Turgay Efe

Navigation of total knee arthroplasty: rotation of components and clinical results in a prospectively randomized study

BackgroundNavigation was introduced into total knee arthroplasty (TKA) to improve accuracy of component position, function and survival of implants. This study was designed to assess the outcome of navigated TKA in comparison with conventional implantation with the focus on rotational component position and clinical mid-term results.MethodsIn a prospectively randomized single-blinded approach, 90 patients with primary gonarthrosis were assigned to three different groups. Thirty patients each were assigned to NexGen LPS without and with navigation (groups 1 and 2), and 30 patients to navigation with the Stryker Scorpio PS (group 3). The navigation system used was the imageless Stryker KneeTrac, version 1.0. Clinical outcome was assessed by a blinded observer applying the Knee Society Score (KSS) and a visual analogue scale (VAS) for pain. CT scans and radiographs were conducted prior to and 12 weeks after index surgery.ResultsSeventy-nine patients were available for clinical evaluation at 3 ± 0.4 years follow-up. Four implants had to be revised for early loosening or infection (4.4%). Four patients had died and three patients were not able to follow the invitation for clinical assessment. Functional results in the KSS were significantly lower after navigated TKA. Operation time and incisions with navigation were significantly longer. Significantly less radiological outliers with navigation were found for coronal alignment of the femur, only.ConclusionIn this series, no beneficial effect for navigation in TKA could be shown assessing clinical data, as functional results in the presented series seemed to be lower after first generation navigated TKA. The clinical mid- to long-term value of navigation remains to be evaluated in larger patient series or meta-analyses at longer follow-up.Trial registration numberDRKS 00000430

Closing-wedge high tibial osteotomy: survival and risk factor analysis at long-term follow up

BackgroundClosing-wedge high tibial osteotomy (HTO) is successful for the treatment of medial osteoarthritis with varus malalignment. Preoperative risk factors for HTO failure are still controversial. The aim of this study was to elucidate the outcome and assess the influence of risk factors on long term HTO survival.Methods199 patients were retrospectively studied with a mean follow-up period of 9.6 years after HTO. HTO failure was defined as the need for conversion to TKA. Survival was analyzed with the Kaplan-Meier method. Knee function was evaluated by the Hospital for Special Surgery (HSS) score. HTO-associated complications were also assessed. Univariate, multivariate, and logistic regression analysis were performed to evaluate the influence of age, gender, BMI, preoperative Kellgren-Lawrence osteoarthritis grade, and varus angle on HTO failure.Results39 complications were recorded. Thus far, 36 HTOs were converted to TKA. The survival of HTO was 84% after 9.6 years. Knee function was considered excellent or good in 64% of patients. A significant preoperative risk factor for HTO failure was osteoarthritis, Kellgren-Lawrence grade >2.ConclusionHTO provides good clinical results in long-term follow-up. Preoperative osteoarthritis Kellgren-Lawrence grade >2 is a significant predictive risk factor for HTO failure. Results of HTO may be improved by careful patient selection. Complications associated with HTO should not be underestimated.

Shoulder Sport-Specific Impairments After Arthroscopic Bankart Repair A Prospective Longitudinal Assessment

