Atesch Ateschrang

Acetabular bone reconstruction in revision arthroplasty: A COMPARISON OF FREEZE-DRIED, IRRADIATED AND CHEMICALLY-TREATED ALLOGRAFT VITALISED WITH AUTOLOGOUS MARROW VERSUS FROZEN NON-IRRADIATED ALLOGRAFT

Deficiencies of acetabular bone stock at revision hip replacement were reconstructed with two different types of allograft using impaction bone grafting and a Burch-Schneider reinforcement ring. We compared a standard frozen non-irradiated bone bank allograft (group A) with a freeze-dried irradiated bone allograft, vitalised with autologous marrow (group B). We studied 78 patients (79 hips), of whom 87% (69 hips) had type III acetabular defects according to the American Academy of Orthopaedic Surgeons classification at a mean of 31.4 months (14 to 51) after surgery. At the latest follow-up, the mean Harris hip score was 69.9 points (13.5 to 97.1) in group A and 71.0 points (11.5 to 96.5) in group B. Each hip showed evidence of trabeculation and incorporation of the allograft with no acetabular loosening. These results suggest that the use of an acetabular reinforcement ring and a living composite of sterile allograft and autologous marrow appears to be a method of reconstructing acetabular deficiencies which gives comparable results to current forms of treatment.

Current concepts review: Septic arthritis of the knee pathophysiology, diagnostics, and therapy

ZusammenfassungDie Behandlung der bakteriellen Kniegelenksinfektion erfolgt durch die arthroskopische Revision mit Spülung und Debridement sowie systemischer Gabe von Antibiotika. Dieser Artikel fasst die relevanten Untersuchungen zu Pathophysiologie, Infektklassifikation, klinischen Symptome mit dazugehöriger Diagnostik und stadiengerechter Therapie der Kniegelenksinfektion zusammen. Die wichtigsten Behandlungsprinzipien sind die Gelenkdekompression mit Eliminierung der Bakterien sowie proteolytischer und lysosomaler Enzyme durch eine intensive Gelenkspülung. Das Debridement sollte auf nekrotische synoviale und periartikuläte Strukturen begrenzt bleiben mit der Zielsetzung die Synovia als natürliche Barriere und immunkompetentes Organ zu erhalten. Gute Ausheilungsergebnisse konnten durch die arthroskopische Spülung mit Debridement bei stadiengerechter Therapie erzielt werden. Die Infektklassifikation nach Gächter mit den Stadien I–IV wurde dabei am häufigsten genutzt, wobei diese die pathophysiologischen Stadien widerspiegelt. Für die Infektstadien I–III ist die arthroskopische Gelenkrevision mit Spülung und Debridement effektiv, die bei persistierendem Infektgeschehen auch wiederholt werden kann. Die Häufigkeit der wiederholten arthroskopischen Spülung hängt von dem primären Infektstadium ab und schwankt zwischen 0 und 41% der Fälle. Für das Infektstadium IV nach Gächter sowie für persisitierende Infektionen trotz mehrfacher arthroskopischer Spülung weniger schwerer Infektstadien (I–III) wird die offene Gelenkrevision empfohlen. Die Ausheilungsrate der Kniegelenksinfektionen durch die arthroskopische Revision liegt derzeit bei 90 bis 100 %.SummaryTreatments for bacterial arthritis of the knee joint are arthroscopic irrigation and debridement with systemic antibiotic medication. This article summarizes the relevant data of pathophysiology, stage of infection, symptoms, and diagnostics as well as stage-dependent treatment of bacterial arthritis of the knee joint. The major treatment principles are joint decompression, elimination of the causative organisms by intensive irrigation of the joint with elimination of proteolytic and lysosomal enzymes. Debridement of necrotic soft tissues with the aim of preserving the synovial membrane as an immune-competent structure, and a natural barrier, is recommended. Good results in treating knee infections have been achieved with arthroscopic joint revision and stage-dependent surgical therapy. The infection staging I–IV suggested by Gächter was used most commonly, which mainly reflects the pathophysiologic infection stages. For stages I–III, arthroscopic joint decompression with joint irrigation and debridement is effective and can be repeated in cases of persisting infection. The incidence of repeated arthroscopic joint irrigation depends on the initial stage of the infection and varies between 0 and 41% of the cases. For stage IV infections, the open revision is needed or in seldom cases of therapy failure under initial or repeated arthroscopic joint revision. The success rate of healing infections by arthroscopic irrigation was high with 90–100%.

