The learning curve of patient-specific unikondylar arthroplasty may be advantageous to off-the-shelf implants: A preliminary study.

INTRODUCTION: Introducing a new arthroplasty system into clinical routine is challenging and could have an effect on early results. Since UKA are known to have failure mechanisms related to technical factors, reliable results and easy adoption are ideal. The question remains whether there are differences in objective procedure parameters in the early learning curve of different UKA systems. METHODS: two different UKA implants (Biomet Oxford[BO] followed by Conformis iuni[CI]) were introduced consecutively into clinical routine. We retrospectively analyzed the first 20 cases of each implant for one arthroplasty surgeon regarding operating time, correction of the mechanical axis, learning curve parameters, and revision rate of implants for 1.5 years postoperatively. RESULTS: Operating time (BO:98.3 ± 26.3min, CI:83.85 ± 21.8min (p < 0.078)), and tourniquet time differed in favor of the CI implant (BO:97.5 ± 29.5min; CI:73.5 ± 33.2 min; p < 0.017)). Mechanical alignment was restored in boths (preop:BO:mean 2.9°varus, CI:2.7°varus, postop:BOmean1.3°varus, CI:1°varus), while one BO patient and two CI patients were overcorrected. Operating time decreased from the first five implants to implants 16-20 for CI (95.2 ± 18.5min to 69 ± 21.5min, p < 0.076) and BO (130.6 ± 27.6min to 78 ± 17.3min, p < 0.009). Within 18 months of follow-up, 2 BO and 1 CI implants were revised. CONCLUSION: The introduction of an UKA implant was associated with longer surgery in both implants. Procedure time seems to differ between implants, while a learning curve was observed regarding instrumentation. CI implants seem to be reliable and adaptable in a medium-volume practice. The early results of this retrospective single-surgeon study were in favor of the individualized implant. Certainly, further studies encompassing larger cohorts with various implants are needed.

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.

[Slipped capital femoral epiphysis: clinical presentation, diagnostic procedure and classification]. / Epiphyseolysis capitis femoris: Klinik, Diagnoseverfahren und Klassifikation.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a frequent chronic and often bilateral atraumatic slippage of the epiphysis relative to the femoral neck in adolescence. The success of the treatment depends on the extent of the slippage and possible complications. OBJECTIVES: Review on current trends in clinical examination and diagnostic imaging protocols. Commonly used imaging techniques, methods of measuring the slippage and treatment-relevant classification schemes are presented. MATERIALS AND METHODS: An overview on the clinical findings, the diagnostic procedures and the classification of SCFE based on relevant study results and experience gained in our daily clinical practice. RESULTS: Early diagnosis of SCFE is essential, as a delay in diagnosis regularly leads to an increase in slippage with an increased risk of subsequent damage to the blood vessels, which can lead to irreversible damage of the joint. Symptoms and findings are frequently subtle and nonspecific, often leading to delay in diagnosis and treatment and, consequently, to the manifestation of massive deformities. X­ray imaging is the primary imaging modality, whereas MRI, computed tomography (CT) and ultrasound are helpful in surgical planning and prognostic evaluation. Postoperatively, they provide information on short and long-term complications. DISCUSSION: The delay in the diagnosis of SCFE is still present in the literature as well as in our own patient population, indicating that a repeated, consistent training on this topic is essential to prevent harm to patients. Whether patients benefit from advanced imaging techniques such as MRI or CT is questionable and should be screened case by case.

[Perthes disease-news in diagnostics and treatment]. / Morbus Perthes ­ Neuigkeiten in der Diagnostik und Behandlung.