Background: Reports of return to shoulder-dependent sport after surgical stabilization previously underestimated impairments, which were not reflected in the score systems used. Hypothesis: Return to shoulder-dependent sport depends on the type of sport performed. Study Design: Case series; Level of evidence, 4. Methods: Forty-seven athletes (26.9 years of age at surgery) who underwent isolated arthroscopic Bankart repair were longitudinally monitored by shoulder-dependent sport-specific activity (Shoulder Sport Activity Score [SSAS]) and ability (Athletic Shoulder Outcome Scoring System [ASOSS]) scores and visual analog scales for reachieved proficiency level, sport-specific shoulder pain, and functional deficits. Data were assessed at 4 points of treatment: preoperatively, and postoperatively after 6, 16, and 32 months (P0-P3). Athletes were analyzed separately according to shoulder sport: noncollision/nonoverhead (G1), collision (G2), overhead (G3), and martial arts (G4). Results: The G1 and G2 athletes had reachieved the preinjury sport activity and sport proficiency status and excellent ASOSS scores after 32 months (SSASG1 = 7.2, SSASG2 = 8.1, ASOSSG1 = 94.4, ASOSSG2 = 95.2), whereas G3 and G4 athletes remained at an inferior activity level (SSASG3 = 8.0, SSASG4 = 8.3) and proficiency level. The ASOSS documented a prolonged period of shoulder rehabilitation for G3 and G4 athletes to reach a good shoulder-dependent sport ability outcome after 32 months (ASOSSG3 = 89.0, ASOSSG4 = 93.1). All groups recorded persisting limitations in visual analog scales for sport-specific shoulder function and pain. The established scores (Rowe = 95.9, Walch-Duplay = 93.3, Constant = 94.0) did not reflect these sport-specific impairments. Athletes with 5 or more preoperative dislocations had significantly longer surgery-to-sport resumption intervals with a prolonged proficiency recovery. Conclusion: The athletes’ shoulder stabilization resulted in a prolonged rehabilitation depending on the functional demand of the performed shoulder-dependent sport, as shown by the specific shoulder sport score systems.

TKA following high tibial osteotomy versus primary TKA - a matched pair analysis

BackgroundHigh tibial osteotomy (HTO) is a well established technique for the treatment of medial osteoarthritis of the knee with varus malalignment. Results of total knee arthroplasty (TKA) after previous HTO are still discussed controversially. The aim of this study was to elucidate the clinical and radiological results as well as perioperative data of prior HTO on TKA.MethodsForty-one TKA after HTO were compared to 41 primary TKA at minimum of six years follow-up. Patients were matched according to age, gender, follow-up, etiology, and prosthetic design. Surgical data and complications were evaluated. Clinical outcome was assessed using a number of clinical scores and the visual analogue scale (VAS) for pain. X-rays were evaluated by the method of the American Knee Society. The patellar position was measured by the Insall-Salvati ratio.ResultsThere was no significant difference in mean operation time (p = 0.47) and complication rate (p = 0.08). The Knee Score of the KSS (p = 0.0007) and the ROM (p = 0.006 for extension and p = 0.004 for flexion, respectively) were significantly better in the control group. Mid-term results of the VAS, WOMAC, Lequesne, UCLA, Fellers Patellar Score and SF-36 showed no significant difference. Femoral and tibial component alignment were similar in both groups. One tibial component showed suspect radiolucencies in the HTO group. The Insall-Salvati ratio showed three patients with patella alta and one patient with patella baja in the HTO group. At latest follow-up all implants were still in place.ConclusionsEvaluating the clinical and radiological outcome, significant differences were only detected for range of motion and the Knee Score of the KSS. The present study suggests that the results of TKA with and without prior HTO are mainly identical. Although patients with a previous HTO had more complications, no statistically significant differences were noted with this group size.

Analyses of Prosthesis Stem Failures in Noncemented Modular Hip Revision Prostheses

In recent years, hip prosthesis stem revision by means of modular revision systems has reached an essential role in revision prosthetics. It is an extremely successful technique. Reports about mechanical failure in nonmodular revision stems have already been published. This complication is rare, but feared. We report about mechanical failure of four non-cemented modular revision stems over a period of 28 months. All failures became clinically apparent because of severe inguinal or thigh pain and were confirmed by conventional x-ray imaging. All stem failures occurred just below the interface between prosthesis stem and neck, which is a biomechanically stressed area. Distal of the failure, all stems were still firmly fixed. In all cases, there was obvious evidence of loosening at the proximal component. Metallographic and energy-dispensive x-ray analysis of one stem showed a fatigue fracture due to dynamic stress. If new pain arises after revision surgery with modular non-cemented prosthesis systems, the possibility of an implant failure should be kept in mind. Patients should be informed accordingly about the risk of implant failure.