High Success Rate for Augmentation Compression Plating Leaving the Nail In Situ for Aseptic Diaphyseal Tibial Nonunions

Objectives: To evaluate adjunctive compression plating leaving the previously unreamed inserted intramedullary nail (URIMN) in situ for treating a resultant diaphyseal tibial nonunion. Design: Retrospective study. Setting: Level 1 trauma center (University Hospital). Patients/Participants: Patients treated by URIMN for diaphyseal tibial fractures that developed an aseptic hypertrophic nonunion. Intervention: Dynamization of the nail and compression plating leaving the URIMN in situ. Main Outcome Measurements: Radiographic and clinical parameters. Results: The mean follow-up was 3.8 years (range 2–7 years). Mean time for healing was 15 weeks with a mean operation time of 63 minutes. Union occurred in 27/28 (96.4%). There were no infections. Conclusions: This simple technique seems to have a high success rate and should be considered when a nonunion occurs after URIMN. The need for an additional incision and removal of symptomatic implants remains a disadvantage. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Retrograde lag screw placement in anterior acetabular column with regard to the anterior pelvic plane and midsagittal plane -- virtual mapping of 260 three-dimensional hemipelvises for quantitative anatomic analysis.

Percutaneous screw placement can be used for minimally invasive treatment of none or minimally displaced fractures of the anterior column. The complex pelvic geometry can pose a major challenge even for experienced surgeons. The present study examined the preformed bone stock of the anterior column in 260 hemipelvises (130 male and 130 female). Screws were virtually implanted using iPlan(®) CMF (BrainLAB AG, Feldkirchen, Germany); the maximal implant length and the maximal implant diameter were assessed. The study showed, that 6.5mm can generally be used in men; in women however individual planning is essential in regard to the maximal implant diameter since we found that in 15.4% of women, screws with a diameter less than 6.5mm were necessary. The virtual analysis of the preformed bone stock corridor of the anterior column showed two constrictions of crucial clinical importance. These can be found after 18% and 55% (men) respectively 16% and 55% (women) measured from the entry point along the axis of the implant. The entry point of the retrograde anterior column screw in our collective was located lateral of tuberculum pubicum at the level of the superior-medial margin of foramen obturatum. In female patients, the entry point was located significantly more lateral of symphysis and closer to the cranial margin of ramus superior ossis pubis. The mean angle between the screw trajectory and the anterior pelvic plane in sagittal section was 31.6 ± 5.5°, the mean angle between the screw trajectory and the midsagittal plane in axial section was 55.9 ± 4.6° and the mean angle between the screw trajectory and the midsagittal plane in coronal section was 42.1 ± 3.9° with no significant deviation between both sexes. The individual angles formed by the screw trajectory and the anterior pelvic and midsagittal plane are independent from anthropometric parameters sex, age, body length and weight. Therefore, they can be used for orientation in lag screw placement keeping in mind that the entry point differs in both sexes.

