Hakan Pilge

Nontraumatic Subluxation of the Atlanto-Axial Joint as Rare Form of Aquired Torticollis: Diagnosis and Clinical Features of the Griselʼs Syndrome

Study Design. Case report and review of the literature. Objective. We report a case of Grisels syndrom with a delayed diagnosis. The patients first presentation in our pediatric orthopedics department was 2 month after surgery (cochlea implantation) with a persistent torticollis. Radiographs revealed a subluxated atlantoaxial joint. We treated our patient with manual repositioning and calculated antibiotics, which lead to a restitutio ad integrum within a short time. Summary of Background Data. Grisels syndrome is synonymous with rare nontraumatic, rotational subluxation of the atlantoaxial joint (C1–C2). All formerly reported cases showed a clear association to infection or were related to head and neck surgery. Still, there is a lack of understanding about pathogenetic features and causative agents. In 1977 Fielding proposed a classification of the atlantoaxial subluxation and stage-related therapy was recommended. Methods. Our patient was a 11-year-old girl with a torticollis after insertion of a cochlea implant. After surgery, physiotherapy was performed because of her wryneck. As the symptoms did not improve, she was presented in our clinic. Our radiographs revealed a subluxated atlantoaxial joint. Results. In general anesthesia we performed a manual repositioning and she was temporarily immobilized with a cervical collar for 2 weeks. In addition, we administered calculated antibiotics, although CRP and leukocytes were not elevated. The follow up showed a good repositioning within a short time. Conclusion. At least in this case, our treatment led to shorter recovery and avoidance of halo fixation. Our new therapeutic approach to patients with Grisels syndrome might lead to a shorter recovery.

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.

Diagnostics and therapy of spinal metastases

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.

Total hip replacement in developmental dysplasia using an oval-shaped cementless press-fit cup

PurposeAcetabular roof deficiency due to subluxation of the femoral head (Hartofilakidis type II) increases the complexity of total hip arthroplasty. In these cases some form of support is usually required, to reach stable fixation of the acetabular component. Pursuing this aim, the oval-shaped cementless cranial socket could be an alternative to conventional treatment options.MethodsBetween 1998 and 2008, 37 patients (40 hips) underwent primary total hip arthroplasty using the cranial socket (mean follow-up 5.6 years, range 26 to 133 months). In a retrospective study we compared these clinical and radiological results with the results of a matched control group consisting of 35 patients (40 hips) treated with a standard cementless hemispherical cup in combination with bulk femoral autografting (mean follow-up 6.9 years, range 30 to 151 months).ResultsThere were no statistically significant differences in the HHS (p = 0.205) or the SF-36 (p = 0.26) between both groups. There was no prosthesis failure due to septic or aseptic loosening. Time of surgery was significantly shorter in the cranial socket group (p < 0.001). The acetabular component could be placed in the ideal rotational hip centre in 24 (60%) hips in the cranial socket group and 32 (80%) hips in the control group, respectively.ConclusionsOur study indicates, that the cranial socket can be an alternative treatment option for the reconstruction of acetabular deficiency in osteoarthritis secondary to developmental dysplasia.

Alloplastic reconstruction of the extensor mechanism after resection of tibial sarcoma.

Reconstruction of the extensor mechanism is essential for good extremity function after endoprosthetic knee replacement following tumor resection. Only a few biological methods have been able to reliably restore a functional extensor mechanism, but they are often associated with significant complication rates. Reattachment of the patellar tendon to the prosthesis using an alloplastic patellar ligament (Trevira cord) can be an appropriate alternative. In vivo and in vitro studies have already shown that complete fibrous ingrowth in polyethylene chords can be seen after a period of six months. However, until now, no biomechanical study has shown the efficacy of an alloplastic cord and its fixation device in providing sufficient stability and endurance in daily life-activity until newly formed scar tissue can take over this function. In a special test bench developed for this study, different loading regimes were applied to simulate loads during everyday life. Failure loads and failure modes were evaluated. The properties of the cord were compared before and after physiological conditioning. It was shown that rubbing was the mode of failure under dynamic loading. Tensile forces up to 2558 N did not result in material failure. Thus, using an artificial cord together with this fixation device, temporary sufficient stable fixation can be expected.