DIAGNOSTICS: Perthes disease remains a challenge for paediatric orthopedic surgeons. X­ray imaging is still the method of choice for diagnostics and follow-up examination. A more detailed differentiation of Waldenström's classification, especially in early and late fragmentation stages, might be relevant to optimize timing of containment surgery. So-called "advanced MRI" imaging might help to detect patients at risk earlier than conventional x­ray imaging, which could lead to earlier surgical intervention. TREATMENT: Currently there is no treatment modality available which would improve the bone changes in Perthes disease. Non-operative treatment like improving hip range of motion as well as unloading is still the basic standard of care, with analgesic and/or anti-inflammatory medication, according to symptoms or findings. In the case of loss of containment, especially in children older than 6 years, surgery is indicated. Currently, there is a trend favoring acetabular reorientation techniques-especially the triple osteotomy, since the biomechanical relations would not be additionally impaired as in case of femoral varus osteotomy.

[Fixation techniques for slipped capital femoral epiphysis : Principles, surgical techniques, and complications]. / Fixationstechniken bei der Epiphyseolysis capitis femoris : Prinzipien, operative Techniken und Komplikationen.

The purpose of this review is to present the pros and cons as well as the surgical techniques of conventional implants used for fixation of slipped capital femoral epiphysis (SCFE). Worth mentioning are K­wires, Hansson pins, transfixing screws, and gliding screws. We searched PubMed for "ECF" and "SCFE" in combination with "in situ fixation," "pin," "wire," "screw," and "nail." We considered Johansson nail, Knowles pin, and Nyström nail to be obsolete and of historical interest only. We noticed a trend from absolute stability towards some form of dynamic fixation over time, likely related to considerations of growth disturbance of the proximal femur and also the inherent potential for remodeling with time.

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.

Gait deviations in transverse plane after SCFE in dependence on the femoral offset.

Residual deformity of the femoral head after slipped capital femoral epiphysis (SCFE) may be accompanied by a loss of femoral offset and lead to femoro-acetabular impingement (FAI), especially during hip flexion. It is hypothesized that during phases of the gait cycle, when the hip is flexed, the offset-loss is compensated by an increased external rotation. The gait pattern of 36 patients suffering from SCFE, who were treated by pinning-in-situ, were compared to a control group of 40 healthy adults by an instrumented 3D-gait analysis. Total patient group was subdivided into 3 subgroups in dependence on the offset (offset groups (OG)) quantified by the angle α according to Nötzli: OG1: α-angle <55°, OG2: α-angle between 55 and 75°, OG3: α-angle >75°. Comparisons were made at 3 instants: initial foot contact (0% gait cycle (GC)), 40-60% GC and 90-100% GC. Patients showed an increased external hip rotation during all 3 periods of the GC with a tendency of increasing external rotation in association with offset-loss. Only during hip extension (40-60% GC) there was a weak correlation between angle α and hip rotation (r=-0.375, p=0.024). In conclusion, the offset-loss does not lead to a functional relevant impingement during walking which needs compensation strategies like increasing external rotation during periods of hip flexion.

Special symposium issue: slipped capital femoral epiphysis (SCFE).

Up-date on the pathogenesis, epidemiology, pathology, histopathology, clinical findings, diagnosis & classification, imaging modalities and all treatment options in slipped capital femoral epiphysis. This symposium issue of JCO is based on lectures presented at the Pre-Course at the 35th Annual Congress of the European Paediatric Orthopaedic Society (EPOS) in 2016.

Imaging modalities in patients with slipped capital femoral epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a frequent disorder of the adolescent hip, which may lead to avascular necrosis (AVN) of the femoral head, chondrolysis and early osteoarthritis due to the post-slip deformity of the proximal femur. To warrant the best possible outcome for the affected (and contralateral) hip, early diagnosis and proper treatment are needed. METHODS: A review of the literature was undertaken to identify today's role of available imaging modalities in the management of SCFE. SUMMARY: This review outlines the relevancy of different imaging modalities such as radiography, ultrasound, CT, MRI and bone scintigraphy in the treatment of SCFE patients. While standard radiography is the first-choice imaging modality for patients with suspected SCFE, ultrasound and advanced imaging modalities may aid in surgical planning, diagnosis of complications such as AVN and treatment follow-up.

Vertical expandable prosthetic titanium ribs (VEPTR) in early-onset scoliosis: impact on thoracic compliance and sagittal balance.