Influence of nanofibers on growth and gene expression of human tendon derived fibroblast

BackgroundRotator cuff tears are a common and frequent lesion especially in older patients. The mechanisms of tendon repair are not fully understood. Common therapy options for tendon repair include mini-open or arthroscopic surgery. The use of growth factors in experimental studies is mentioned in the literature. Nanofiber scaffolds, which provide several criteria for the healing process, might be a suitable therapy option for operative treatment. The aim of this study was to explore the effects of nanofiber scaffolds on human tendon derived fibroblasts (TDFs), as well as the gene expression and matrix deposition of these fibroblasts.MethodsNanofibers composed of PLLA and PLLA/Col-I were seeded with human tendon derived fibroblasts and cultivated over a period of 22 days under growth-inductive conditions, and analyzed during the course of culture, with respect to gene expression of different extra cellular matrix components such as collagens, bigylcan and decorin. Furthermore, we measured cell densities and proliferation by using fluorescene microscopy.ResultsPLLA nanofibers possessed a growth inhibitory effect on TDFs. Furthermore, no meaningful influence on the gene expression of collagen I, collagen III and decorin could be observed, while the expression of collagen X increased during the course of cultivation. On the other hand, PLLA/Col-I blend nanofibers had no negative influence on the growth of TDFs. Furthermore, blending PLLA nanofibers with collagen had a positive effect on the gene expression of collagen I, III, X and decorin. Here, gene expression indicated that focal adherence kinases might be involved.ConclusionThis study indicates that the use of nanofibers influence expression of genes associated with the extra cellular matrix formation. The composition of the nanofibers plays a critical role. While PLLA/Col-I blend nanofibers enhance the collagen I and III formation, their expression on PLLA nanofibers was more comparable to controls. However, irrespective of the chemical composition of the fibres, the collagen deposition was altered, an effect which might be associated with a decreased expression of biglycanes.

Co-occurrence of outlet impingement syndrome of the shoulder and restricted range of motion in the thoracic spine - a prospective study with ultrasound-based motion analysis

BackgroundShoulder complaints, and especially the outlet-impingement syndrome, are a common condition. Among other things, poor posture has been discussed as a cause. A correlation between impingement syndrome and restricted mobility of the thoracic spine (T) has been described earlier, but there has been no motion analysis of the thoracic spine to show these correlations. In the present prospective study, we intended to find out whether there is a significant difference in the thoracic sagittal range of motion (ROM) between patients with a shoulder outlet impingement syndrome and a group of patients who had no shoulder pathology. Secondly, we wanted to clarify whether Otts sign correlates with ultrasound topometric measurements.MethodsTwo sex- and age-matched groups (2 × n = 39) underwent a clinical and an ultrasound topometric examination. The postures examined were sitting up straight, sitting in maximal flexion and sitting in maximal extension. The disabilities of the arm, shoulder and hand (DASH) score (obtained by means of a self-assessment questionnaire) and the Constant score were calculated. Lengthening and shortening of the dorsal projections of the spine in functional positions was measured by tape with Otts sign.ResultsOn examination of the thoracic kyphosis in the erect seated posture there were no significant differences between the two groups (p = 0.66). With ultrasound topometric measurement it was possible to show a significantly restricted segmental mobility of the thoracic spine in the study group compared with the control group (p = 0.01). An in-depth look at the mobility of the subsegments T1-4, T5-8 and T9-12 revealed that differences between the groups in the mobility in the lower two sections of the thoracic spine were significant (T5-8: p = 0.03; T9-12: p = 0.02). The study group had an average Constant score of 35.1 points and the control group, 85.5 (p < 0.001). On the DASH score the patient group reached 34.2 points and the control group, 1.4 (p < 0.001). The results of Otts sign differed significantly between the two collectives (p = 0.0018), but showed a weak correlation with the ultrasound topometric measurements (study group flexion/extension: r = 0.36/0.43, control group flexion/extension: r = 0.29/0.26).ConclusionThe mobility of the thoracic spine should receive more attention in the diagnosis and therapy of patients with shoulder outlet impingement syndrome.