Precision in the Planning of Open Wedge HTO

INTRODUCTION The high tibial osteotomy (HTO) is regarded as an established method for varus deformity. To quantify the varus deformity, the anatomic and the mechanical leg axis can be determined. The success of HTO depends on the correct assessment of the preoperative axis deviation and the exact as planned correction. The aim of the retrospective study was to verify the accuracy (± 1.5° of mechanical tibiofemoral angle tolerance compared to the planning) with the preoperative planning compared to the postoperative result after correction using the TomoFix™ plate in open wedge HTO. MATERIALS AND METHOD A retrospective study of patients was carried out after open wedge HTO with the TomoFix™ plate. A full-weight bearing, long-standing anteroposterior radiograph of the whole lower extremity was performed before and after correction. The mechanical angles in the frontal plane were determined and compared with the plan as drawn. RESULTS The preoperative mechanical tibiofemoral angle (mTFA) was -5.33 ± 3.29° (varus) and at follow-up -0.3 ± 3.0° (varus). The mean correction was 4.9 ± 2.9°. The planned mTFA was 2.2 ± 1.6°(valgus). The corrected lower extremity showed a mean difference of -2.5 ± 3.4° in angle correction of the varus deformity as preoperatively assumed to be the optimal correction compared to the planning. The planning goal was not achieved in 73 % of the cases. CONCLUSION The results are comparable to those of other publications. However, taking into account the required accuracy of the drawn plan combined with the surgical precedure, it is not possible to achieve results within the desired tolerance.

Early Functional Postoperative Therapy of Distal Radius Fracture with a Dynamic Orthosis: Results of a Prospective Randomized Cross-Over Comparative Study

Introduction This study was conducted according to GCP criteria as a prospective randomized cross-over study. The primary goal of the study was to determine clinical findings and patient satisfaction with postoperative treatment. 29 patients with a distal radius fracture that was surgically stabilized from volar and who met the inclusion criteria were enrolled over a 12-month period. Each patient randomly received either a dorsal plaster splint or a vacuum-fit flexible but blocked orthosis applied postoperatively in the operating theatre to achieve postoperative immobilization. After one week all patients were crossed over to the complementary device maintaining the immobilization until end of week 2. After week 2 both groups were allowed to exercise wrist mobility with a physiotherapist, in the orthosis group the device was deblocked, thus allowing limited wrist mobility. After week 4 the devices were removed in both groups. Follow-up exams were performed after postoperative weeks 1, 2, 4 and 12. Results and Discussion Results were determined after week 1 and 2 using SF 36 and a personally compiled questionnaire; after weeks 4 and 12 with a clinical check-up, calculation of ROM and the DASH Score. Comparison of the two groups showed a significant difference in ROM for volar flexion after 4 weeks, but no significant differences in DASH Score, duration of disability or x-ray findings. With regard to satisfaction with comfort and hygiene, patients were significantly more satisfied with the dynamic orthosis, and 23 of the 29 patients would prefer the flexible vacuum orthosis in future. Trial Registration German Clinical Trials Register (DRKS) DRKS00006097

Long-Term Results Using the Straight Tapered Femoral Cementless Hip Stem in Total Hip Arthroplasty: A Minimum of Twenty-Year Follow-Up

We report the first long-term results of a prospective cohort study after total hip arthroplasty using the cementless Bicontact hip stem. Between 1987 and 1990, 250 total hip arthroplasties in 236 patients were performed using the cementless Bicontact hip stem. The average follow-up was 22.8 years (20.4-24.8) and average age at index surgery was 58.1 years. Eighty-one patients died and 9 were lost to follow-up. We noted 11 stem revisions revealing an overall Kaplan Meier survival rate of 95.0% (CI 95%: 91.1-97.2%). The average Harris Hip Score revealed 81 points (range 24-93). The Bicontact hip stem demonstrated high survival rates despite high ages and osteopenic changes, which are equivalent to other long-term reports of cementless stem fixation.

