Radiological outcome after treatment of juvenile flatfeet with subtalar arthroereisis: a matched pair analysis of 38 cases comparing neurogenic and non-neurogenic patients.

PURPOSE: Therapy of juvenile neurogenic flatfoot (JNF) with subtalar arthroereisis (SA) is currently under critical clinical investigation. In this retrospective matched pair analysis, the radiological outcome after arthroereisis in paediatric patients with infantile cerebral palsy and JNF was compared with children with juvenile flatfeet (JF) without neurological diseases. METHODS: From October 2007 to April 2018 80 patients with 149 flatfeet underwent surgery with SA. Inclusion criteria were: 1) JNF or JF with age at surgery ≤ 13 years; 2) treatment with SA; 3) presence of three sets of biplane radiographs (preoperative, postoperative and follow-up (FU)). The radiographs were analyzed for: 1) navicular-cuboidal-index (NCI); 2) talocalcaneal angle anteroposterior; 3) talocalcaneal angle lateral; 4) calcaneal-pitch (CP); and 5) talometatarsal-index (TMTI). Following this, 25 patients with 38 flatfeet could be included. RESULTS: The mean age at SA of the JNF group was 9.2 years (JF group: 9.3 years) and the mean time of FU was 35.2 months (JF group: 39.4 months). In comparison with preoperatively, a significant decrease of the NCI was seen in both groups (p = ≤ 0.05 and p = ≤ 0.001) in the FU radiographs. The analysis of CP and TMTI in the JF group also resulted in a significant improvement (p = ≤ 0.001 and p = ≤ 0.05). Overall, the comparison between the JNF and JF group showed no significant differences in regard to the analyzed postoperative parameters. CONCLUSION: Based on this data, treatment of flatfeet by SA in patient with neurological disorders shows an improvement of radiological parameters comparable with neurologically unimpaired patients and might be considered as additional treatment option. LEVEL OF EVIDENCE: IV.

Poorer radiological outcome after delayed diagnosis and treatment in human position in Fettweis plaster cast in 93 unstable hip joints type D, III and IV according to Graf.

PURPOSE: In this study the course of unstable hips after successful treatment with Fettweis plaster of Paris (POP) is examined. Special focus will be given to age at beginning of treatment and initial hip type. METHODS: The development of 93 unstable hips treated between November 2001 and April 2015 was examined. Inclusion criteria were: 1) unstable hips with successful treatment with Fettweis POP; 2) presence of two pelvic radiographs (12 to 24 months and 24 to 48 months). We analyzed: 1) the initial ultrasound hip type according to Graf; 2) the average age at first and second radiograph; 3) the Tönnis classification: normal findings (< 1 SD), slightly (1 SD to 2 SD) and severely dysplastic hips (> 2 SD). RESULTS: In all, there were 14 hips type D, 41 hips type III and 38 hips type IV. Mean age of the first radiograph was 13.9 months and of the second 28.5 months. The first radiograph showed: (< 1 SD): 36, (1 SD to 2 SD): 34, (> 2 SD): 23 hips, the second radiograph: (< 1 SD): 33, (1 SD to 2 SD): 19, (> 2 SD): 30 hips. With subdivision at the start of treatment at age eight or fewer weeks 2/16 hips (12.5%) and with initiation of the treatment more than eight weeks 22/77 (26.0%) deteriorated. During the course between first and second radiograph a total of 35.7% of initial hip type D, 19.5% of type III and 23.7% of type IV deteriorated. CONCLUSION: Radiograph controls after treatment with Fettweis POP show poorer outcome after delaying the start of treatment more than 8 weeks. These findings were independent of the initial ultrasound hip type. Regular radiograph controls of all hip types treated for unstable hips are justified to detect residual dysplasia. LEVEL OF EVIDENCE: IV.

Enoxaparin and rivaroxaban have different effects on human mesenchymal stromal cells in the early stages of bone healing.

