S. Gravius

Open Lateral Patellar Retinacular Lengthening Versus Open Retinacular Release in Lateral Patellar Hypercompression Syndrome: A Prospective Double-Blinded Comparative Study on Complications and Outcome

PURPOSE To compare complication rates and outcome of open lateral retinacular (LR) lengthening and open LR release in the treatment of lateral patellar hypercompression syndrome (LPHS). METHODS In a prospective double-blinded study, 28 patients (mean age, 48 years; 21 women and 7 men) received either LR release (14 patients) or LR lengthening (14 patients) in alternating fashion over the same lateral parapatellar skin incision for LPHS (blinding of patients to surgical procedure [i.e., single blinding]). Strict inclusion criteria (retinacular pain, tight retinaculum, decreased patellar mobility) were used to exclude other reasons for anterior knee pain (patellar instability, leg malalignment or maltorsion, trochlear dysplasia, patella alta). The surgeon and postsurgical rehabilitation were the same. Preoperatively and at 3, 6, 12, and 24 months postoperatively, complications, muscle atrophy, and Kujala patellofemoral outcome score were documented by examiners blinded to the surgical procedure (double blinding). All patients completed 2 years of follow-up. RESULTS The results of 2 years of follow-up showed that recurrence of LPHS, as indicated by the patellar tilt test and decreased medial patellar glide test, developed in 2 cases after LR release and 1 case after LR lengthening (P > .999). Medial patellar subluxation, as indicated by the gravitation-subluxation test and increased medial patellar glide test, developed in 5 cases after LR release and no case after LR lengthening (P = .041). Quadriceps atrophy, as indicated by the mean circumference difference compared with the healthy contralateral side, was significantly higher (P = .001) in the LR release group (1.8 cm) than in the LR lengthening group (0.2 cm). The mean Kujala score was significantly lower (P = .035) in the LR release group (77.2 points) than in the LR lengthening group (88.4 points). CONCLUSIONS In this prospective double-blinded study, retinacular lengthening showed less medial instability, less quadriceps atrophy, and a better clinical outcome at 2 years compared with retinacular release. We believe that this may be explained by the controlled preservation of the lateral patellar muscle-capsuloligamentous continuity after retinacular lengthening. LEVEL OF EVIDENCE Level II, prospective double-blinded comparative study.

Klinische Drei-Jahres-Ergebnisse der matrixgekoppelten ACT zur Behandlung osteochondraler Defekte am Kniegelenk

AIM The aim of this study was to examine the clinical results after the treatment of osteochondral defects of the knee with autologous bone grafting and matrix-supported autologous chondrocyte transplantation (ACT). METHOD In this study 13 patients with osteochondral defects of the knee (12 femoral, 1 tibial) with OCD ICRS grade IV or ICRS grade IV B were included. The osteochondral defects were reconstructed simultaneously with autologous monocortical cancellous bone cylinders or chips from cancellous bone and matrix-supported autologous chondrocyte transplantation (CaReS). Data were analysed in accordance with the ICRS criteria and the Brittberg score. Patients were followed up to 36 months after the operation. RESULTS The average age of the patients was 34.9 (16 - 47) years at the time of surgery. The size of the defect was 8.1 (3.8 - 13.5) cm(2). The subjective and objective IKDC scores, the Brittberg and the ICRS function score were statistically significantly improved during the observation time. In one patient the transplantation failed and another patient was not available for the follow-up at 36 months. The objective IKDC score and the ICRS function score increased from 0/13 (0 %) to 11/12 (91.7 %) in categories A and B, or I and II, respectively, after 3 years. At this point of time 83.4 % (10/12) of the patients voted the treatment as excellent or good. The subjective IKDC score improved from 38.4 (+/- 12.7) preoperatively to 66.1 (+/- 17.0) after 3 years. CONCLUSION The treatment of osteochondral defects of the knee with autologous bone grafting and matrix-supported autologous chondrocyte transplantation shows promising results even for larger defects. But for a final decision about this therapy the present sample size was too small. There is a need for further long-term investigation with a larger number of patients.

