Jens Decking

Shock Wave Application for Chronic Plantar Fasciitis in Running Athletes: A Prospective, Randomized, Placebo-Controlled Trial:

Background: Recent articles have reported success with repeated low-energy shock wave application for treatment of chronic plantar fasciitis in runners. Hypothesis: Shock wave treatment for chronic plantar fasciitis is safe and effective. Study Design: Prospective, randomized, placebo-controlled trial. Methods: Forty-five running athletes with intractable plantar heel pain for more than 12 months were enrolled; half were assigned to a treatment group that received three applications of 2100 impulses of low-energy shock waves, and half received sham treatment. Follow-up examinations were performed at 6 months and at 1 year by a blinded observer. Results: After 6 months, self-assessment of pain on first walking in the morning was significantly reduced from an average of 6.9 to 2.1 points on a visual analog scale in the treatment group and from an average of 7.0 to 4.7 points in the sham group. The mean difference between groups was 2.6 points. After 12 months, there was a further reduction of pain in both groups, to an average 1.5 points in the treatment group, and to 4.4 points in the sham group. Conclusion: Three treatments with 2100 impulses of low-energy shock waves were a safe and effective method for treatment of chronic plantar fasciitis in long-distance runners.

Repetitive Low-Energy Shock Wave Treatment for Chronic Lateral Epicondylitis in Tennis Players

Background There is conflicting evidence regarding extracorporeal shock wave treatment for chronic tennis elbow. Hypothesis Treatment with repetitive low-energy extracorporeal shock wave treatment is superior to repetitive placebo extracorporeal shock wave treatment. Methods Seventy-eight patients enrolled in a placebo-controlled trial. All patients were tennis players with recalcitrant MRIconfirmed tennis elbow of at least 12 months’ duration. Patients were randomly assigned to receive either active low-energy extracorporeal shock wave treatment given weekly for 3 weeks (treatment group 1) or an identical placebo extracorporeal shock wave treatment (sham group 2). Main outcome measure was pain during resisted wrist extension at 3 months; secondary measures were >50% reduction of pain andthe Upper Extremity Function Scale. Results At 3 months, there was a significantly higher improvement in pain during resisted wrist extension in group 1 than in group 2 (mean [SD] improvement, 3.5 [2.0] and 2.0 [1.9]; P= .001 for between-group difference of improvement) and in the Upper Extremity Function Scale (mean [SD] improvement, 23.4 [14.8] and 10.9 [14.9]; P< .001 for between-group difference of improvement). In the treatment group, 65% of patients achieved at least a 50% reduction of pain, compared with 28% of patients in the sham group (P= .001 for between-group difference). Conclusion Low-energy extracorporeal shock wave treatment as applied is superior to sham treatment for tennis elbow.

Reliability of the Crowe und Hartofilakidis classifications used in the assessment of the adult dysplastic hip

ObjectiveTo assess the inter-observer and intra-observer reliability of two commonly used radiographic classification systems in the evaluation of hip dysplasia in skeletally mature adults.DesignThree observers with different levels of training independently classified 62 dysplastic hips on 51 standard anteriorposterior pelvis radiographs according to the criteria defined by Crowe and by Hartofilakidis. To assess intra-observer reliability, the same radiographs were reviewed 3 months later by the same observers.PatientsAt the time of the radiographic examination, the mean age of the 51 patients had been 54 years (range 18–82 years).ResultsA high correlation concerning the inter- and intra-observer reliability of both systems was demonstrated. Inter-observer reliability displayed a weighted kappa coefficient of 0.82 for the Crowe and 0.75 for the Hartofilakidis classification. Intra-observer reliability showed a kappa coefficient of 0.86 and 0.79, respectively.ConclusionsBoth classification systems can be recommended to compare collectives of adult patients with congenital dysplasia of the hip. However, for future clinical practice, it would be advisable to agree on one universally accepted system as a standard in the literature.

Robotic total knee arthroplasty: the accuracy of CT-based component placement.