Bone marrow aspirate concentrate in combination with intravenous iloprost increases bone healing in patients with avascular necrosis of the femoral head: a matched pair analysis

With disease progression, avascular necrosis (AVN) of the femoral head may lead to a collapse of the articular surface. The exact pathophysiology of AVN remains unclear, although several conditions are known that can result in spontaneous cell death, leading to a reduction of trabecular bone and the development of AVN. Hip AVN treatment is stage-dependent in which two main stages of the disease can be distinguished: pre-collapse (ARCO 0-II) and post-collapse stage (ARCO III-IV, crescent sign). In the pre-collapse phase, core decompression (CD), with or without the addition of bone marrow (e.g. bone marrow aspirate concentrate, BMAC) or bone graft, is a common treatment alternative. In the post-collapse phase, THA (total hip arthroplasty) must be performed in most of the patients. In addition to surgical treatment, the intravenous application of Iloprost has been shown to have a curative potential and analgesic effect. From October 2009 to October 2014, 49 patients with AVN (stages I-III) were treated with core decompression at our institution. All patients were divided into group A (CD + BMAC) and group B (CD alone). Of these patients, 20 were included in a matched pair analysis. The patients were matched to age, gender, ARCO-stage, Kerboul combined necrotic angle, the cause of AVN, and whether Iloprost-therapy was performed. The Merle d’Aubigné Score and the Kerboul combined necrotic angle in a-p and lateral radiographs were evaluated pre- and postoperatively. The primary endpoint was a total hip arthroplasty. In group A, two patients needed THA while in group B four patients were treated with THA. In group A, the Merle d’Aubigné Score improved from 13.5 (pre-operatively) to 15.3 (postoperatively). In group B there was no difference between the pre- (14.3) and postoperative (14.1) assessment. The mean of the Kerboul angle showed no difference in both groups compared pre- to postoperatively (group A: pre-op 212°, postop 220°, group B: pre-op 213, postop 222°). Regarding radiographic evaluation, the interobserver variability revealed a moderate agreement between two raters regarding the pre-(ICC 0.594) and postoperative analysis (ICC 0.604).This study demonstrates that CD in combination with the application of autologous bone marrow aspirate concentrate into the femoral head seems to be a safe and efficient treatment alternative in the early stages of AVN of the femoral head when compared to CD alone.

Incidence and outcome after infection of megaprostheses

Recent advances in chemotherapy and radiation therapy in the treatment of malignant bone tumours as well as the consistent increase of revision arthroplasties have been followed by an increased use of megaprostheses. These large foreign bodies make infection a common and feared complication. Infection rates of 3 - 31% have been reported (average approx. 15%), often in conjunction with risk factors, e.g. the anatomic region (pelvis implants in particular), implant alloy, and underlying reason for implantation of a megaprosthesis. Apart from the basic principles of septic revision arthroplasty, special patient and implant factors have to be considered in infected megaprosthesis, which we have summarised in our paper (e.g. life expectancy, implant design, spacers and external stabilisation). This article further analyses the current literature available for these cases and summarises outcome after treatment of periprosthetic infections.

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.

Development of hip resurfacing

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.

Effects of thromboprophylaxis on mesenchymal stromal cells during osteogenic differentiation: an in-vitro study comparing enoxaparin with rivaroxaban

BackgroundLow-molecular-weight heparins (e.g. Enoxaparin) are widely used to prevent venous thromboembolism after orthopaedic surgery, but there are reports about serious side effects including reduction in bone density and strength. In recent years new oral antithrombotic drugs (e.g. direct Factor Xa-inhibitor, Rivaroxaban) have been used to prevent venous thromboembolism. However, there is lack of information on the effects of these new drugs on human mesenchymal stromal cells during osteogenic differentiation and, therefore, effects during postoperative bone healing.MethodsWe evaluated the effects of Rivaroxaban and Enoxaparin on the proliferation, mRNA and surface receptor expression as well as differentiation capacity of primary human mesenchymal stromal cells during their osteogenic differentiation.ResultsEnoxaparin, but not Rivaroxaban treatment significantly increased human mesenchymal stromal cell (hMSC) proliferation during the first week of osteogenic differentiation while suppressing osteogenic marker genes, surface receptor expression and calcification.ConclusionsThis is the first paper to demonstrate that Rivaroxaban had no significant influence on hMSC differentiation towards the osteogenic lineage, indicating a less affected bone healing process compared with Enoxaparin in vitro. Based on these findings Rivaroxaban seems to be superior to Enoxaparin in early stages of bone healing in vitro.