BACKGROUND: Theoretically, dynamic thoracic compliance (DTC) should be reduced by vertical expandable prosthetic titanium ribs (VEPTR) since titanium rods, scar tissue and ossifications increase stiffness of the rib cage. The effect of VEPTR on thoracic compliance has not yet been elucidated. The impact of VEPTR on the development of sagittal balance has not been fully investigated. PATIENTS AND METHODS: In a retrospective study, we investigated 21 consecutive children who were treated by VEPTR from 2004 to 2011 and three control groups. We compared the development of thoracic compliance during growth to Nr1. Development of sagittal balance during growth was compared to Nr2 and to Nr3 (which has been instrumented from ileum to rib). Mean follow-up was 60.67 months (standard error of the mean (SE 4.77). RESULTS: The difference of change of DTC during growth of VEPTR group versus a control group was not significant (p < 0.05). However, initial DTC and DTC at last follow-up of VEPTR group were lower than DTC of the control group. The difference was significant (p < 0.05). Mean correction of Cobb angle after the first operation was 16.41° (SE 3.01). Until last follow-up, we saw a loss of correction of 8.23° (SE 3.22). The differences between the development of parameters of sagittal balance during growth between the VEPTR group, control group 2 and control group 3 were not significant (p > 0.05). CONCLUSIONS: VEPTR treatment should start as early as possible since VEPTR seems to lead to an increased rate of DTC that is similar to healthy controls. Sagittal balance showed a similar development as in healthy children.

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.

[Irreparable rotator cuff tears. Debridement, partial reconstruction, tendon transfer or reversed shoulder arthroplasty]. / Irreparable Rupturen der Rotatorenmanschette. Debridement, Partialrekonstruktion, Muskeltransfer oder inverse Schulterprothese.

Therapeutic options for the treatment of irreparable rotator cuff tears are fluent, are dependent on the patients' claims and demands and on the grade of the ongoing cuff tear arthropathy.A partial rotator cuff reconstruction with sufficient tenolysis combined with interval slide techniques to restore the anterior and posterior force couple may be indicated if there is no fatty degeneration > grade 3 of the rotator cuff muscles in a well-centered joint. The margin convergence technique with side-by-side adaptation of the tendon limbs may reduce the load on the reconstructed tendons.The role of the suprascapular nerve, which can probably be constricted by the retracted rotator cuff, and its therapy has not been completely clarified. When distinct symptoms are present neurolysis may be reasonable.Tendon transfers can be indicated in a cooperative patient < 65 years with a higher grade of muscular atrophy but without degenerative changes > grade II according to Hamada with the loss of active external rotation but performable active flexion. For posterosuperior tears the latissimus dorsi or recently the teres major tendon transfer to the rotator cuff footprint may be appropriate. For nonreconstructable anterosuperior tears a partial transfer of the pectoralis major tendon is possible.Careful subacromial debridement combined with biceps tenotomy and a cautious or reversed decompression may reduce the pain temporarily without having an influence on active motion until with the loss of active elevation the indication for a reversed shoulder arthroplasty is reached.In the mean time, absorbable subacromial spacers may re-center the humeral head, but the effectiveness of this therapy on clinical outcome should be analyzed in further studies.

Ibandronate in stable renal transplant recipients with low bone mineral density on long-term follow-up.

