The Orthopaedic forum 2011 Austrian-Swiss-German traveling fellowship tour summary

From January 31st to March 11th 2011 four traveling fellows representing the German speaking associated orthopaedic societies visited different academic orthopaedic centers in the U.K., Canada and the USA

Femoroazetabuläres Impingement beim Jugendlichen und Adoleszenten

Femoroacetabular impingement syndrome (FAIS) is caused by a repetitive mechanical conflict between the acetabulum and the proximal femur, occurring in flexion and internal rotation. In cam impingement, bony prominences of the femoral head-neck junction induce chondrolabral damage. The acetabular type of FAIS, termed pincer FAIS, may be either due to focal or global retroversion and/or acetabular overcoverage. Combinations of cam and pincer morphology are common. Pathological femoral torsion may aggravate or decrease the mechanical conflict in FAI but can also occur in isolation. Of note, a high percentage of adolescents with FAI-like shape changes remain asymptomatic. The diagnosis of FAIS is therefore made clinically, whereas imaging reveals the underlying morphology. X‑rays in two planes remain the primary imaging modality, the exact evaluation of the osseous deformities of the femur and chondrolabral damage is assessed by magnetic resonance imaging (MRI). Acetabular coverage and version are primarily assessed on radiographs. Evaluation of the entire circumference of the proximal femur warrants MRI which is further used in the assessment of chondrolabral lesions, and also bone marrow and adjacent soft tissue abnormalities. The MRI protocol should routinely include measurements of femoral torsion. Fluid-sensitive sequences should be acquired to rule out degenerative or inflammatory extra-articular changes.Das femoroazetabuläre Impingement-Syndrom (FAIS) wird durch einen repetitiven mechanischen Konflikt zwischen Azetabulum und proximalem Femur insbesondere bei Flexion und Innenrotation hervorgerufen. Beim femoroazetabulären Impingement (FAI) vom Cam-Typ bewirkt eine Asphärizität am femoralen Kopf-Hals-Übergang die Induktion von Scherkräften am Azetabulum. Beim Pincer-Typ kann eine Retroversion der Pfanne und/oder eine vermehrte Überdachung vorliegen. Ein wichtiger mechanischer Einflussfaktor, welcher ein Impingement oder auch Hüftinstabilität verstärken oder kompensieren kann, ist die Femurtorsion. Meistens treten Torsionsstörungen kombiniert mit anderen ossären Deformitäten auf. Zu beachten ist, dass ein hoher Prozentsatz der Adoleszenten mit knöchernen FAI-Morphologien asymptomatisch bleibt. Die Diagnose des FAIS wird daher klinisch gestellt, die Bildgebung zeigt die zugrundeliegende Morphologie. Primäre Bildgebung ist das Röntgenbild in 2 Ebenen zur Beurteilung der Hüftgelenküberdachung und der azetabulären Version. Die vollständige Zirkumferenz des Femurs ist jedoch nur in der Magnetresonanztomographie (MRT) beurteilbar, ebenso Läsionen des Labrums und Knorpels sowie des Knochenmarks und der umgebenden Weichteile. Das MRT-Protokoll sollte routinemäßig eine Bestimmung der Rotation des Femurs beinhalten. Zudem sollten flüssigkeitssensitive Sequenzen des Beckens zum groben Ausschluss degenerativer oder entzündlicher extraartikulärer Veränderungen akquiriert werden

Tissue engineering for total meniscal substitution : Animal study in sheep model

Objective: The aim of the study was to investigate the use of a novel hyaluronic acid/polycaprolactone material for meniscal tissue engineering and to evaluate the tissue regeneration after the augmentation of the implant with expanded autologous chondrocytes. Two different surgical implantation techniques in a sheep model were evaluated. Methods: Twenty-four skeletally mature sheep were treated with total medial meniscus replacements, while two meniscectomies served as empty controls. The animals were divided into two groups: cell-free scaffold and scaffold seeded with autologous chondrocytes. Two different surgical techniques were compared: in 12 animals, the implant was sutured to the capsule and to the meniscal ligament; in the other 12 animals, also a transtibial fixation of the horns was used. The animals were euthanized after 4 months. The specimens were assessed by gross inspection and histology. Results: All implants showed excellent capsular ingrowth at the periphery. Macroscopically, no difference was observed between cell-seeded and cell-free groups. Better implant appearance and integrity was observed in the group without transosseous horns fixation. Using the latter implantation technique, lower joint degeneration was observed in the cell-seeded group with respect to cell-free implants. The histological analysis indicated cellular infiltration and vascularization throughout the implanted constructs. Cartilaginous tissue formation was significantly more frequent in the cell-seeded constructs. Conclusion: The current study supports the potential of a novel HYAFF/polycaprolactone scaffold for total meniscal substitution. Seeding of the scaffolds with autologous chondrocytes provides some benefit in the extent of fibrocartilaginous tissue repair

Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider

Objective To perform a systematic literature review (SLR) about the effect of non-pharmacological interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Methods Eight clinical questions based on two criteria guided the SLR: (1) adults >= 50 years at high risk of osteoporotic fracture and (2) interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Interventions focused on diagnostic procedures to identify risk of falling, therapeutic approaches and implementation strategies. Outcomes included fractures, falls, risk of falling and change in bone mineral density. Systematic reviews and randomised controlled trials were preferentially selected. Data were synthesised using a qualitative descriptive approach. Results Of 15 917 records, 43 articles were included. Studies were clinically and methodologically diverse. We identified sufficient evidence that structured exercise, incorporating progressive resistance training delivered to people who had undergone hip fracture surgery, and multicomponent exercise, delivered to people at risk of primary fracture, reduced risk of falling. The effectiveness of multidisciplinary fracture liaison services in reducing refracture rate was confirmed. There was insufficient evidence found to support the effectiveness of nutrients and falls prevention programmes in this patient population. Conclusion Despite study heterogeneity, our SLR showed beneficial effects of some interventions delivered by non-physician health professionals and the positive impact of multidisciplinary team working and patient educational approaches to prevent and manage osteoporotic fractures. These results informed a EULAR taskforce that developed points to consider for non-physician health professionals to prevent and manage osteoporotic fractures.This study was funded by the EULAR. Grant reference HPR 032.info:eu-repo/semantics/publishedVersio

2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older

Objective To establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older. Methods Points to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated. Results Two overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6. Conclusion These first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.HPR 032info:eu-repo/semantics/publishedVersio

Can Adding BMP2 Improve Outcomes in Patients Undergoing the SUPERhip Procedure?

Congenital femoral deficiency (CFD) Paley type 1b is characterized by severe bony deformity of the upper femur, extra-articular contractures of the hip, and, delayed ossification of the femoral neck and/or subtrochanteric region. The Systematic Utilitarian Procedure for Extremity Reconstruction of the hip (SUPERhip) procedure for the correction of CFD deformities was developed in 1997. Initially, a non-fixed angle device (rush rod) was used for fixation. Late complications of persistent delayed ossification and recurrent varus deformity occurred. In order to reduce and treat such complications, fixation with a fixed angle device and the off-label use of BMP2 to induce ossification of the un-ossified femoral neck were employed. The purpose of this study is to determine if the use of a fixed angle device, and, BMP2 inserted into a drill hole in the cartilage of the femoral neck, decreases the incidence of these late complications. We retrospectively reviewed 72 SUPERhip procedures performed for Paley type 1b CFD between 1997 and 2012. Due to recurrent varus or persistent delayed ossification of the femoral neck, 34 revision SUPERhip procedures were performed. In total, 106 SUPERhip procedures were studied. Sixty-eight SUPERhips were performed using internal fixation without BMP2, while 38 SUPERhips were performed with both internal fixation and the addition of BMP2. Forty-one were performed using non-fixed angle internal fixation while 65 had fixed angle internal fixation. Fixed angle devices significantly reduced the incidence of recurrent varus compared with non-fixed angle devices. Inserting BMP2 in the femoral neck significantly reduced the incidence of persistent delayed ossification. Using only a fixed angle device but no BMP2 did not reduce the incidence of delayed ossification. The combination of both a fixed angle device and BMP2 reduced the incidence of recurrent coxa vara and persistent delayed ossification of the femoral neck. The SUPERhip procedure corrects the pathoanatomy of the proximal femur in CFD Paley type 1b but is associated with a very high risk of recurrence of coxa vara and persistence of femoral neck delayed ossification, unless, a fixed angle internal fixation device is used to prevent recurrent coxa vara and BMP2 is used to induce ossification of the femoral neck

Analysis and quantification of bone healing after open wedge high tibial osteotomy