Background Accurate alignment of the components in total knee arthroplasty is important. By use of postoperative CT controls, we studied the ability of a robotic effector to accurately place and align total knee arthroplasty (TKA) components according to a purely CT-based preoperative plan.Patients and methods Robotic TKA was performed in 13 patients (6 men) with primary gonarthrosis. Locator screws were placed into femur and tibia under spinal anesthesia. A CT-scan including the femoral head, knee and ankle was performed. In the preoperative planning software, virtual components were positioned into the CT volume. In a second operation, the robot milled femur and tibia with a high-speed milling tool according to the preoperative plan. On the 10th day, CT controls were performed following the same protocol as preoperatively.Results The mean deviation of the postoperative from the preoperatively planned mechanical axis was 0.2° (95% CI: −0.1° to 0.5°). The accuracy of angular component placement in frontal, sagittal and transverse planes was within±1.2°, and the accuracy of linear component placement in mediolateral, dorsoventral and caudocranial directions was within±1.1 mm.Interpretation Robotic TKA allows placement of components with unparalleled accuracy, but further development is mandatory to integrate soft-tissue balancing into the procedure and make it faster, easier and cheaper.

Maintenance of bone mineral density after implantation of a femoral neck hip prosthesis

BackgroundStress shielding of the proximal femur has been observed in a number of conventional cementless implants used in total hip arthroplasty. Short femoral-neck implants are claiming less interference with the biomechanics of the proximal femur. The goal of this study was to investigate the changes of bone-mineral density in the proximal femur and the clinical outcome after implantation of a short femoral-neck prosthesis.MethodsWe prospectively assessed the clinical outcome and the changes of bone mineral density of the proximal femur up to one year after implantation of a short femoral neck prosthesis in 20 patients with a mean age of 47 years (range 17 to 65). Clinical outcome was assessed using the Harris Hip Score. The WOMAC was used as a patient-relevant outcome-measure. The bone mineral density was determined using dual energy x-ray absorptiometry, performed 10 days, three months and 12 months after surgery.ResultsThe Harris Hip Score improved from an average preoperative score of 46 to a postoperative score at 12 months of 89 points, the global WOMAC index from 5,3 preoperatively to 0,8 at 12 months postoperatively. In contrast to conventional implants, the DEXA-scans overall revealed a slight increase of bone mineral density in the proximal femur in the 12 months following the implantation.ConclusionThe short femoral neck stem lead to a distinct bone reaction. This was significantly different when compared to the changes in bone mineral density reported after implantation of conventional implants.

