Objectives

Venous thromboembolism (VTE) is a major potential complication following orthopaedic surgery. Subcutaneously administered enoxaparin has been used as the benchmark to reduce the incidence of VTE. However, concerns have been raised regarding the long-term administration of enoxaparin and its possible negative effects on bone healing and bone density with an increase of the risk of osteoporotic fractures. New oral anticoagulants such as rivaroxaban have recently been introduced, however, there is a lack of information regarding how these drugs affect bone metabolism and post-operative bone healing.

Spondylodiscitis is a severe infectious disease of the vertebral column and the intervertebral disc space and may be complicated by an epidural abscess. A wide range of pathogens have been described as causative agents. Since several weeks of antibiotics are necessary for successful therapy detection of the causative pathogen is essential. Specific antibiotic therapy improves outcome and reduces antibiotic related complications. Antibiotic Stewardship (ABS) programs are bundled approaches aimed at improving antibiotic therapy. In 2012 an ABS program including weekly interdisciplinary clinical rounds and development of algorithms for diagnosis and therapy of patients with spondylodiscitis was established in the Department of Orthopedic Surgery in a University hospital. We evaluated the effects of ABS with regard to the appropriateness of specimen and pathogen detection and antibiotic therapy in patients with spondylodiscitis.

We retrospectively analysed diagnostic procedures and pathogen detection of 100 patients that were hospitalized with spondylodiscitis and compared the data of patients that were treated before (2004–2011) and after introduction of ABS measures (2012–2014). After introduction the effect of ABS on antibiotic therapy was analysed.

100 patients with radiologically confirmed spondylodiscits were enrolled. The pre-ABS group (2004–2011) contained 58 patients. Of these no samples were taken for microbiological examination from 21 patients (36%) and from 8 patients (14%) only swabs were submitted for culture. Aspirates or tissue samples were taken from 22 patients (38%) and blood cultures from 18 patients (31%). Pathogen detection was successful in 18 patients (31%).

After introduction of ABS in the beginning of 2012 aspirates or tissue samples were taken from 34 patients (81%) and blood cultures were taken from 34 patients (81%). Pathogen detection was successful in 26 patients (62%). The most commonly detected pathogens were Gram positive cocci (S.aureus, S. epidermidis, and streptococci) in 31 patients. Less common pathogens were found in 12 patients (Gram negative rods (8), fungi (3), Moraxella (1) and Propionibacterium (1). After introduction of ABS antibiotic therapy was changed in 18 of 20 patients (90%) after pathogen identification.

In 50 % of cases the inappropriate empiric therapy was changed (MRSA, MRSE and Gram negative rods) and in 50 % broad-spectrum antibiotic therapy could be deescalated.

ABS significantly improved the number and quality of samples, increased the number of blood cultures taken and doubled the pathogen detection rates in patients with spondylodiscitis leading to an improvement in antibiotic therapy in almost all patients with pathogen detection.

Our understanding of the origin of hip pain in degenerative disorders of the hip, including primary osteoarthritis, avascular necrosis and femoroacetabular impingement (FAI), is limited. We undertook a histological investigation of the nociceptive innervation of the acetabular labrum, ligamentum teres and capsule of the hip, in order to prove pain- and proprioceptive-associated marker expression. These structures were isolated from 57 patients who had undergone elective hip surgery (44 labral samples, 33 ligamentum teres specimens, 34 capsular samples; in 19 patients all three structures were harvested). A total of 15 000 histological sections were prepared that were investigated immunohistochemically for the presence of protein S-100, 68 kDa neurofilament, neuropeptide Y, nociceptin and substance P. The tissues were evaluated in six representative areas.

Within the labrum, pain-associated free nerve ending expression was located predominantly at its base, decreasing in the periphery. In contrast, the distribution within the ligamentum teres showed a high local concentration in the centre. The hip capsule had an almost homogeneous marker expression in all investigated areas.