Background: The aim of this study was to analyze radiographic imaging techniques and to quantify bone ossification in the osteotomy gap after high tibial osteotomy. ------ Material and methods: Study phase 1: high tibial osteotomy was performed on six lower extremities of human body donors and experimental X‑rays and computed tomography (CT) scans were applied. Different techniques were evaluated by three specialists for best representation of the osteotomy gap. Study phase 2: optimized radiological techniques were used for follow-up on 12 patients. The radiographs were examined by 3 specialists measuring 10 different parameters. The CT scans were analyzed with semiautomatic computer software for quantification of bone ossification. ----- Results: The osteotomy gap was best represented in 30° of flexion in the knee and 20° internal rotation of the leg. There were significant changes of the medial width over time (p < 0.019) as well as of the length of fused osteotomy, the Schröter score, sclerosis, trabecular structure and zone area measurements. Sclerosis, medial width of the osteotomy and area measurements were detected as reproducible parameters. Bone mineral density was calculated using CT scans, showing a significantly higher value 12 weeks postoperatively (112.5 mg/cm3) than at baseline (54.6 mg/cm3). The ossification of the gap was visualized by color coding. ----- Conclusion: Sclerosis and medial width of the osteotomy gap as well as area measurements were determined as reproducible parameters for evaluation of bone healing. Quantification of bone ossification can be calculated with CT scans using a semiautomatic computer program and should be used for research in bone healing

International Orthopaedics / The impact of different types of talus deformation after treatment of clubfeet

Purpose Deformation of the talus in idiopathic congenital clubfeet is a known problem after treatment. However evidence on types of talus deformation and clinical relevance is rare. The aims of this study were first to define different types of talus deformation, and second, to evaluate the impact of these types on long-term results. Methods At a minimum follow-up of ten years 40 idiopathic clubfeet treated by a modified dorsomedial release were analyzed. Based on morphological appearance and the widened range of radius to length ratios (R/L-ratio) in treated clubfeet deformed tali were divided into two groups: tali with decreased R/L-ratios were classified as small-dome talus deformation (SD), tali with increased R/L-ratios were classified as flat-top talus deformation (FT). The impact on degree of arthrosis in the ankle joint, clinical outcome, and ankle range of motion was analyzed. Results Small-dome talus deformation (SD) was found in nine feet. This group showed decreased R/L-ratios and increased talus opening angles, which were linked to an increased range of motion of the ankle joint (p=0.033). The impact on onset of arthrosis was not significant for this group (p=0.056). The group of flat top talus deformation (nine feet) showed increased R/L-ratios and decreased talus opening angles, decreased range of motion (p=0.019), and a significant impact on onset of arthrosis (p=0.010). Conclusion Our study defines a new subgroup of talus deformation: the small dome talus deformation tends to show a better ankle joint range of motion and a lower risk of arthrosis compared to the classical flat dome talus deformation.(VLID)349715

International Orthopaedics / Measurement considerations on examiner-dependent factors in the ultrasound assessment of developmental dysplasia of the hip

Purpose The standardized sonographic hip screening according to Graf has increased reliability and comparability of measurements in the screening of developmental dysplasia of the hip (DDH). However, examiner dependent factors have been discussed to influence sonographic measurements. The objectives of this study were to examine the tolerance of the transducer positioning and to analyse the impact of transducer inclinations on Grafs hip grading system. Materials and methods Twenty-four hips in consecutive newborns were screened sonographically in combination with an optoelectronic motion capture system to trace transducer positions in space. Subsequently five defined inclinations of the transducer relative to Grafs neutral transducer position were analysed, giving a total of 144 sonographic images. Results We found a permissible transducer inclination in the axial plane of 8.8 to anterior and 8.1 to posterior. In the frontal plane we found a permissible inclination of 15.4 to caudal and 7.2 to cranial. The impact on the -angle was significant for posterior-cranial (p < 0.001), cranial (p = 0.009), and caudal (p < 0.001) inclined transducer positions. The effect on the results according to Grafs grading system was significant for the caudal inclination of the transducer position (p < 0.001). Conclusion Our findings show that the standardized plane defined by Grafs criteria allows notable inclinations of the transducer positions. Transducer inclinations show an impact on measurement results, which are clinically relevant. Those effects cannot be ruled out using Grafs ultrasound criteria alone. The examiner should pay attention to avoid transducer inclinations in the frontal plane and a combination of posterior and cranial inclination.(VLID)354443