OBJECTIVES: Venous thromboembolism (VTE) is a major potential complication following orthopaedic surgery. Subcutaneously administered enoxaparin has been used as the benchmark to reduce the incidence of VTE. However, concerns have been raised regarding the long-term administration of enoxaparin and its possible negative effects on bone healing and bone density with an increase of the risk of osteoporotic fractures. New oral anticoagulants such as rivaroxaban have recently been introduced, however, there is a lack of information regarding how these drugs affect bone metabolism and post-operative bone healing. METHODS: We measured the migration and proliferation capacity of mesenchymal stem cells (MSCs) under enoxaparin or rivaroxaban treatment for three consecutive weeks, and evaluated effects on MSC mRNA expression of markers for stress and osteogenic differentiation. RESULTS: We demonstrate that enoxaparin, but not rivaroxaban, increases the migration potential of MSCs and increases their cell count in line with elevated mRNA expression of C-X-C chemokine receptor type 4 (CXCR4), tumor necrosis factor alpha (TNFα), and alpha-B-crystallin (CryaB). However, a decrease in early osteogenic markers (insulin-like growth factors 1 and 2 (IGF1, IGF2), bone morphogenetic protein2 (BMP2)) indicated inhibitory effects on MSC differentiation into osteoblasts caused by enoxaparin, but not by rivaroxaban. CONCLUSIONS: Our findings may explain the adverse effects of enoxaparin treatment on bone healing. Rivaroxaban has no significant impact on MSC metabolism or capacity for osteogenic differentiation in vitro.Cite this article: Dr H. Pilge. Enoxaparin and rivaroxaban have different effects on human mesenchymal stromal cells in the early stages of bone healing. Bone Joint Res 2016;5:95-100. DOI: 10.1302/2046-3758.53.2000595.

Function of the extensor mechanism of the knee after using the 'patellar-loop technique' to reconstruct the patellar tendon when replacing the proximal tibia for tumour.

The aim of this study was to analyse the gait pattern, muscle force and functional outcome of patients who had undergone replacement of the proximal tibia for tumour and alloplastic reconstruction of the extensor mechanism using the patellar-loop technique. Between February 1998 and December 2009, we carried out wide local excision of a primary sarcoma of the proximal tibia, proximal tibial replacement and reconstruction of the extensor mechanism using the patellar-loop technique in 18 patients. Of these, nine were available for evaluation after a mean of 11.6 years (0.5 to 21.6). The strength of the knee extensors was measured using an Isobex machine and gait analysis was undertaken in our gait assessment laboratory. Functional outcome was assessed using the American Knee Society (AKS) and Musculoskeletal Tumor Society (MSTS) scores. The gait pattern of the patients differed in ground contact time, flexion heel strike, maximal flexion loading response and total sagittal plane excursion. The mean maximum active flexion was 91° (30° to 110°). The overall mean extensor lag was 1° (0° to 5°). The mean extensor muscle strength was 25.8% (8.3% to 90.3%) of that in the non-operated leg (p < 0.001). The mean functional scores were 68.7% (43.4% to 83.3%) (MSTS) and 71.1 (30 to 90) (AKS functional score). In summary, the results show that reconstruction of the extensor mechanism using this technique gives good biomechanical and functional results. The patients' gait pattern is close to normal, except for a somewhat stiff knee gait pattern. The strength of the extensor mechanism is reduced, but sufficient for walking.

[Determination of activity levels in patients with cerebral palsy]. / Ermittlung des Aktivitätslevels bei Patienten mit infantiler Zerebralparese.

AIM: The aim of this study is the determination of physical activity in everyday life of handicapped persons due to cerebral palsy using standardised testing procedures. METHOD: The subjects were examined according to the Conconi test on a treadmill at increasing speeds for their fitness. We used a continuous heart rate monitoring, 3-axis acceleration sensors, lactate measurements and pedography. RESULTS: Three groups of subjects could be differentiated. In one group, a rapid rise in heart rate even at lower walking speed was observed. In a second group of persons with poor motor coordination, the maximum walking speed was limited. Single subjects were not limited neither in their physical performance nor in their condition. CONCLUSION: In the physical therapy for patients with cerebral palsy one should not lose sight of possible cardiovascular limitations additional to the physical disabilities.

[Partial pelvic resection (internal hemipelvectomy) and endoprosthetic replacement in periacetabular tumors]. / Beckenteilresektion (innere Hemipelvektomie) und endoprothetischer Ersatz bei hüftgelenksnahen Tumoren.

