are subject to numerous factors that can change which makes estimation of an individual's long-term prognosis difficult. Compensation and decompensation may influence radiographic signs of degeneration, e.g. the degree of misalignment and segmental angulation caused by LSI is influenced by the tonus of the local musculature. This conceptual model of compensation/decompensation may help solve the debate on functional and psychosocial factors that influence low back pain and to establish a new definition of non-specific low back pain. Individual differences of identical structural disorders could be explained by compensated or decompensated LSI leading to changes in clinical symptoms and pain. Future spine surgery will have to carefully define and measure functional aspects of LSI, e.g. to identify a point of no return where multidisciplinary interventions do not allow a re-compensation and surgery becomes the treatment of choice.

Osseofix® system for percutaneous stabilization of osteoporotic and tumorous vertebral compression fractures - clinical and radiological results after 12 months.

PURPOSE: Determining whether implantation of an expandable titanium mesh cage (Osseofix® system) is a successful and safe minimally invasive therapy for osteoporotic and tumorous vertebral compression fractures (VCFs). MATERIALS AND METHODS: 32 patients (25 women, 7 men, mean age 71) with 46 osteoporotic or tumorous VCFs (T6 to L4) from June 2010 to January 2012 were included. All of them were stabilized with the Osseofix® system. Preinterventionally we performed X-ray, MRI, and bone density measurements (DXA). The clinical and radiological results were evaluated preop, postop and 12 months postop based on the visual analog scale (VAS) and the Oswestry Disability Index (ODI), X-ray (Beck Index, Cobb angle) and CT. RESULTS: There was a significant improvement in pain intensity (VAS) (7.8 to 1.6) as well as a significant reduction in the mean ODI (71.36 % to 30.4 %) after 12 months. The mean kyphotic angle according to Cobb showed significant improvements (12.3° to 10.8°) after 12 months. Postinterventional imaging showed one case of loss of height in a stabilized lumbar vertebral body (2.2 %) in osteoporosis and one case with adjacent fracture (2.2 %) in osteoporosis. We saw no changes in the posterior vertebral wall. Except for one pronounced postoperative hematoma, we saw no surgical complications including no cement leakage. CONCLUSION: The clinical mid-term results are good at a low complication rate. The stabilization of symptomatic osteoporotic and tumorous VCFs with the Osseofix® system is a safe and effective procedure, even in fractures with posterior wall involvement. The Osseofix® system is an interesting alternative to the established procedures of cement augmentation. KEY POINTS: • The Osseofix® system is well suited for stabilizing osteoporotic and tumorous VCFs.• It is a safe and effective procedure without cement leakage and with a low complication rate.• The procedure is an interesting alternative to established cement augmentation procedures.

Ganglions of the wrist and associated triangular fibrocartilage lesions: a prospective study in arthroscopically-treated patients.

PURPOSE: Wrist ganglions are the most common soft tissue tumors of the hand and wrist and can occur at any age. Their etiology remains controversial. A high prevalence of associated intrinsic ligamentous lesions has been described. We hypothesized that painful wrist ganglions are an indicator of an underlying joint abnormality, particularly of lesions of the triangular fibrocartilage complex (TFCC). The aim of our study was to prospectively determine the prevalence of associated TFCC lesions in patients with painful wrist ganglions. METHODS: Forty-six patients (35 women, 11 men; mean age, 36 ± 11 y; range, 18-57 y) with painful wrist ganglions (20 radiopalmar and 26 dorsal) had surgery from January 2008 to June 2010. There were 18 primary and 28 recurrent ganglions. Clinical examinations, pain score evaluations, disabilities in daily life evaluations, plain radiographs, and magnetic resonance imaging were obtained before arthroscopic resection. Concomitant intrinsic lesions of the wrist were assessed with magnetic resonance imaging and re-evaluated by arthroscopy. RESULTS: All ganglions were successfully resected. Overall, arthroscopy identified 22 TFCC lesions (48%) and 2 intracarpal ligament lesions. The TFCC perforations were more commonly associated with radiopalmar ganglions with a positive ulnocarpal stress test result and with recurrent radiopalmar ganglions. At 1-year follow-up, all patients were meaningfully improved in terms of pain and disabilities in daily life. CONCLUSIONS: Arthroscopy allows for the simultaneous treatment of ganglions and other pathologies. Therefore, arthroscopy should be contemplated as the primary treatment option for patients with painful ganglions of the wrist if they are in a radiopalmar location with a positive ulnocarpal stress test and for patients with recurrent radiopalmar ganglions, which are also highly associated with TFCC abnormalities. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

