Thomas Barthel

A Prospective Multicenter Study on the Outcome of Type I Collagen Hydrogel–Based Autologous Chondrocyte Implantation (CaReS) for the Repair of Articular Cartilage Defects in the Knee

Background: The Cartilage Regeneration System (CaReS) is a novel matrix-associated autologous chondrocyte implantation (ACI) technique for the treatment of chondral and osteochondral lesions (Outerbridge grades III and IV). For this technology, no expansion of the chondrocytes in a monolayer culture is needed, and a homogeneous cell distribution within the gel is guaranteed. Purpose: To report a prospective multicenter study of matrix-associated ACI of the knee using a new type I collagen hydrogel (CaReS). Study Design: Case series; Level of evidence, 4. Methods: From 2003 to 2008, 116 patients (49 women and 67 men; mean age, 32.5 ± 8.9 years) had CaReS implantation of the knee in 9 different centers. On the basis of the International Cartilage Repair Society (ICRS) Cartilage Injury Evaluation Package 2000, the International Knee Documentation Committee (IKDC) score, pain score (visual analog scale [VAS]), SF-36 score, overall treatment satisfaction and the IKDC functional status were evaluated. Patient follow-up was performed at 3, 6, and 12 months after surgery and annually thereafter. Mean follow-up was 30.2 ± 17.4 months (range, 12-60 months). There were 67 defects of the medial condyle, 14 of the lateral, 22 of the patella/trochlea, and 3 of the tibial plateau, and 10 patients had 2 lesions. The mean defect size was 5.4 ± 2.4 cm2. Thirty percent of the defects were <4 cm2 and 70% were >4 cm2. Results: The IKDC score improved significantly from 42.4 ± 13.8 preoperatively to 70.5 ± 18.7 (P < .001) at latest follow-up. Global pain level significantly decreased (P < .001) from 6.7 ± 2.2 preoperatively to 3.2 ± 3.1 at latest follow-up. There also was a significant increase of both components of the SF-36 score. The overall treatment satisfaction was judged as very good or good in 88% by the surgeon and 80% by the patient. The IKDC functional knee status was grade I in 23.4%, II in 56.3%, III in 17.2%, and IV in 3.1% of the patients. Conclusion: Matrix-associated ACI employing the CaReS technology for the treatment of chondral or osteochondral defects of the knee is a safe and clinically effective treatment that yields significant functional improvement and improvement in pain level. However, further investigation is necessary to determine the long-term viability and clinical outcome of this procedure.

Randomized trial comparing early postoperative irradiation vs. the use of nonsteroidal antiinflammatory drugs for prevention of heterotopic ossification following prosthetic total hip replacement.

PURPOSE A randomized trial was undertaken to assess the comparative efficacy of early postoperative irradiation with either 5 or 7 Gy vs. the use of nonsteroidal antiinflammatory drug (NSAID) for prevention of heterotopic ossification (HO) following prosthetic total hip replacement (THP). METHODS AND MATERIALS Between 1993 and 1994, 301 patients were randomized to receive postoperative irradiation (5 or 7 Gy) or NSAID. One hundred and thirteen patients were treated with NSAID (indomethacin 2 x 50 mg/day for 1 week), 93 patients were irradiated with a single 7 Gy fraction, 95 patients with a single 5 Gy fraction. The treatment volume included the soft tissues between the periacetabular region of pelvis and the intertrochanteric portion of the femur. X-rays of treated hips were obtained immediately and 6 months after surgery. Heterotopic ossification was scored according to the Brooker Grading system. One hundred patients receiving no prophylactic therapy after total hip arthroplasty between 1988 and 1992, were analyzed and defined as historical control group. RESULTS Incidence of heterotopic ossification was 16.0% in NSAID-group (Brooker Score I: 8.0%; II: 6.2%; III: 1.8%; IV: 0%), 30.1% in 5 Gy group (Brooker Score I: 24.7%; II: 4.3%; III: 1.1%; IV: 0%), and 11.1% in 7 Gy group (Brooker Score I: 11.6%; II: 0%; III: 0%; IV: 0%). Regarding overall heterotopic ossification there was a significant difference between the NSAID group and the 5 Gy group (p < .015), respectively, between the 7 Gy group and the 5 Gy group (p < .0001). No significant difference was noted in the influence of overall HO between the NSAID and the 7 Gy group (p > 0.3). Analyzing the clinically significant HO (Brooker Score III and IV) patients irradiated with 7 Gy developed less HO than those treated with NSAID (p = 0.003). Incidence of HO was greater in the untreated historical control group (Brooker Score I: 26%; II: 15%; III: 19%; IV: 5%) than in all three prophylacticly treated groups. CONCLUSION Prophylactic irradiation of the operative site after hip replacement with single a 7 Gy fraction is the most effective postoperative treatment schedule in prevention of clinically significant heterotopic ossification. This therapy modality is more effective than irradiation with a single 5 Gy fraction or use of NSAID.