OBJECTIVE: Treatment of tumors of the pelvic girdle by resection of part or all of the innominate bone with preservation of the extremity. Implantation and stable fixation using a custom-made megaprosthesis to restore painless joint function and loading capacity. The surgical goal is to obtain a wide surgical margin and local tumor control. INDICATIONS: Primary bone and soft tissue sarcomas, benign or semi-malignant aggressive lesions, metastatic disease (radiation resistance and/or good prognosis). CONTRAINDICATIONS: Limited life expectancy and poor physical status, extensive metastatic disease, persistent deep infection or recalcitrant osteomyelitis, poor therapeutic compliance, local recurrence following a previous limb-sparing resection, extensive infiltration of the neurovascular structures and the intra- and extrapelvic soft tissues. SURGICAL TECHNIQUE: Levels of osteotomy are defined preoperatively by a CT-controlled manufactured three-dimensional 1:1 model of the pelvis. Using these data, the custom-made prosthesis and osteotomy templates are then constructed by the manufacturer. The anterior (internal, retroperitoneal) and posterior (extrapelvic, retrogluteal) aspects of the pelvis are exposed using the utilitarian incision surgical approach. The external iliac and femoral vessels are mobilized as they cross the superior pubic ramus. The adductor muscles, the rectus femoris and sartorius muscle are released from their insertions on the pelvis and the obturator vessels and nerve are transected. If the tumor extends to the hip joint, the femur is transected at a level distal to the intertrochanteric line to ensure hip joint integrity and to prevent tumor contamination. A large myocutaneous flap with the gluteus maximus muscle is retracted posteriorly. The pelvitrochanteric and small gluteal muscles are divided near their insertion in the upper border of the femur. To release the hamstrings and the attachment of the sacrotuberous ligament, the ischial tuberosity is exposed. After osteotomy using the prefabricated templates, the pelvis is released and the specimen is removed en bloc. The custom made prosthesis can either be fixed to the remaining iliac bone or to the massa lateralis of the sacrum. The released muscles are refixated on the remaining bone or the implant. POSTOPERATIVE MANAGEMENT: Time of mobilization and degree of weight-bearing depends on the extent of muscle resection. Usually partial loading of the operated limb with 10 kg for a period of 6-12 weeks, then increased loading with 10 kg per week. Thrombosis prophylaxis until full weight bearing. Physiotherapy and gait training. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination, and radiographic studies. RESULTS: Between 1994 and 2008, 38 consecutive patients with periacetabular tumors were treated by resection and reconstruction with a custom-made pelvic megaprosthesis. The overall survival of the patients was 58% at 5 years and 30% at 10 years. One or more operative revisions were performed in 52.6% of the patients. The rate of local recurrence was 15.8%. Deep infection (21%) was the most common reason for revision. In two of these cases (5.3%), a secondary external hemipelvectomy had to be performed. There were four cases of aseptic loosening (10.5%) in which the prosthesis had to be revised. Six patients had recurrent hip dislocation (15.8%). In four of them a modification of the inserted inlay and an implantation of a trevira tube had to be performed respectively. Peroneal palsy occurred in 6 patients (15.8%) with recovery in only two. There were 4 operative interventions because of postoperative bleeding (10.5%). The mean MSTS score for 12 of the 18 living patients was 43.7%. In particular, gait was classified as poor and almost all patients were reliant on walking aids. However, most patients showed good emotional acceptance.

[Proximal tibial replacement and alloplastic reconstruction of the extensor mechanism after bone tumor resection]. / Proximaler Tibiaersatz und alloplastische Rekonstruktion des Streckapparats nach Resektion kniegelenksnaher Tumoren.