Impaction grafting in the femur in cementless modular revision total hip arthroplasty: a descriptive outcome analysis of 243 cases with the MRP-TITAN revision implant

BackgroundWe present a descriptive and retrospective analysis of revision total hip arthroplasties (THA) using the MRP-TITAN stem (Peter Brehm, Weisendorf, GER) with distal diaphyseal fixation and metaphyseal defect augmentation. Our hypothesis was that the metaphyseal defect augmentation (Impaction Bone Grafting) improves the stem survival.MethodsWe retrospectively analyzed the aggregated and anonymized data of 243 femoral stem revisions. 68 patients with 70 implants (28.8%) received an allograft augmentation for metaphyseal defects; 165 patients with 173 implants (71.2%) did not, and served as controls. The mean follow-up was 4.4 ± 1.8 years (range, 2.1–9.6 years). There were no significant differences (p > 0.05) between the study and control group regarding age, body mass index (BMI), femoral defects (types I-III as described by Paprosky), and preoperative Harris Hip Score (HHS). Postoperative clinical function was evaluated using the HHS. Postoperative radiologic examination evaluated implant stability, axial implant migration, signs of implant loosening, periprosthetic radiolucencies, as well as bone regeneration and resorption.ResultsThere were comparable rates of intraoperative and postoperative complications in the study and control groups (p > 0.05). Clinical function, expressed as the increase in the postoperative HHS over the preoperative score, showed significantly greater improvement in the group with Impaction Bone Grafting (35.6 ± 14.3 vs. 30.8 ± 15.8; p ≤ 0.05). The study group showed better outcome especially for larger defects (types II C and III as described by Paprosky) and stem diameters ≥ 17 mm. The two groups did not show significant differences in the rate of aseptic loosening (1.4% vs. 2.9%) and the rate of revisions (8.6% vs. 11%). The Kaplan-Meier survival for the MRP-TITAN stem in both groups together was 93.8% after 8.8 years. [Study group 95.7% after 8.54 years ; control group 93.1% after 8.7 years]. Radiologic evaluation showed no significant change in axial implant migration (4.3% vs. 9.3%; p = 0.19) but a significant reduction in proximal stress shielding (5.7% vs. 17.9%; p < 0.05) in the study group. Periprosthetic radiolucencies were detected in 5.7% of the study group and in 9.8% of the control group (p = 0.30). Radiolucencies in the proximal zones 1 and 7 according to Gruen occurred significantly more often in the control group without allograft augmentation (p ≤ 0.05).ConclusionWe present the largest analysis of the impaction grafting technique in combination with cementless distal diaphyseal stem fixation published so far. Our data provides initial evidence of improved bone regeneration after graft augmentation of metaphyseal bone defects. The data suggests that proximal metaphyseal graft augmentation is beneficial for large metaphyseal bone defects (Paprosky types IIC and III) and stem diameters of 17 mm and above. Due to the limitations of a retrospective and descriptive study the level of evidence remains low and prospective trials should be conducted.

Monitoring of plasma levels of activated protein C using a clinically applicable oligonucleotide-based enzyme capture assay

Summary.  Background: Human‐activated protein C (APC) is a serine protease with anticoagulant, anti‐inflammatory and cytoprotective functions. This feature renders APC to be a promising vascular‐inflammatory biomarker.Objective: The aim of the present study was the development and validation of a technique that allows the measurement of APC plasma levels under practical laboratory conditions.Methods/patients: Based on the APC‐binding ssDNA aptamer HS02‐52G we developed an oligonucleotide‐based enzyme capture assay (OECA) that quantifies aptamer‐captured APC through hydrolysis rates of a fluorogenic peptide substrate. After optimization of pre‐analytical conditions, plasma APC levels were measured in healthy individuals and patients undergoing hip replacement surgery.Results and conclusion: A combination of APC–OECA with an aprotinin‐based quenching strategy allowed APC analysis with a limit of detection as low as 0.022 ± 0.005 ng mL−1 (0.39 ± 0.10 pmol L−1) and a limit of quantification of 0.116 ± 0.055 ng mL−1 (2.06 ± 0.98 pmol L−1). While APC plasma levels in healthy individuals fell below the quantifiable range of the APC–OECA platform, levels substantially increased in patients undergoing hip replacement surgery reaching peak values of up to 12 ng mL−1 (214 pmol L−1). When normalized to the amount of thrombin generated, interindividual variabilities in the APC generating capacity were observed. In general, with a turn‐around time from blood sampling to generation of test results of < 7 h, the APC–OECA platform allows sensitive and rapid determination of circulating APC levels under pathological conditions.

Total ankle replacement in patients with haemophilia and virus infections--a safe alternative to ankle arthrodesis?