PREOPERATIVE IRRADIATION VERSUS THE USE OF NONSTEROIDAL ANTI-INFLAMMATORY DRUGS FOR PREVENTION OF HETEROTOPIC OSSIFICATION FOLLOWING TOTAL HIP REPLACEMENT: THE RESULTS OF A RANDOMIZED TRIAL

PURPOSE Previous studies showed the effectiveness of early preoperative (4 h before operation) irradiation for prevention of heterotopic ossification (HO) after total hip replacement. This procedure can result in logistic problems, if there is a great distance between the department of radiotherapy and the orthopedic clinic. To avoid these organizational problems a prospective study was undertaken to analyze the effectiveness of preoperative irradiation on the day preceding surgery (16-20 h before operation). METHODS AND MATERIALS Between 1995 and 1996, 100 patients were randomized to receive a prophylactic therapy for prevention of heterotopic ossification. Forty-six patients were irradiated with 7 Gy single dose within 16-20 h before operation. Fifty-four patients were treated with nonsteroidal anti-inflammatory drugs (NSAID) (Voltaren resinat 2 x 75 mg/day for 2 weeks). Heterotopic ossification was scored according to the Brooker Grading system. One hundred patients receiving no prophylactic therapy after total hip arthroplasty between 1988 and 1992 were analyzed and defined as the historical control group. RESULTS Incidence of heterotopic ossification was 47.8% in the 7 Gy preoperative group (Brooker Score I: 36.9%; II: 8.7%; III: 2.2%; IV: 0%) and 11.1% in the NSAID group (Brooker Score I: 9.3%; II: 1.8%; III: 0%; IV: 0%). Regarding overall heterotopic ossification there was a significant difference between the NSAID group and the 7 Gy group (p < 0.01). Analyzing the clinically significant heterotopic ossification (Brooker Score III and IV) there was no significant difference between the two treatment arms (p > 0.05). In the untreated historical control group the incidence of heterotopic ossification was 65% (Brooker Score I: 26%; II: 15%; III: 19%; IV: 5%). Referring to overall and to clinically relevant heterotopic ossification the incidence of HO was greater in the control group than in the prophylactically treated groups (p < 0.05). CONCLUSION Irradiation within 16-20 h before operation and use of NSAID (Voltaren resinat) can reduce the incidence of clinically relevant heterotopic ossification after total hip replacement.

The influence of variations of the coracoacromial arch on the development of rotator cuff tears

In order to define the geometry of the coracoacromial arch in both its bony and soft parts and to bring it into relationship with rotator cuff tears, 54 cadaver shoulders (from subjects aged 47–90 years) were dissected And X-rayed (anteroposterior projection and supraspinatus outlet view). Partial rotator cuff tears were assessed additionally by transillumination and polarized microscopy. After transfixation of the coracoacromial arch with a polyurethane mould, sections were made along the coracoacromial ligament. The morphology of the acromion was described following the classification of Bigliani et al. [5]. Amongst other parameters, measurements were taken between the long axis of the scapula, the spina, and the acromion. In 19 of 22 cases, a traction osteophyte was associated with rotator cuff tears. In incomplete tears, spurs were completely encased within the ligament and did not impair the subacromial space. The number of rotator cuff tears was significantly increased in shoulders with “curved” acromia, flat acromial slope, and increased angle between the scapular plane and the spina (intact, mean 58°; tears, mean 47°). The morphology of the subacromial space was secondarily determined by this angle. In contrast to Bigliani et al. we were unable to find a “hooked” acromion. These results indicate that the combination of a flat and curved acromion or a position of the acromioclavicular joint above the cranial pole of the glenoid must be regarded as considerable risks for the development of rotator cuff tears. The concept of anterior acromioplasty is supported by our results.

Prophylaxis of heterotopic ossification after total hip arthroplasty: a prospective randomized study comparing indomethacin and meloxicam.