OBJECTIVE: The goal of the operation is limb-sparing resection of tumors arising from the proximal tibia with adequate surgical margins and local tumor control. Implantation of a constrained tumor prosthesis with an alloplastic reconstruction of the extensor mechanism to restore painless joint function and loading capacity of the extremity. INDICATIONS: Primary bone and soft tissue sarcomas. Benign or semimalignant aggressive lesions. Metastatic disease (radiation resistance and/or good prognosis). CONTRAINDICATIONS: Poor physical status. Extensive metastatic disease with life expectancy <6 months. Tumor penetration through the skin. Local infection or recalcitrant osteomyelitis. Poor therapeutic compliance. Large popliteal extraosseous tumor masses with infiltration of neurovascular structures. SURGICAL TECHNIQUE: A single incision is made from the anteromedial aspect of the distal femur to the distal one third of the medial lower leg. Preparation of large medial and lateral fasciocutaneous flaps. The popliteal vessels are explored through a medial approach by releasing the pes anserinus and semimembranosus tendon, mobilizing the medial gastrocnemius muscle and detaching the soleus muscle from the tibial margo medialis. The anterior tibial artery and vein are ligated. If the knee joint is free of tumor, circumferential dissection of the knee capsule is performed and the patellar ligament is dissected. An osteotomy of the tibia shaft is performed with safety margins according to preoperative planning. In order to obtain adequate surgical margins, in some cases an en bloc resection of the tibiofibular joint becomes necessary. Therefore, the peroneal nerve is exposed. Parts of the M. tibialis anterior, a portion of the M. soleus and the entire M. popliteus are left on the resected tibial bone. After implantation of the prosthesis and coupling of the femoral and tibial component, the extensor mechanism is reconstructed using an alloplastic cord. It is passed transversely through the distal end of the quadriceps tendon looping the proximal margin of the patella. Both ends are passed distally through a subsynovial tunnel and are fixed under adequate pretension in a metal block of the tibial component. The detached hamstrings and remaining ligaments can be fixed on preformed eyes of the prosthesis. A medial gastrocnemius muscle flap is used to provide soft tissue coverage of the tibial component. POSTOPERATIVE MANAGEMENT: Immobilization and elevation of the extremity for 5 days, then flap conditioning. Mobilization in a hinged knee brace locked in extension for 6 weeks without weight bearing. During this time active flexion with a stepwise progress, isometric quadriceps training. Then beginning of straight leg raising exercises, stepwise unlocking of the brace with 30° every 2 weeks. Weight-bearing is increased by 10 kg/week. Thrombosis prophylaxis until full weight-bearing. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination and radiographic studies. RESULTS: Between 1988 and 2009, endoprosthetic replacement and alloplastic reconstruction of the extensor mechanism after resection of tibial bone tumors was performed in 17 consecutive patients (9 females and 8 males) with a mean age of 31.1 years (range 11-65 years). There were no local recurrences. Until now, 5 patients have died of tumor disease. One or more operative revisions were necessary in 53.9% of the patients. According to Kaplan-Meier survival analysis, the implant survival at 5 years was 53.6% and 35.7% at 10 years, respectively. In 2 cases, a distal transfemoral amputation had to be performed due to deep infection. There were 3 cases of tibial stem revision due to implant failure and aseptic loosening, respectively. In 3 patients, the hinge of the prosthesis had to be revised. Impaired wound healing occurred in 2 cases. Peroneal nerve palsy was observed in 3 patients with recovery in only one. The mean Oxford knee score for 9 of the 12 living patients was 30.7 ± 7.5 (24-36). No patient had a clinically relevant extension lag. The mean range of motion at the last follow-up was 90.2° ± 26.7 (range 35-130°). All patients were well satisfied with their postoperative outcomes.

[Grisel's syndrome after otoplasty]. / Grisel-Syndrom nach Anthelixplastik.

Grisel's syndrome is known as a very rare complication of ENT surgery. It is described as non-traumatic atlantoaxial rotatory subluxation, often seen after tonsillectomy or adenoidectomy in children. Therapy is staged according to the Fielding classification. We report the case of a 9-year-old female patient with Grisel's syndrome after otoplasty. The diagnosis was confirmed by CT scan. Manual reposition was performed under general anaesthesia, followed by temporary immobilization with a Minerva orthesis.

Osteolysis after rotator cuff repair with bioabsorbable anchors.