Despite reliable results of ankle fusion for advanced haemophilic arthropathy, total ankle replacement (TAR) may be functionally advantageous. There is only very limited literature data available on TAR in patients with haemophilia. The objective of this study is to evaluate the short‐ and mid‐term results after TAR in patients with end‐stage haemophilic ankle arthropathy and concomitant virus infections. In a retrospective study, results after eleven TAR in 10 patients with severe (n = 8) and moderate (n = 2) haemophilia (mean age: 49 ± 7 years, range, 37–59) were evaluated at a mean follow‐up of 3.0 years (range, 1.2–5.4). Nine patients were positive for hepatitis C, five were HIV‐positive. Range of motion (ROM), AOFAS‐hindfoot‐score, pain status (visual analogue scale, VAS) as well as patient satisfaction were evaluated. In two cases deep prosthesis infection occurred leading to the removal of the implant. In the remaining eight patients the mean AOFAS score improved significantly from 21.5 to 68.0 points (P < 0.0005), the VAS score decreased significantly from 7.6 to 1.9 points (P < 0.0005). ROM increased from 23.2 to 25.0 degrees (P = 0.51). At final follow‐up all patients without any complications were satisfied with the postoperative results. Radiographic examination did not reveal any signs of prosthetic loosening. TAR is a viable surgical treatment option in patients with end‐stage ankle osteoarthritis due to haemophilia. It provides significant pain relieve and high patient satisfaction. However, due to the increased risk of infection and lack of long‐term results, TAR particularly in patients with severe haemophilia and virus infections should be indicated carefully.

Azetabuläre Defektrekonstruktion in der Revisionschirurgie der Hüfte

ZusammenfassungDie Behandlung periprothetischer Knochendefekte am Acetabulum stellt eine therapeutische Herausforderung in der Revisionschirurgie der Hüfte dar. Ziel sollte neben der Wiederherstellung der physiologischen Gelenkbiomechanik sowie der primär- und belastungsstabilen Verankerung des Revisionsimplantats am vitalen Beckenknochen die biologische Rekonstruktion knöcherner azetabulärer Defekte mit Wiederherstellung eines tragfähigen Pfannenlagers sein. Dabei sollte der biologische Wiederaufbau des Pfannenlagers ein sog. „down grading“ der azetabulären Defektsituation vor dem Hintergrund eines erneuten Revisionseingriffs beinhalten.Für die Rekonstruktion azetabulärer Defekte stehen heutzutage eine Vielzahl von Implantaten und Rekonstruktionsverfahren zur Verfügung. Kontrovers wird derzeit die Wahl der geeigneten Materialien (ossär vs. metallisch) zur Wiederherstellung eines tragfähigen Pfannenlagers diskutiert.Dieser Artikel beleuchtet die verschiedenen Möglichkeiten der Rekonstruktion azetabulärer Knochendefekte unter Berücksichtigung der derzeitigen Erkenntnisse der wissenschaftlichen Literatur.AbstractThe treatment of periprosthetic bone defects of the acetabulum is a therapeutic challenge in hip revision surgery. The aims are the biological reconstruction of osseous acetabular defects and the restoration of a load-bearing acetabular bone stock as well as restoring the physiological joint biomechanics and achieving primary and load-stable fixation of the revision graft in the vital pelvic bone. The biological reconstruction of the acetabular bone stock should include what is referred to as “down-grading” of the acetabular defect situation in case a repeat revision procedure becomes necessary.Nowadays, a large variety of grafts and reconstruction procedures are available for the reconstruction of acetabular defects. The choice of suitable materials (osseous or metallic) for the restoration of a load-bearing acetabular bone stock is currently the subject of controversial discussion.This article reviews the various options for the reconstruction of acetabular bone defects taking into consideration the current findings in the scientific literature.

MALDI imaging of predictive ferritin, fibrinogen and proteases in haemophilic arthropathy.

Arthropathy as a result of repeated joint bleeding is a severe complication in patients with haemophilia. In the evaluation of synovial tissue specimens, histology alone is non‐specific and there is considerable morphological overlap with other joint diseases. Formalin‐fixed paraffin‐embedded specimens are available in pathological institutes and can be studied to understand the pathogenesis of haemophilic arthropathy. A powerful technique to identify hundreds of proteins in a tissue section combining proteomics with morphology is imaging mass spectrometry (IMS). We determined whether matrix‐assisted laser desorption/ionization (MALDI) IMS can be used to identify and map protein signatures in the synovial tissue of patients with haemophilic arthropathy. MALDI IMS was applied to synovial tissue of six patients with haemophilic arthropathy. We detected several peaks predictive in mass with ferritin light (m/z 1608) and heavy chain (m/z 1345), alpha‐ (m/z 1071) and beta (m/z 1274) haemoglobin subunits, truncated coagulation factor VIII peptide (m/z 1502, 1176), beta‐ and gamma fibrinogen peptides (m/z 980, 1032, 1117 and 1683), and annexin A2 (m/z 1111, 1268, 1460, 2164). In addition, the distribution of these proteins in synovial tissue sections was demonstrated. MALDI IMS identified and mapped specific proteins in the synovial membrane of patients with haemophilic arthropathy known to be involved in the pathogenesis of other joint diseases. This technique is a powerful tool to analyse the distribution of proteins in synovial tissue sections.