BACKGROUND: Bone mineral density (BMD) has been reported to increase without specific treatment in long-term renal transplant recipients. The aim of this study was to evaluate the effect of ibandronate on BMD and kidney function in long-term renal transplant recipients as compared to a control group. Furthermore, we searched for a gender-specific treatment effect of ibandronate on BMD. METHODS: In a retrospective, matched case-control study 60 stable renal transplant recipients were included on long-term follow-up. The patient cohort was divided into two groups. The control group (n = 30) comprised patients with close-to-normal bone mineral density who did not receive ibandronate treatment and the treatment group (n = 30) comprised patients with reduced bone mineral density who received ibandronate treatment. The groups were matched for sex, age at the time of renal transplantation, use of steroids, renal transplant function and time lag between the dual-energy X-ray absorptiometry (DEXA) measurements and renal transplantation. Patients of the treatment group were treated with 12.0 ± 6.7 g ibandronate. Treatment cycles lasted 19.3 ± 11.0 months. The first bone mineral density testing was performed 55.3 ± 60.2 months after renal transplantation followed by a second measurement 26.8 ± 12.1 months later. RESULTS: Both groups did not differ in absolute (g/cm(2)) or relative (%) changes in BMD at the lumbar spine (0.033 ± 0.079 vs. 0.055 ± 0.066 g/cm(2), p = 0.217 and 3.6 ± 7.8 vs. 6.4 ± 8.1 %, p = 0.124) or femoral neck (0.013 ± 0.106 vs. 0.025 ± 0.077 g/cm(2), p = 0.647 and 3.2 ± 13.6 vs. 5.0 ± 13.1 %, p = 0.544) over the study period. There was no correlation of ibandronate dosages with changes in BMD (LS: r = -0.089; p = 0.639 and FN: r =+0.288; p = 0.445). We could neither determine a negative effect of ibandronate on renal transplant function over the study period, estimated via the CKD-EPI formula (-2.9 ± 7.6 vs. -2.7 ± 10.6 mL/min/1.73 m(2), p = 0.900) nor a gender-specific action of ibandronate on bone mass changes. CONCLUSIONS: Ibandronate treatment was safe with respect to renal transplant function but did not result in a significant additive improvement in bone mineral density as compared to the untreated control group. A gender-specific action of ibandronate on BMD at the LS or FN could not be determined either.

[Perthes disease]. / Morbus Perthes.

Morbus Perthes today still poses a challenge for the orthopaedic surgeon because of the unclear aetiology as well as the controversial discussion about the role and kind of multiple treatment principles. The prognosis depends upon clinical (e.g. age at onset, reduction of range of motion, gender) and radiological (extent of necrosis, containment) parameters. Of these, only the reduced range of motion and a loss of containment can be adressed therapeutically, be it in a conservative and/or operative concept. Pelvic osteotomies have the advantage of a high potential of correction without the biomechanic disadvantages which are associated with intertrochanteric varus osteotomies. Nowadays, the use of orthoses is considered to be obsolete. Non-containment is targeted mainly on the symptomatic treatment and the correction of residual deformities. Based on the outcome after the final stage there is a risk of premature osteoarthritis with the need of early total hip replacement.

[Hereditary multiple exostoses]. / Multiple kartilaginäre Exostosenkrankheit.

BACKGROUND: Hereditary multiple exostosis (HME) is a hereditary autosomal dominant disease in which multiple exostoses occur. Typically, the exostoses are primarily located at the metaphysis and migrate with continued growth towards the diaphysis. Clinical problems are caused by local pain, impingement of muscle tendons and neurovascular structures, malformation - especially in the forearm - and malignant transformation - especially exostoses at the trunc and pelvic girdle. METHODS: A causal therapy is currently not available. Mechanical irritation is an indication for resection of the exostosis. Axial deviation of the lower extremity is treated according to the same principles as primary malalignments (temporary hemiepiphysiodesis/corrective osteotomy). RESULTS: The indication for correction of axial deviation at the upper extremity depends on age, extent as well as functional and cosmetic impairment. This should be discussed with the patient in detail. The patient has to be informed about the risk of malignant transformation after cessation of growth. Growing mass or new occurrence of symptoms after end of growth are suspicious and require further diagnostic examinations.

[Bilateral spastic cerebral palsy with ambulatory ability (diplegia): pathophysiology, state of the art of conservative and surgical treatment and rehabilitation]. / Bilaterale spastische Parese mit Gehfähigkeit (Diparese) : Pathophysiologie, State of the Art konservativer und operativer Behandlung und Rehabilitation.