: We performed a randomized, prospective study on the prophylaxis of heterotopic ossification (HO) after total hip arthroplasty (THR), comparing indomethacin and the selective COX-2 inhibitor meloxicam. From the day after surgery, 272 patients were treated with 7.5 mg meloxicam, 15 mg meloxicam, or 2 x 50 mg indomethacin a day, for 14 days. After 6 months, radiographs of patients treated with 7.5 mg meloxicam showed that HO had occurred in one third. This treatment was therefore stopped after 26 patients have been assigned to this group. According to the intention-to-treat principle, patients given 15 mg meloxicam developed HO in 25% (20% Brooker grade I, 4% grade II and 1% grade III) and those given indomethacin in 10% (7% Brooker grade I, 1% grade II and 2% grade III), a statistically significant difference.

Heterotopic ossification after total knee arthroplasty : 54/615 cases after 1-6 years'follow-up

We found heterotopic ossifications in 54 (9%) of 615 cases after total knee arthroplasty. The largest ossifications were located in the anterior distal femur. In 12 cases smaller ossifications were found in other knee regions. The development of heterotopic ossification showed a positive correlation with hypertrophic arthrosis and a negative correlation with rheumatoid arthritis. We propose a new 3-grade classification which refers only to the anterior distal femoral region. Grade III heterotopic ossifications occurred in 4 patients (4 knees) who had clinical symptoms; 2 were successfully reoperated with removal of the ossifications. Prophylaxis should be considered in patients with marked hypertrophic arthrosis or marked periosteal damage to the anterior distal femur.

PREVENTION OF HETEROTOPIC OSSIFICATION AFTER TOTAL HIP REPLACEMENT

We have carried out a prospective, randomised study of prophylaxis for heterotopic ossification (HO) comparing indomethacin for 7 and 14 days, acetylsalicylic acid, and fractional (4 x 3 Gy) or single exposure of 5 or 7 Gy irradiation after operation. We initially had 723 patients (733 hip replacements), but after withdrawals there were 685 hips of which 18.4% developed HO; 14% were grade I, 2.9% grade II and 1.5% grade III of the Brooker classification. We compared the results between these groups with those of a matched control series and found that indomethacin, 2 x 50 mg for 7 and 14 days, and postoperative irradiation of 4 x 3 Gy or 1 x 7 Gy, significantly reduced the development of HO compared with the control group. Patients in the acetylsalicylic acid group and those with a single irradiation of 5 Gy after operation developed significantly more ossification than those in the indomethacin and other irradiation groups. We suggest the use of 2 x 50 mg of indomethacin with mucoprotection for seven days as prophylaxis against HO after total hip replacement for all patients. A single irradiation of 7 Gy is recommended for patients who have developed HO after previous operations or to whom administration of indomethacin is contraindicated.

9- to 11-Year Results of Cemented Titanium Mueller Straight Stem in Total Hip Arthroplasty

This retrospective study reviewed 9- to 11-year results after total hip arthroplasty (THA) with cemented titanium stems (Mueller-Straight-Stem). Ninety-one patients (110 hips) were examined clinically and radiologically at an average 9.5-year follow-up. Revisions for aseptic loosening were performed in 4 (4%) patients. Subsidence or varus position could only be observed in one of these patients. Radiolucent lines were found in 37 patients, mainly located around the proximal zones of the stem (zone 1, 7, 8, and 14). Harris scores were good or excellent in 78% and satisfactory in 20% of patients. The 9.5-year survival rate of the cemented titanium stem with regard to aseptic loosening was 96.4%. Body weight was significantly higher (88 +/- 5.4 kg) in the 4 patients with aseptic loosening, compared to patients without radiolucent lines (75 +/- 15 kg). The body weight to stem surface ratio showed a significant difference (1.5 kg/cm2 versus 1 kg/cm2; P < .05). No significant differences were found in other factors, including sex, size or type of stem, Harris score, heterotopic ossification, or body mass index. Good long-term results can be achieved with cemented titanium stem implants. This titanium implant is recommended for patients with hypersensitivity to chrome, cobalt, and nickel. mplanting the biggest possible stem seems to be most beneficial.

