Dirk Albrecht

High Complication Rate After Biplanar Open Wedge High Tibial Osteotomy Stabilized With a New Spacer Plate (Position HTO Plate) Without Bone Substitute

PURPOSE We performed a prospective clinical and radiographic evaluation after open wedge high tibial osteotomy (HTO) using the new Position HTO plate (Aesculap, Tuttlingen, Germany) without bone transplantation. METHODS Thirty-five open wedge HTOs with the Position HTO plate were performed without bone wedges. The mean patient age was 44.6 ± 9.2 years at the time of osteotomy, which was planned with mediCAD II software (Hectec, Niederviehbach, Germany). The Hospital for Special Surgery score, Lysholm-Gillquist score, Tegner activity level, and International Knee Documentation Committee subjective score were used for clinical assessment. We evaluated radiographs obtained preoperatively and at 2, 6, and 12 months postoperatively using full-weight-bearing anteroposterior whole-leg views and anteroposterior and lateral views of the knee. For statistical analyses, JMP 8.0.1 (SAS, Cary, NC) was used. RESULTS We observed an overall complication rate of 34% and a plate-related complication rate of 23%. Plate-related complications included loss of correction, fracture of the tibial plateau, screw failure, malunion, and fracture of the lateral cortical bone. A significant difference in the mechanical tibiofemoral angle of -1.3° ± 1.4° (P < .001) was found between the follow-up at 2 and 6 months. The mean Hospital for Special Surgery score was 74.8 ± 11.7 preoperatively, and it increased to 87.8 ± 11.0 (P < .001). The mean score on the Lysholm-Gillquist knee functional scoring scale was 55.5 ± 21.7 preoperatively, and it improved to 73.0 ± 23.9 (P < .001). The Tegner activity level was 2.6 ± 0.9 preoperatively, and it improved significantly at final follow-up to 3.7 ± 1.8 (P < .02). The International Knee Documentation Committee subjective score was 43.0 ± 14.9 preoperatively, and it increased to 66.1 ± 21 (P < .001). CONCLUSIONS We have shown a high plate-related complication rate and a significant loss of correction between 2 and 6 months of follow-up after open wedge HTO using the new Position HTO plate without bone wedges. The preoperatively planned mechanical tibiofemoral angle was not achieved. Despite these complications, the clinical outcome improved significantly. The Position HTO plate cannot be recommended with the presented technique. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Remodeling of Articular Cartilage and Subchondral Bone After Bone Grafting and Matrix-Associated Autologous Chondrocyte Implantation for Osteochondritis Dissecans of the Knee

Background: Osteochondritis dissecans (OCD) of the knee is a challenging problem. Previously, the authors implemented a novel 1-step surgical procedure for OCD treatment consisting of matrix-associated autologous chondrocyte implantation (ACI) and simultaneous bone reconstruction including the subchondral lamina. Purpose: This study presents the 2-to 5-year results after this technique, assessing correlations of clinical function and cartilage and bone remodeling processes. Study Design: Case series; Level of evidence, 4. Methods: Twenty-six patients with symptomatic condylar knee OCD (International Cartilage Repair Society OCD III/IV) were treated with matrix-associated ACI and monocortical cancellous cylinders for defect filling and subchondral bone plate reconstruction using cortical graft layers as novel subchondral lamina. Evaluations were performed with clinical rating scales and 1.5-T magnetic resonance imaging using the magnetic resonance observation of cartilage repair tissue (MOCART) score and a newly implemented subchondral lamina remodeling grade. Results: The defect size was 5.3 ± 2.3 cm2. The defect depth was 8.7 ± 2.4 mm. After a follow-up of 39.8 ± 12.0 months, all scores improved significantly. Nineteen patients (73%) reached good/excellent results in the Lysholm-Gillquist score (preoperatively: 53.2 ± 18.0 points; latest follow-up: 88.5 ± 9.5 points) and the Cincinnati knee rating score (preoperatively: 51.7 ± 13.0 points; latest follow-up: 84.6 ± 11.7 points) and significant improvements in the subjective International Knee Documentation Committee (IKDC) score by 27.9% (preoperatively: 50.5% ± 16.1%; latest follow-up: 78.4% ± 13.4%). The MOCART score reached 62.4 ± 18.9 points. The clinical improvement and tissue remodeling occurred simultaneously and timed; thus, the cartilage defect filling and the lamina remodeling grades correlated significantly with each other, the follow-up time, and almost all clinical scores. Conclusion: The simultaneous reconstruction of deep osteochondral defects of the knee OCD with monocortical cancellous cylinders and matrix-associated ACI is a biological, 1-step alternative to osteochondral cylinder transfer or conventional ACI that leads to good clinical and magnetic resonance imaging results after an intermediate follow-up period. The present study demonstrated simultaneous remodeling processes of articular cartilage repair tissue and subchondral lamina; this synchronization is not yet understood and deserves further investigation.

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%.

[Changes of patella position after closed and open wedge high tibial osteotomy: review of the literature].