BACKGROUND: Infantile cerebral palsy is one of the most common diseases resulting in chronic disability and is mostly concomitant with impairment in the ability to walk. DISEASE PATTERN: Muscle contractions typically develop during the growth phase with subsequent joint contracture and instability as well as bone deformities to various extents. From a biomechanical viewpoint the gait impairment is due to a lever arm dysfunction. THERAPEUTIC STRATEGIES: The therapy concept is multimodal and involves conservative as well as operative measures. The objectives are to lower the muscle tonus, to avoid muscle and joint contractures and bone deformities and to correct already fixed malformations in order to achieve the best possible function for the patient. Complicated multilevel operations are often necessary to achieve this aim. CONCLUSION: Extensive knowledge on the biomechanics of gait and the pathobiomechanics of spastic bilateral cerebral palsy are necessary to carry out surgery. Using instrumental gait analyses the biomechanical relationships can be analyzed better and complicated operations can be planned with greater precision.

[Current treatment strategies in Legg-Calvé-Perthes disease]. / Aktuelle Behandlungsstrategie des Morbus Perthes.

The long-term prognosis of Legg-Calvé-Perthes disease primarily depends on the spherical form of the femoral head and the congruency of the hip joint after healing. Of the many factors influencing the outcome only the range of mobility and containment can be addressed therapeutically. The mobility of the joint is maintained or restored through various conservative measures thus reducing joint deforming forces. If loss of containment becomes evident operative treatment is indicated, preferably in the early fragmentation stage. For biomechanical reasons correction of the acetabulum is preferred. For children less than 8.5 years old greater trochanteric apophyseodesis is warranted to prevent trochanteric overgrowth. The results of containment ameliorating surgery are promising. In older children with severe Legg-Calvé-Perthes disease the results are less promising.

The distribution of nociceptive innervation in the painful hip: a histological investigation.

Our understanding of the origin of hip pain in degenerative disorders of the hip, including primary osteoarthritis, avascular necrosis and femoroacetabular impingement (FAI), is limited. We undertook a histological investigation of the nociceptive innervation of the acetabular labrum, ligamentum teres and capsule of the hip, in order to prove pain- and proprioceptive-associated marker expression. These structures were isolated from 57 patients who had undergone elective hip surgery (44 labral samples, 33 ligamentum teres specimens, 34 capsular samples; in 19 patients all three structures were harvested). A total of 15,000 histological sections were prepared that were investigated immunohistochemically for the presence of protein S-100, 68 kDa neurofilament, neuropeptide Y, nociceptin and substance P. The tissues were evaluated in six representative areas. Within the labrum, pain-associated free nerve ending expression was located predominantly at its base, decreasing in the periphery. In contrast, the distribution within the ligamentum teres showed a high local concentration in the centre. The hip capsule had an almost homogeneous marker expression in all investigated areas. This study showed characteristic distribution profiles of nociceptive and pain-related nerve fibres, which may help in understanding the origin of hip pain.

[Treatment of recurrent clubfoot and residual deformities after congenital clubfoot]. / Therapie des Rezidivklumpfußes und residueller Deformitäten nach kongenitalem Klumpfuß

Relapse and residual deformity after treatment of congenital clubfoot are common problems. Recurrences occur in up to 48 % of cases after successful initial treatment using Ponseti's technique. By casting and anterior tibial tendon transfer as recommended by Ponseti a flexible and well functioning foot can be achieved in most cases. Neglected clubfoot remains a demanding challenge. Depending on the severity of the deformity, the impairment of function and patient age, conservative and/or different operative treatment options can be considered. Manipulation and casting according to Ponseti is also recommended in toddlers with relapses even after peritalar joint release. Thus the need and extent of operative treatment can be reduced. Additional osteotomy may be indicated in more rigid feet and older children. An accurate evaluation of the existing deformity and functional impairment is mandatory for the individual choice of treatment. The number of previous operative procedures reduces the amount of improvement and mobility of the foot. Therefore, the best and most efficient treatment for recurrent clubfoot is prevention in the form of consistent primary treatment, consistently wearing braces and regular follow-up examinations.