Prospektive Studie zur Vermeidung heterotoper Ossifikationen nach Hüftgelenksersatz

ZusammenfassungZielsetzungMittels zweier prospektiver Studien wurde untersucht, inwieweit eine postoperative Radiotherapie mit unterschiedlichen Bestrahlungsdosen und die postoperative Gabe nichtsteroidaler Antirheumatika die Inzidenz heterotoper Ossifikationen nach endoprothetischem Gelenkersatz der Hüfte reduzieren können.Patienten und Methode585 Patienten erhielten in den Jahren 1992 bis 1994 eine Totalendoprothese des Hüftgelenks. Diese Patienten wurden innerhalb zweier longitudinal angelegter, jeweils dreiarmiger Studien randomisiert. Verglichen wurde dabei eine postoperative fraktionierte Bestrahlung mit 4×3 Gy (101 Patienten), eine einmalige postoperative Bestrahlung mit 1×5 Gy (93 Patienten) und 1×7 Gy (95 Patienten), die postoperative Gabe der nichtsteroidalen Antirheumatika Indometacin über sieben Tage (113 Patienten) bzw. über 14 Tage (90 Patienten) und Acetylsalicylsäure über 14 Tage (93 Patienten). Das Ausmaß der Ossifikationen wurde nach dem Brooker-Score beurteilt. Als zusätzliches Vergleichskollektiv wurde eine Gruppe von 100 Patienten ausgewertet, die in den Jahren 1988 bis 1992 ebenfalls eine Endoprothese des Hüftgelenks bekamen, bei denen jedoch keine Ossifikationsprophylaxe durchgeführt worden war.ErgebnisseDie Rate der heterotopen Ossifikationen betrug in der mit 4×3 Gy bestrahlten Gruppe 5% (Brooker-Grad I 5%, Grad II 0%, Grad III 0%), in der mit 1×5 Gy bestrahlten Gruppe 30,5% (Brooker-Grad I 24,7%, Grad II 4,1%, Grad III 1,0%) und in der mit 1×7 Gy bestrahlten Gruppe 10,5% (Brooker-Grad I 10,5%, Grad II 0%, Grad III 0%). Bei 15,9% (Brooker-Grad I 8,0%, Grad II 6,2%, Grad III 1,7%) der mit Indometacin über sieben Tage behandelten Patienten bzw. bei 12,2% (Brooker-Grad I 8,9%, Grad II 2,2%, Grad III 1,1%) der über 14 Tage behandelten und bei 37,5% (Brooker-Grad I 27,9%, Grad II 4,3%, Grad III 5,3%) der mit Acetylsalicylsäure behandelten Patienten kam es zur Ausbildung von heterotopen Ossifikationen. Die geringsten Raten an heterotopen Ossifikationen fanden sich demnach bei den mit 4×3 Gy oder 1×7 Gy bestrahlten Patienten, ohne daß zwischen diesen beiden Gruppen ein signifikanter Unterschied bestanden hätte.SchlußfolgerungDie postoperative Bestrahlung ist der Gabe von nichtsteroidalen Antirheumatika hinsichthch der Verringerung der Ossifikationsrate nach totalendoprothetischem Hüftgelenkersatz überlegen. Da sich kein signifikanter Unterschied zwischen der fraktionierten Bestrahlung mit 4×3 Gy und der einmaligen Bestrahlung mit 1×7 Gy fand, die einmalige Bestrahlung aber den Vorteil der geringeren Belastung für den Patienten hat und zusätzlich kostengünstiger ist, ist diese einem fraktionierten Bestrahlungskonzept vorzuziehen.AbstractPurposeTwo prospective trials were undertaken to assess the comparative efficacy of early postoperative irradiation with different radiation doses versus the postoperative use of nonsteroidal antiinflammatory drugs (NSAID) for prevention of heterotopic ossification (HO) following prothetic total hip replacement (THP).Patients and MethodBetween 1992 and 1994 585 patients received THP. These patients were randomwed in two longitudinal studies each with 3 treatment arms comparing postoperative irradiation with 4×3 Gy (101 patients), 1×5 Gy (93 patients), 1×7 Gy (95 patients) and the postoperative use of the NSAID indometacin for 7 days (113 patients) respectively for 14 days (90 patients) und acetyl salicyl acid (ASS) for 14 days (93 patients). Heterotopic ossification was scored according to the Brooker grading system. One hundred patients receiving no prophylactic therapy after total hip arthroplasty between 1988 and 1992 were analysed and defined as historical control group.ResultsIncidence of heterotopic ossification was 5% in the 4×3 Gy group (Brooker grade I 5%, grade II 0%, grade III 0%), 30,5% in the 1×5 Gy group (Brooker grade I 24,7%, grade II 4,1%, grade III 1.0%) and 10,5% in the 1×7 Gy group (Brooker grade I 10.5%, grade II 0%, grade III 0%). 