This study showed characteristic distribution profiles of nociceptive and pain-related nerve fibres, which may help in understanding the origin of hip pain.

Cite this article: Bone Joint J 2013;95-B:770–6.

Aims

A new therapy, based on the intra-articular injection of autologous conditioned serum (ACS), is used in several European countries for osteoarthritis (OA) treatment. ACS is generated by incubating venous blood with medical grade glass beads. Peripheral blood leukocytes produce elevated amounts of endogenous anti-inflammatory cytokines such as interleukin-1 receptor antagonist (IL-1Ra) and growth factors that are recovered in the serum(1). ACS has been shown to improve the clinical lameness in horses significantly to enhance the healing of muscle injuries in animal models, and in human athletes. In the present study, the efficacy and safety of ACS was compared to intra-articular hyaluronan (HA), and saline in patients with confirmed knee OA.

Purpose: The aetiology of primary omarthrosis is still unclear. Typical radiological changes are joint space narrowing and the development of caudal osteophytes. The objective of the study is the analysis of the joint space of the shoulder in four different age groups.

Materials and Methods: Retrospective analysis of n=342 standardized X-rays (2002–2009) (true ap, axillary). Inclusion criteria: normal adulthood group I (n=60), instability group II (n=53), calcifying tendonitis of the supraspinatus tendon group III (n=109), advanced primary omarthrosis group IV (n=120). Measurement of joint space at three levels (ap: superior, central, inferior; axillary: anterior, central, posterior). Two independent measurements. Statistical analysis SPSS 17.0: U-Test acc. Mann and Whitney. Bivariate correlation analysis (Spearman), partial correlation analysis, intraclass correlation coefficient.

Results: Mean age group I 17.84±1.54, group II 31.6±11.8, group III 48.2±8.0, group IV 66.43 ±9.74 (p=0.001). Measurement joint space: interobserver reliability excellent in the ap-projection (r=0.887–0.910) and in the axillary projection (r=0.879–0.886). Joint space group I: 4.79mm±0.84 superior ap, 4.28mm±0.75 central ap, 4.57mm±0.80 inferior ap, 6.59mm±1.44 anterior axillary, 6.12mm±1.09 central axillary and 7.03mm±1.17 posterior axillary; group II: 3.78mm±0.99 superior ap, 3.12mm±0.73 central ap, 3.38mm±0.80 inferior ap, 3.92mm±1.08 anterior axillary, 3.92mm±0.77 central axillary and 4.79mm±1.18 posterior axillary; group III: 3.43mm±1.06 superior ap, 2.87mm±0.80 central ap, 3.25mm±0.79 inferior ap, 3.95mm±0.83 anterior axillary, 3.34mm±0.84 central axillary and 4.05mm±0.84 posterior axillary; group IV: 2.00mm±1.40 superior ap, 1.47mm±1.07 central ap, 1.48mm±1.93 inferior ap, 3.01mm±2.22 anterior axillary, 1.08mm±1.12 central axillary and 1.17mm±1.04 posterior axillary. The differences between the four groups for the joint space width are all statistically significant with p< 0.001 (except the difference between group I and group II for ap-central, ap-inferior and axillary anterior).

There is a significant negative correlation (r= −0,579–0,813) between the joint space width and patients age at all measured levels in both projections (p< 0.001). This negative correlation is only little smaller (r= −0,430–0,655) but still clearly significant for all measurements, if the patients with present osteoarthritis (group III) are excluded.

Conclusion: The data of the study show a decrease of joint space width in group I–IV in all measurements. This effect is negatively correlated with age. The data suggest that the decrease in joint space with loss of cartilage cover is an age-dependant process which is independent from the presence of osteoarthritis. This is in contrast to historical findings but in concordance with recent basic studies about cartilage ageing.