Patellaluxation: Diagnostik- und Behandlungsalgorithmus unter Berücksichtigung der Torsion

BACKGROUND Patella dislocation and re-dislocation are common diseases. Although patella dislocation is frequent, it always poses a challenge concerning diagnostics and therapy. Mixed forms of pathological disorder in the patellofemoral joint make the analysis of the malalignment and the choice of the correct treatment more difficult. MATERIAL AND METHODS By reviewing the available literature of the last few years and taking into account considerations concerning the malalignment, an overview of the necessary diagnostics can be given. Radiographs and MRI are essential parts of the diagnostics after a traumatic patella dislocation. After re-dislocation, more extensive diagnostics are required to determine all pathological aspects of the malalignment. In this situation, a CT scan for measuring the torsion of the femur and the tibia as well as the TT-TG distance (tibial tubercle - trochlea groove), and the full weight-bearing long leg standing radiograph are part of the fundamental diagnostics. RESULTS The results that are presented in the literature provide some indications for a successful treatment. In consideration of the thorough analysis of the malalignment, the torsional correction of the femur and/or the tibia gains a new importance in the patellofemoral joint. The presented algorithm for diagnostics and treatment should make the decision for the best treatment easier. CONCLUSION The proposed algorithm for diagnostics and treatment is only partially founded on evidence-based results. Moreover, it takes into consideration reflections concerning the biomechanics of the patellofemoral joint and the realignment of this joint.

The effect of the arthroscopic augmentation of the subscapularis tendon on shoulder instability and range of motion: A biomechanical study

BACKGROUND Anterior shoulder dislocation is common. The treatment of recurrence with glenoid bone defect is still considered controversial. A new arthroscopic subscapularis augmentation has recently been described that functions to decrease the anterior translation of the humeral head. The purpose of the presented study was to examine the biomechanical effect on glenohumeral joint motion and stability. METHODS Eight fresh frozen cadaver shoulders were studied by use of a force guided industrial robot fitted with a six-component force-moment sensor to which the humerus was attached. The testing protocol includes measurement of glenohumeral translation in the anterior, anterior-inferior and inferior directions at 0°, 30° and 60° of glenohumeral abduction, respectively, with a passive humerus load of 30N in the testing direction. The maximum possible external rotation was measured at each abduction angle applying a moment of 1Nm. Each specimen was measured in a physiologic state, as well as after Bankart lesion with an anterior bone defect of 15-20% of the glenoid, after arthroscopic subscapularis augmentation and after Bankart repair. FINDINGS The arthroscopic subscapularis augmentation decreased the anterior and anterior-inferior translation. The Bankart repair did not restore the mechanical stability compared to the physiologic shoulder group. External rotation was decreased after arthroscopic subscapularis augmentation compared to the physiologic state, however, the limitation of external rotation was decreased at 60° abduction. INTERPRETATION The arthroscopic subscapularis augmentation investigated herein was observed to restore shoulder stability in an experimental model.

Septic arthritis of the knee: Presentation of a novel irrigation-suction system tested in a cadaver study

BackgroundThe established treatment for bacterial arthritis of the knee joint is arthroscopic surgery with irrigation and debridement. The aim of this article is to summarize the relevant data in treating bacterial arthritis of the knee joint, and based on these findings to present a novel irrigation suction system, tested in a cadaver study, as an additional tool in the postoperative treatment phase of arthroscopic surgery for knee joint infections.MethodThe novel automated irrigation-suction system presented here was compared to conventional continuous suction irrigation in a total of six knee joints. All knee joints were filled with 80 ml methylene blue stain and rinsed by two different methods. Fluid specimens were taken after ten and twenty minutes to be compared by photometric extinction measurement at a wave length of 500 nm.ResultsAfter ten minutes, the average extinction was e1C = 0.8 for the continuous suction irrigation and e1N = 0.4 for the novel irrigation-suction system. After twenty minutes, we recorded an average extinction of e2C = 0.3 for continuous suction irrigation and e2N = 0.001 for the novel irrigation-suction system. The students t- test revealed superior results after ten and twenty minutes of washing out the knee joints with a p < 0.001 for the novel irrigation-suction system.ConclusionA novel irrigation-suction system may be an effective tool for postoperative knee joint irrigation in arthroscopic therapy for bacterial arthritis of the knee. Further animal studies are needed to verify the effects in vivo.