[Osteoblastic differentiation of human adult mesenchymal stem cells after through gene transfer of BMP-2 in the absence of dexamethasone]. / Osteoblastäre Differenzierung von humanen adulten mesenchymalen Stammzellen durch transgenes BMP-2 in Abwesenheit von Dexamethason.

AIM: Mesenchymal stem cells (MSC) of various species appear to require different cues to differentiate towards the osteoblastic lineage. For MSC of human origin, recombinant hBMP-2 is reported to be not sufficient but dexamethasone seems to be essential. The aim of this study was to analyse changes in genotype and phenotype of hMSC after adenoviral transfer of the BMP-2 gene in the absence of dexamethasone. METHODS: We employed hMSC and analysed changes in expression of the Runx2, Osterix and type I collagen gene by quantitative PCR after adenoviral transfer of the human BMP-2 gene in the absence of dexamethasone. As a phenotypic marker alkaline phosphatase activity was assessed. ANOVA and post hoc statistical analyses were used to determine differences among data (p < 0.05). RESULTS: Transfer of the hBMP-2 gene and consecutive production of transgenic BMP-2 up-regulated bone marker gene expression and increased alkaline phosphatase activity and thus promoted an enhanced lineage progression to the osteoblast phenotype without the addition of dexamethasone. CONCLUSION: These findings are noteworthy in the light of a possible superiority of endogenous transgenic proteins compared to exogenous recombinant proteins.

Proximal focal femoral deficiency -- a rare entity in the sonographic differential diagnosis of developmental dysplasia of the hip,.

In the present study, we will describe the differential diagnosis of the rare hip anomaly of proximal focal femoral deficiency (PFFD), based on an analysis of 12,488 ultrasound images of the hips of 6244 neonates, examined in our orthopaedic clinics between 1988 and 1998. The clinical manifestations and ultrasound features of PFFD will be characterised and compared with those of the normal, the mildly dysplastic, and the severely dysplastic hip. Two cases of PFFD (0.032 %) were detected during the investigation period. Both neonates had been referred to the orthopaedic clinic for further evaluation after the initial ultrasound findings suggested an anomaly in the coxal-femoral region. Correct identification of anatomical structures in the acetabular region (acetabular labrum and lower edge of the ilium) was not possible, but the iliac line, femoral head, and greater trochanter could be reliably visualised. Because of these findings, a deformity in the coxal-femoral region was suspected, and further diagnosis was recommended. PFFD was subsequently diagnosed, and specific treatment was initiated. PFFD should be suspected in any neonate with suspicious clinical findings and failure of ultrasound to clearly visualise anatomical landmarks in the region of the acetabulum (acetabular labrum, lower edge of the ilium, cartilage-bone interface) despite the use of a sufficient imaging technique. Radiographs should then be obtained to confirm or refute the tentative diagnosis. Infants with PFFD can then receive proper treatment without unnecessary therapeutic trial and error.

[The effect of growth/differentiation factor-5 (GDF-5) on genotype and phenotype in human adult mesenchymal stem cells]. / Effekt von Growth/Differentiation Factor-5 (GDF-5) auf Genotyp und Phänotyp humaner adulter mesenchymaler Stammzellen.

AIM: To evaluate the effects of GDF-5 on genotype and phenotype of human mesenchymal stem cells (hMSC). HYPOTHESIS: GDF-5 leads to up-regulation of the Type I-collagen (Col) gene without altering bone marker genes or alkaline phosphatase activity. METHODS: To test our hypothesis hMSC were treated with rmGDF-5. Using quantitative real-time PCR we analyzed mRNA for Col, Runx2 and Osterix (Osx). Furthermore, we analyzed alkaline phosphatase activity (ALP) as a phenotypical bone marker. ANOVA and post hoc statistical analyses were used to determine differences among treatments (p < 0.05). RESULTS: HMSC showed a biphasic response in both Col and Runx2 after rmGDF-5. Initial up-regulation was followed by a significant down-regulation below controls. Interestingly, the controls presented with changes for Col and Runx2 over time. There was no Osx expression in either treated hMSC or controls. No significant differences could be detected in ALP. CONCLUSION: Increased expression of Col and Runx2 might indicate differentiation towards both osteoblast and fibroblast lineage. However, no Osx expression and no change in ALP support the assumption that rmGDF-5 does not lead to an osteoblast phenotype in hMSC. Our in vitro studies confirm a possible therapeutic benefit of GDF-5 in the treatment of tendon and ligament injuries and tissue engineering approaches. Further research is necessary to prove its clinical value.