[What can be done when hip prostheses fail? : New trends in revision endoprosthetics].

ZusammenfassungDie Zahl der Revisionsoperationen nach künstlichem Gelenkersatz des Hüftgelenks steigt stetig. Die Rekonstruktionsverfahren stellen hohe Ansprüche an den Operateur  und die verwendeten Implantatsysteme. Neue Entwicklungen aus der Forschung und Industrie erweitern die Möglichkeiten zur Versorgung der Patienten. Der vorliegende Artikel soll einen Überblick über den „state of the art“ der Revisionsendoprothetik des Hüftgelenks geben und neue Trends aufzeigen.AbstractRevision surgery after total hip arthroplasty is increasing steadily in numbers. These procedures demand high performance from both the treating surgeon as well as the implants used. Novel developments from basic research and industrial partners extend the possibilities for treating affected patients. This article gives an overview of the state of the art in revision hip arthroplasty: new techniques and trends are outlined and presented.Revision surgery after total hip arthroplasty is increasing steadily in numbers. These procedures demand high performance from both the treating surgeon as well as the implants used. Novel developments from basic research and industrial partners extend the possibilities for treating affected patients. This article gives an overview of the state of the art in revision hip arthroplasty: new techniques and trends are outlined and presented.

[Acetabular defect reconstruction in revision surgery of the hip. Autologous, homologous or metal?].

ZusammenfassungDie Behandlung periprothetischer Knochendefekte am Acetabulum stellt eine therapeutische Herausforderung in der Revisionschirurgie der Hüfte dar. Ziel sollte neben der Wiederherstellung der physiologischen Gelenkbiomechanik sowie der primär- und belastungsstabilen Verankerung des Revisionsimplantats am vitalen Beckenknochen die biologische Rekonstruktion knöcherner azetabulärer Defekte mit Wiederherstellung eines tragfähigen Pfannenlagers sein. Dabei sollte der biologische Wiederaufbau des Pfannenlagers ein sog. „down grading“ der azetabulären Defektsituation vor dem Hintergrund eines erneuten Revisionseingriffs beinhalten.Für die Rekonstruktion azetabulärer Defekte stehen heutzutage eine Vielzahl von Implantaten und Rekonstruktionsverfahren zur Verfügung. Kontrovers wird derzeit die Wahl der geeigneten Materialien (ossär vs. metallisch) zur Wiederherstellung eines tragfähigen Pfannenlagers diskutiert.Dieser Artikel beleuchtet die verschiedenen Möglichkeiten der Rekonstruktion azetabulärer Knochendefekte unter Berücksichtigung der derzeitigen Erkenntnisse der wissenschaftlichen Literatur.AbstractThe treatment of periprosthetic bone defects of the acetabulum is a therapeutic challenge in hip revision surgery. The aims are the biological reconstruction of osseous acetabular defects and the restoration of a load-bearing acetabular bone stock as well as restoring the physiological joint biomechanics and achieving primary and load-stable fixation of the revision graft in the vital pelvic bone. The biological reconstruction of the acetabular bone stock should include what is referred to as “down-grading” of the acetabular defect situation in case a repeat revision procedure becomes necessary.Nowadays, a large variety of grafts and reconstruction procedures are available for the reconstruction of acetabular defects. The choice of suitable materials (osseous or metallic) for the restoration of a load-bearing acetabular bone stock is currently the subject of controversial discussion.This article reviews the various options for the reconstruction of acetabular bone defects taking into consideration the current findings in the scientific literature.

Was tun, wenn die Hüftendoprothese versagt?

ZusammenfassungDie Zahl der Revisionsoperationen nach künstlichem Gelenkersatz des Hüftgelenks steigt stetig. Die Rekonstruktionsverfahren stellen hohe Ansprüche an den Operateur  und die verwendeten Implantatsysteme. Neue Entwicklungen aus der Forschung und Industrie erweitern die Möglichkeiten zur Versorgung der Patienten. Der vorliegende Artikel soll einen Überblick über den „state of the art“ der Revisionsendoprothetik des Hüftgelenks geben und neue Trends aufzeigen.AbstractRevision surgery after total hip arthroplasty is increasing steadily in numbers. These procedures demand high performance from both the treating surgeon as well as the implants used. Novel developments from basic research and industrial partners extend the possibilities for treating affected patients. This article gives an overview of the state of the art in revision hip arthroplasty: new techniques and trends are outlined and presented.Revision surgery after total hip arthroplasty is increasing steadily in numbers. These procedures demand high performance from both the treating surgeon as well as the implants used. Novel developments from basic research and industrial partners extend the possibilities for treating affected patients. This article gives an overview of the state of the art in revision hip arthroplasty: new techniques and trends are outlined and presented.