The anterolateral ligament (ALL) and its role in rotational extra-articular stability of the knee joint: a review of anatomy and surgical concepts.

The anterolateral ligament of the knee (ALL) has caused a lot of rumors in orthopaedics these days. The structure that was first described by Segond back in 1879 has experienced a long history of anatomic descriptions and speculations until its rediscovery by Claes in 2013. Its biomechanical properties and function have been examined recently, but are not yet fully understood. While the structure seems to act as a limiter of internal rotation and lateral meniscal extrusion its possible proprioceptive effect remains questionable. Its contribution to the pivot shift phenomenon has been uncovered in parts, therefore it has been recognized that a concomitant anterolateral stabilization together with ACL reconstruction may aid in prevention of postoperative instability after severe ligamentous knee damages. However, there are a lot of different methods to perform this procedure and the clinical outcome has yet to be examined. This concise review will give an overview on the present literature to outline the long history of the ALL under its different names, its anatomic variances and topography as well as on histologic examinations, imaging modalities, arthroscopic aspects and methods for a possible anterolateral stabilization of the knee joint.

Improvement in outcomes after implantation of a novel polyurethane meniscal scaffold for the treatment of medial meniscus deficiency.

Pain 47 ± 14.5 75 ± 17.7 p < 0.0001 82 ± 17.4 p < 0.0001 83 ± 18.6 p < 0.0001 Symptom 60 ± 16.2 67 ± 18.5 p = 0.0091 85 ± 9.7 p < 0.0001 81 ± 13.4 p = 0.0003 ADL 53 ± 16.0 85 ± 14.5 p < 0.0001 88 ± 13.0 p < 0.0001 91 ± 14.7 p < 0.0001 Sport/Rec 26 ± 20.5 60 ± 25.3 p = 0.0001 68 ± 24.0 p < 0.0001 66 ± 28.5 p < 0.0001 QOL 28 ± 16.6 55 ± 26.9 p = 0.0007 67 ± 20.4 p < 0.0001 63 ± 18.9 p < 0.0001 KSS Function score 61 ± 22.2 87 ± 10.2 p = 0.0001 89 ± 15.7 p = 0.0001 96 ± 7.9 p < 0.0001 Knee score 65 ± 9.4 89 ± 13.1 p < 0.0001 87 ± 14.1 p < 0.0001 88 ± 12.4 p < 0.0001 UCLA 5.4 ± 1.8 6.1 ± 1.8 n.s. 6.5 ± 2.1 n.s. 7.3 ± 1.8 p = 0.0035 VAS 5.1 ± 2.0 2.1 ± 2.4 p = 0.0004 1.8 ± 2.3 p < 0.0001 1.5 ± 2.1 p < 0.0001

[Arthroscopically assisted reduction of acute acromioclavicular joint separations: comparison of clinical and radiological results of single versus double TightRope™ technique].

BACKGROUND The aim of this study was to compare the results of the single (STR) versus double TightRope™ (DTR) technique for stabilisation of acute separations of the AC joint with the hypothesis that DTR achieves lower CC distance. PATIENTS AND METHODS A total of 29 consecutive patients treated operatively with the TR technique (mean age 38.1 years, n=26 male) were analysed in a cohort study with a mean follow-up of 13.3 months (12.0-21.7). Acute AC joint separations types III and V according to Rockwood (R) were included; R types I, II, IV and VI were excluded. The prospective scores determined pre-op and 3, 6 and 12 months post-op and X-rays were evaluated. RESULTS Of the patients 12 suffered an R type III and 17 an R V separation; 14 were treated with STR and 15 with DTR. With STR, 8 R III and 6 R V injuries and with DTR 4 R III and 11 R V injuries were treated arthroscopically. STR achieved an increased CC distance >125% compared to the contralateral AC joint in five cases (36%). Two of them occurred as R V and three as R III injury. DTR achieved a CC distance >125% in two cases of an R V injury (13%). CONCLUSION The DTR technique provides lower CC distance compared to the STR technique, without a significant difference of CC distance and scores.