PURPOSE: The current study was designed to evaluate the rate of osteolysis and the clinical and functional outcomes in patients who underwent mini-open rotator cuff repairs using first generation bioabsorbable suture anchors. Our hypothesis was that patients with osteolysis noted on post-repair MRI would have an accompanying decrease in functional and clinical patient outcomes when compared with patients who did not have osteolysis evident on post-repair MRI. TYPE OF STUDY: Clinical retrospective study. METHODS: Between September 2000 and May 2004, 76 patients were repaired using first generation Bio-Corkscrew suture anchors (Arthrex, Naples, FL). 30 patients were available for complete follow-up evaluation. The mean follow-up time was 36 months (range 24-58). Patients were assessed with the Constant-Murley Score, radiographs and magnetic resonance imaging (MRI). Post-operative strength was measured using an Isokinetic Cybex-Dynamometer. 14 patients had osteolysis evident on MRI (Group A) while 16 patients did not have osteolysis on MRI (Group B). RESULTS: In both groups, a total of 70 bio-anchors were used. 22 anchors showed osteolytic changes on MRI (Group A). Concerning ROM, there was no statistical difference in both groups. The Constant-Score was statistically not different in both groups A (92.4) and B (83.7). On MRI-scans, there were repair failures in both groups (A, 2 reruptures; B, 3 reruptures). CONCLUSIONS: Although, we found a high rate of osteolysis after rotator cuff repair with bioabsorbable anchors, these results did not change the clinical outcomes after rotator cuff repair. Recurrent tears were not significantly different in both groups and are comparable to rerupture rates in prior studies. More studies are needed to verify the effect of osteolysis over the long term.

[Diagnostics and therapy of spinal metastases]. / Diagnostik und Therapie von Wirbelsäulenmetastasen.

Out of all skeletal metastases 30% are located in the spine as are 10% of primary bone tumors, whereby 52% of metastases occur in the lumbar region, 36% in the thoracic spine and 12% in the cervical spine. Patients suffer from local pain caused by irritation of the periosteum due to rapid growth of the tumor or subsequent pathologic fractures which may lead to compression and neurological impairment with paresthesia, paresis and paraplegia. If the diagnosis cannot be confirmed exactly by radiological imaging and laboratory tests, a biopsy should be performed. A precise diagnosis of the tumor entity as well as an estimation of the prognosis provides an important basis for further decision-making. The aim of therapy is pain relief and stabilization by operative and non-operative measures. Therapy is palliative with the aim of pain relief and preservation of mobility. In cases of solitary metastasis a curative operative treatment should be performed.

[Mega cups and partial pelvic replacement]. / Megapfannen und Beckenteilersatz.

Extensive bone loss, as encountered in both revision arthroplasty of the hip and after resection of malignant tumors of the pelvis, is a major challenge for the surgeon as well as for the revision implant. The aims are, despite extensive acetabular defects, to achieve a primary and load-stable fixation of the revision prosthesis in the pelvic bone as well as restoring the physiological joint biomechanics. At present, a large number of different alloarthroplastic revision implants and complex techniques are available for reconstruction of acetabular deficiencies. According to D'Antonio's classification of acetabular defects, particularly high-grade defects with loss of the posterior column or a pelvic discontinuity require special attention regarding implant selection and surgical planning. The object of this paper is to highlight the most important tools and techniques of endoprosthetic reconstruction for grade III and IV defects (D'Antonio) of the acetabulum by means of a classification-oriented therapeutic concept and to discuss the pros and cons of the particular implant.

[Development of hip resurfacing]. / Die Entwicklung des Oberflächenersatzes der Hüfte.

Total hip replacement in its current form has proved to be very effective in late middle-aged and elderly patients. However, in the younger patient population the survival rate is still not acceptable. Since the very beginning of hip resurfacing, the procedure has been advocated as an attractive concept to preserve proximal femoral bone stock. Furthermore, it is supposed to optimize stress transfer to the proximal femur and because of the large head size improves joint stability and range of motion. The failure of previous resurfacings has been described to be due to inappropriate materials, poor design, and poor instrumentation and not as an inherent problem of the procedure itself. Progress in materials and material design (metal-on-metal) as well in experience in surgical technique seem to have overcome formerly experienced difficulties. This means a lower rate of femoral neck fractures and aseptic loosenings, at least in the short-term and midterm follow-up of patients with good function. High manufacturing standards are required to consistently produce low-wear metal-on-metal bearings and it is still unclear whether high metal ion levels, which occur in all patients with metal-on-metal hip replacements, have any biologic effect. At least so far there is no evidence of any negative clinical effect in this regard. Only long-term results in a higher number of patients and a more widespread use of this procedure will tell whether early success is durable or it is just a bone-preserving, intermittent step before conventional total hip replacement.