AIM High tibial osteotomy (HTO) is an established treatment for varus osteoarthritis of the knee. The correction can be achieved by lateral closed wedge HTO or medial open wedge HTO techniques. Both techniques can change the patella position which influences alignment of the patella. Patella infera may compromise the result of secondary total knee prosthesis. An analysis of the current literature was carried out focusing on changes of patella position after HTO. METHOD A literature search was performed in PubMed which identified 15 relevant publications and the Insall-Salvati-index, the Blackburne-Peel-index and the Caton-Deschamps-index were analyzed. RESULTS Results after closed wedge HTO: the Insall-Salvati-index decreased in 7 papers, increased in 3 papers and was unchanged in 1 paper. The Blackburne-Peel-index increased in 5 papers and decreased in 2. The Caton-Deschamps-index decreased in 4 papers and increased in 2 papers. Results after open wedge HTO: the InsalI-Salvati-index decreased in 5 papers and increased in 2. The Blackburne-Peel-index decreased in all 7 papers and the Caton-Deschamps-index decreased in all 5 papers. The results of these studies vary significantly and there was a tendency to patella infera in both techniques. The Blackburne-Peel-index and the Caton-Deschamps-index may be biased by slope changes but the exact effect is not yet known. The Insall-Salvati-index seems to be independent of slope changes. The effect of different rehabilitation concepts on patella height is not known. CONCLUSION The clinical relevance of the observed changes in patella position must be clarified by prospective studies with strict criteria.

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.

Veränderung der Patellahöhe nach „open“- und „closed wedge high tibial osteotomy“

AIM High tibial osteotomy (HTO) is an established treatment for varus osteoarthritis of the knee. The correction can be achieved by lateral closed wedge HTO or medial open wedge HTO techniques. Both techniques can change the patella position which influences alignment of the patella. Patella infera may compromise the result of secondary total knee prosthesis. An analysis of the current literature was carried out focusing on changes of patella position after HTO. METHOD A literature search was performed in PubMed which identified 15 relevant publications and the Insall-Salvati-index, the Blackburne-Peel-index and the Caton-Deschamps-index were analyzed. RESULTS Results after closed wedge HTO: the Insall-Salvati-index decreased in 7 papers, increased in 3 papers and was unchanged in 1 paper. The Blackburne-Peel-index increased in 5 papers and decreased in 2. The Caton-Deschamps-index decreased in 4 papers and increased in 2 papers. Results after open wedge HTO: the InsalI-Salvati-index decreased in 5 papers and increased in 2. The Blackburne-Peel-index decreased in all 7 papers and the Caton-Deschamps-index decreased in all 5 papers. The results of these studies vary significantly and there was a tendency to patella infera in both techniques. The Blackburne-Peel-index and the Caton-Deschamps-index may be biased by slope changes but the exact effect is not yet known. The Insall-Salvati-index seems to be independent of slope changes. The effect of different rehabilitation concepts on patella height is not known. CONCLUSION The clinical relevance of the observed changes in patella position must be clarified by prospective studies with strict criteria.

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.

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.

What parameters affect knee function in patients with untreated cartilage defects: baseline data from the German Cartilage Registry

PurposeTo evaluate the factors influencing the baseline Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients with knee cartilage defects and planned cartilage repair surgery and to provide baseline KOOS data from a large patient population.Material and methodsBetween October 2013 and April 2017, a total of 2815 patients assigned for cartilage repair surgery were included into the German Cartilage Registry (KnorpelRegister DGOU) and their data were analyzed for the present study. Multivariate regression model and ANOVA were used to detect patient- and defect-specific factors with an influence on baseline KOOS. In addition, KOOS baseline data was calculated and compared according to these parameters.ResultsSex, age, body mass index (BMI), and smoking status were revealed as patient-specific factors, and defect location and the number of previous knee and cartilage operations were revealed as defect-specific factors with a significant influence on baseline KOOS. Most subscores were affected in accordance with the total KOOS. Interestingly, defect ICRS grade, defect size, and symptom duration had no significant influence. The mean baseline KOOS was 56.7 (± 17.9). Men had significantly higher mean overall KOOS (60 ± 17.3 vs. 51.8 ± 17.6, p < 0.001) than women, and patients with a BMI over 30 and smokers scored significantly lower (58.07 ± 17.67 vs. 50.32 ± 17.29, p < 0.001; 57.64 ± 17.86 vs. 53.59 ± 18.06, p < 0.001). Patients with two or more previous knee operations as well as patients with more than one previous cartilage procedure also showed significantly lower overall KOOS (57.19 ± 17.89 vs. 54.56 ± 17.58, p < 0.001; 57.68 ± 18.01 vs. 52.72 ± 17.58, p < 0.001).ConclusionSeveral factors influencing baseline KOOS data in patients with knee cartilage defects assigned for cartilage repair surgery could be detected. Their individual influence in the multivariate linear regression model was not very strong. Baseline data according to these criteria is presented in this paper.

Hohe Tibiakopfumstellungsosteotomie@@@High tibial osteotomy: Erfahrungen mit der computergesteuerten Navigation@@@Experience with computer-assisted navigation

ZusammenfassungDie hohe valgisierende Tibiakopfumstellungsosteotomie (HTO) wird beim jungen und aktiven Patienten mit Varusgonarthrose als geeignete Methode zur Behandlung angesehen. Ihr Erfolg hängt von ihrer korrekten Planung und Durchführung ab. Für die intraoperative Überprüfung der Beinachse sind Navigationssysteme verfügbar, wobei sich der OrthoPilot® in der Handhabung als geeignet herausgestellt hat. Die klinische Relevanz der Navigationssysteme ist noch nicht nachgewiesen. Die computergestützte Navigation stellt ein Hilfsmittel zur Verbesserung der Genauigkeit dar. Eine präoperative Planung ist weiter erforderlich.AbstractHigh tibial osteotomy (HTO) is a well-established and commonly used treatment for medial unicompartmental osteoarthritis of the knee with varus malalignment in young and older active patients. Successful treatment depends on correct preoperative planning as well as the surgical technique. Intraoperative alignment control can be performed with the image-free navigation tool OrthoPilot® to enhance precision. Influence on clinical outcome has to be proven. Intraoperative navigation is not a substitute for preoperative planning.