[Transabdominal ultrasonography in the diagnosis of lumbar disc herniation]. / Die transabdominale Sonographie in der Diagnostik des lumbalen Bandscheibenprolaps.

AIM: The aim of our study was to assess the value of transabdominal ultrasonography in the diagnosis of a lumbar herniated disc and to investigate the influence of the quality of the ultrasonography investigation on detection of pathological changes in lumbar intervertebral disc. METHOD: 119 patients (55 female, 64 male, mean age 41 years) were included in our study. Patients were suffering from lower back pain and were investigated by transabdominal ultrasonography, using a 3.5 MHz scanner. The results of the ultrasonography investigation were compared with MRI and intraoperative findings RESULTS: The quality of the ultrasonography documentation shows distinct differences between the segments of the lower lumbar spine (L3/4 86.6 %, L4/5 85.7 %, L5/S1 70.6 %). The sonographic evaluations were correct in 75.4 % of cases. Sensitivity of ultrasonography for the detection of an intradiscal lesion was 0.46 for L3/4, 0.83 for L4/5 and 0.78 for L5/S1. Specificity was 0.91 for L3/4, 0.65 for L4/5 and 0.67 for L5/S1. CONCLUSION: Compared to MRI investigation transabdominal ultrasonography of the lumbar herniated disc proved to be distinctly inferior because of methodical limitations and lower diagnostic accuracy. This method, however, can be used as a preliminary diagnostic procedure.

[Experimental validation of DXA and MRI-based bone density measurement by ash-method]. / Experimentelle Validierung einer DXA- und MRT-basierten Knochendichtemessung durch Veraschung.

Different methods have been established for bone density measurements such as dual energy X-ray absorptiometry (DXA), quantitative computertomography (QCT), and scintigraphy (VQ-Scan). There are hints that magnetic resonance imaging (MRI) might become a new option for the evaluation of bone density. The aim of this study was to investigate correlations between MRI vs. DXA and MRI vs. mineral content of lumbar vertebrae. Data were obtained from ten lumbar vertebral bodies of cattles. The T-1 MRI-sequences SE, PS, and the T-2 Sequence STIR were used for analysis. Total pixel numbers and a pixel per area ratio were determined. Values were compared to DXA-measurements, to the wet weight, and to separated measurements of the spongious, trabecular, and total mineral content of the vertebral body after ashing. We found correlations between DXA (g/vertebral body) vs. mineral content by ash-method (0.918; p < 0.01), DXA vs. MRI (SE-sequence) (-0.872; p < 0.01), and MRI (SE-sequence) vs. mineral content (0.775; p < 0.01). No correlations were found between PS- or STIR-sequences and the ash-method. This study shows that the determination of the bone mineral content of vertebrae is possible applying MRI in the T1-weighted SE-sequence. Without radiation, the MRI provides additionally early detection of trabecular lesions, fractures, and deformities at the spine, without other diagnostic procedures becoming necessary.

[Osteochondral shear fractures in children. A case report and critical review of the literature]. / Osteochondrale Abscherfrakturen bei Kindern. Eine Falldarstellung unter kritischer Wertung der Literatur.

Only few articles on osteochondral flake fractures in children have been published. Diagnostic tools have been improved over the past decades, but still, diagnosis of severe osteochondral defects may be delayed. The presented case report describes the different techniques currently being available for the diagnosis of osteochondral flake fractures. The different therapeutic options for the treatment of osteochondral flake fractures in children are discussed based on the current literature. This article demonstrates the necessity to consider severe injuries, even if impressive clinical symptoms are lacking.