15.9% of the indometacin-7 days-group developed heterotopic ossification (Brooker grade I 8%, grade II 6.2%, grade III 1.7%, grade IV 0%), 12.2% of the indometacin-14 days-group (Brooker grade I 8.9%, grade II 2.2%, grade III 1.1%) and 37.5% of the ASS-group (Brooker grade I 27.9%, grade II 4.3%, grade III 5.3%). The lowest incidence of heterotopic ossification was found for the 4××3 Gy and the 1×7 Gy group, but no significant difference between these two different treatments was observed.ConclusionProphylactic irradiation of the operative site after hip replacement is more effective than the use of NSAID. Because no significant difference between the fractionated ingle dose irradiation was found and the latter is more comfortable for patients and more economical, irradiation with single 7 Gy fraction should be prefered.PURPOSE Two prospective trials were undertaken to assess the comparative efficacy of early postoperative irradiation with different radiation doses versus the postoperative use of nonsteroidal antiinflammatory drugs (NSAID) for prevention of heterotopic ossification (HO) following prothetic total hip replacement (THP). PATIENTS AND METHOD Between 1992 and 1994 585 patients received THP. These patients were randomed in two longitudinal studies each with 3 treatment arms comparing postoperative irradiation with 4 x 3 Gy (101 patients), 1 x 5 Gy (93 patients), 1 x 7 Gy (95 patients) and the postoperative use of the NSAID indometacin for 7 days (113 patients) respectively for 14 days (90 patients) und acetyl salicyl acid (ASS) for 14 days (93 patients). Heterotopic ossification was scored according to the Brooker grading system. One hundred patients receiving no prophylactic therapy after total hip arthroplasty between 1988 and 1992 were analysed and defined as historical control group. RESULTS Incidence of heterotopic ossification was 5% in the 4 x 3 Gy group (Brooker grade I 5%, grade II 0%, grade III 0%), 30.5% in the 1 x 5 Gy group (Brooker grade I 24.7%, grade II 4.1%, grade III 1.0%) and 10.5% in the 1 x 7 Gy group (Brooker grade I 10.5%, grade II 0%, grade III 0%). 15.9% of the indometacin-7 days-group developed heterotopic ossification (Brooker grade I 8%, grade II 6.2%, grade III 1.7%, grade IV 0%), 12.2% of the indometacin-14 days-group (Brooker grade I 8.9%, grade II 2.2%, grade III 1.1%) and 37.5% of the ASS-group (Brooker grade I 27.9%, grade II 4.3%, grade III 5.3%). The lowest incidence of heterotopic ossification was found for the 4 xx 3 Gy and the 1 x 7 Gy group, but no significant difference between these two different treatments was observed. CONCLUSION Prophylactic irradiation of the operative site after hip replacement is more effective than the use of NSAID. Because no significant difference between the fractionated ingle dose irradiation was found and the latter is more comfortable for patients and more economical, irradiation with single 7 Gy fraction should be preferred.

Influence of T-shift capsulorrhaphy on rotation and translation of the glenohumeral joint: An experimental study

To evaluate changes in the response of capsuloligamentous restraints to translatory forces and rotation torques caused by experimental capsulorrhaphy (T-shift modification of Bankart repair), eight cadaveric shoulders were tested. Measurements were taken in intact and vented specimens, after severance of the anterior capsule at the glenoid rim (creating an artificial Bankart lesion), T-shaped incision of the anterior capsule, and refixation of the capsule (with a standard Bankart procedure) combined with tightening by T-shift. Rotation torques and translatory forces were applied in different positions of abduction with a specifically designed mounting apparatus that had four degrees of freedom. Dynamic and static measurements were performed with a tracking sysem that had six degrees of freedom. T-shift capsulorrhaphy restored the resistance of the capsuloligamentous restraints to translatory forces in all directions. This restoration was confirmed when we compared these results with data obtained from intact joints. No significant alteration of the centering mechanism resulting from rotation torques was observed, although the extent of external and internal rotation was remarkably decreased. This T-shift modification seems to produce a symmetric reduction of the volume of the capsule without significant displacement of the humeral head.