Die hochenergetische extrakorporale Stoßwellentherapie (ESWT) bei Pseudarthrose

ZusammenfassungDie Therapie der Wahl von Pseudarthrosen war bisher die Operation mit Osteosynthese und Spananlagerung. Seit den 90er Jahren wird die extrakorporale Stoöwellentherapie (ESWT) als nichtinvasive und risikoarme Behandlungsmethode bei Pseudarthrosen eingesetzt.Ziel dieser prospektiven Studie war es, den Behandlungseffekt bei einem homogenen Patientengut zu überprüfen und prognostische Faktoren herauszuarbeiten.An einem Patientengut von 43 voroperierten Patienten mit seit 9 Monaten bestehenden Pseudarthrosen wendeten wir die hochenergetische ESWT (0,6 mJ/mm2) mit 3000 Impulsen (Siemens Osteostar) in einer Sitzung in Regionalanästhesie an. Zuvor wurde zusätzlich eine Skelettszintigraphie zur Differenzierung von aktiven und inaktiven Pseudarthrosen durchgeführt.Nachuntersuchungen erfolgten nach 8 Wochen, danach monatlich bis zum 9. Monat nach ESWT. Nach durchschnittlich 4,0±0,6 Monaten trat bei 31 von 43 (72,1%) Pseudarthrosen ein knöcherner Durchbau auf. In der Mineralisationsphase der Szintigraphie hatten 25 von 31 (80,6%) erfolgreich behandelten Pseudarthrosen eine deutliche Anreicherung gezeigt, gegenüber 4 von 12 (33,3%) der Behandlungsversager. Bei 29 der 35 (82,9%) Patienten mit einer deutlichen Anreicherung in der Mineralisationsphase kam es nach ESWT zu einer knöchernen Konsolidierung im Vergleich zu 2 von 8 (25%) Patienten mit einer negativen Szintigraphie; 6 dieser 8 Patienten rauchten >20 Zigaretten/Tag.Die ESWT bleibt eine klinisch-experimentelle Behandlungsmethode, deren Einsatz jedoch aufgrund fehlender Nebenwirkungen bei Pseudarthrosen gerechtfertigt erscheint. Kontrollierte Studien stehen hierzu noch aus.AbstractThe gold standard for treatment of pseudarthrosis is operation with osteosynthesis and grafting. More than 10 years ago, extracorporeal shock wave therapy (ESWT) was additionally introduced as a noninvasive and low-risk treatment for pseudarthrosis.The aim of our prospective study was to analyze the treatment effect in a homogeneous group of patients and to develop prognostic factors.Forty-three consecutive patients were included in this study. All patients had been operated on for trauma or undergone selective osteotomy and had developed pseudarthrosis that persisted for 9 months. All patients received high-energy ESWT (0.6 mJ/mm2) with 3000 impulses (Siemens Osteostar) in one session under regional anesthesia. To differentiate active from inactive pseudarthrosis, a bone scintigraphy was compulsory.Clinical and radiological follow-ups were done at 4-week intervals starting 8 weeks after ESWT for 9 months. Cortical bridging was found in 31 of 43 (72.1%) pseudarthroses at 4.0±0.6 months after ESWT.Of 31 (80.6%) successfully treated patients, 25 had a positive scintigraphy compared to 4 of 12 (33.3%) treatment failures. Of 35 (82.9%) patients with a positive bone scintigraphy, 29 had bony healing compared to 2 of 8 (25%) patients with a negative bone scintigraphy. Six of these eight patients smoked more than 20 cigarettes a day.ESWT is still a clinically experimental treatment method. The absence of complications justifies its use for pseudarthrosis treatment. Further controlled studies are mandatory.

The internal calcar septum and its contact with the virtual stem in THR: A computer tomographic evaluation

The internal calcar septum is a ridge of cortical bone protruding from the inner cortical wall of the proximal femur into the medullary canal. It extends from the lesser trochanter into the femoral neck and narrows the femoral cavity in its dorsal third. This region is essential for THR stability, but the degree of contact between the septum and standard THR implants has never been studied. We obtained CT scans of 50 arthrotic hip joints from patients requiring THR. Virtual stems (50 straight/wedge-shaped and 50 anatomic stems) were placed in CT images of the femora using a PC-based preoperative planning unit. The dimensions of the septum, degree and location of contact between the septum and implants were recorded. A septum of cortical density was seen in 49/50 CT scans. It was 11 (2.9) mm long (medial-lateral), 3.5 (0.7) mm wide and 32 (10) mm high (caudal-cranial, mean (SD)). 94/100 implanted virtual stems showed direct contact with the septum. 31 straight stems and 5 anatomical stems were supported by the septum along their dorsal side. The internal calcar septum can be consistently seen on CT scans of patients needing THR and it probably contributes to THR stability.

Preserving the abductor mechanism in robotic THR: the influence of stem design and cutterpath.

Objective: The tip of the greater trochanter is the attachment site for the abductor muscles of the hip joint. Its preservation in robotic and conventional THR is important for normal gait. The effect of different stem designs and robotic cutterpaths on the preservation of the trochanter tip is examined. Materials and Methods: One anatomical stem, one straight stem, and one stem specifically designed for robotic THR were implanted virtually in CT scans of osteoarthrotic hip joints using the Torch preoperative planning unit (URS-ortho). In transverse sections of the trochanter tip, dimensions of the trochanter area removed by the milling tool were recorded for each stem design and different cutterpaths (3-axis versus 5-axis milling). Results: Five-axis milling showed significantly better results than 3-axis milling. For straight stems, more bone was removed than for anatomic stems. The most favorable results were achieved with 5-axis milling and a curved stem specifically designed for robotic THR. Conclusions: The introduction of 5-axis milling in robotic THR is an improvement of the technique and makes preservation of the abductor mechanism at the tip of the greater trochanter easier for the surgeon.