Introduction: The use of screw fixation for cementless porous-coated acetabular components for primary total hip arthroplasty (THA) remains controversial. Aim of this study was to evaluate initial acetabular implant stability and late acetabular implant migration with screw fixation of the acetabular component in order to answer the question whether screws are necessary for the fixation of the acetabular component in cementless primary THA.

Methods: In a prospective study, 102 patients (107 hips) were available for follow up after primary THA using a cementless, porous-coated acetabular component. Patients were followed up at 6 and 12 weeks, 6 and 12 months and annually thereafter to an average of 2.6 ± 1.7 years. A total of 428 standardized radiographs were analyzed by the Einzel-Bild-Röntgen-Analyse (EBRA)-digital method. Additionally, the Harris Hip Score (HHS, 0–100) was assessed at the latest follow-up.

Results: 101 (94.4 %) implants did not show significant migration of more than 1 mm of the acetabular component. Six (5.6%) implants showed a migration of more than 1 mm: in 3 cases (2.8%), migration was progressive during follow-up and led to a revision surgery due to aseptic loosening. In 3 cases, migration came to a halt and cups were claimed stable. Individuals without cup migration had an average HHS of 78.4 ± 22.9, whereas patients who showed a cup migration of > 1 mm had 53.3 ± 24.2. Statistical analysis did not reveal preoperative patterns that would identify future migration.

Discussion: and Conclusion: Our findings show that the use of screw fixation for cementless porous-coated acetabular components for primary THA does not prevent cup migration.

Introduction: Femoroacetabular Impingement (FAI) with more or less subtle abnormality of the hip anatomy and function may contribute to the early development of osteoarthritis (OA). Surgical dislocation as well as arthroscopy of the hip joint are effective and save tools to correct these anatomic deformities. Good clinical results could be achieved predominantly in patients not exceeding grade I OA. The aim of the presented study was to evaluate the clinical and radiological outcome of patients that were treated by open surgical hip dislocation for more advanced OA of the hip joint (> grade I).

Patients and Methods: This is a prospective clinical trial on the outcome of patients after surgical hip dislocation. We report on 45 hip joints (41 patients, 16 m, 25 f) that were treated in our institution by offset-correction (removal of osseous bumps at the femoral head-neck junction) and/or labral surgery for FAI. All patients were evaluated prospectively before and after surgery (Harris Hip Score, radiographic parameters, arthro-MRI).

Results: The mean follow up (FU) was 45 months (range: 12–102 months). 9 hips underwent total hip replacement in the further course of FU for persisting pain. In the remaining hips a significant pain reduction but no amelioration of hip range of motion could be accomplished. In 90% of the cases, a good correlation between preop-erative arthro-MRT findings and intraoperative labrum and cartilage assessment could be demonstrated. Concerning the outcome, no patient or radiographic factors could be identified that were strongly associated with failure after surgical dislocation.

Discussion and Conclusion: Our data suggests that even patients with more advanced osteoarthritis of the hip may benefit from the surgical dislocation approach as a hip salvage procedure. However, the high number of conversion to total hip arthroplasty indicates, that the indication for hip salvage should stay restricted. Patient or radiographic factors indicative of failure could not be identified. In the future and with more sophisticated molecular MRI techniques such as delayed Gadolinium Enhanced MRI of Cartilage (dGEMRIC) concrete prediction models could be implemented to preoperatively assess hip cartilage in order to sort out patients who will not profit from salvage surgery for advanced OA due to FAI.

Our aim was to investigate the relationship between urinary excretion of deoxypyridinoline (DPD) as a marker of bone resorption, and Perthes’ disease. There were 39 children with Perthes’ disease in the florid stage who collected first-morning urine samples at regular intervals of at least three months. The level of urinary DPD was analysed by chemiluminescence immunoassay and was correlated with the radiological stage of the disease as classified by Waldenström, and the severity of epiphyseal involvement according to the classification systems of Catterall and Herring. The urinary DPD levels of a group of 44 healthy children were used as a control.

The median urinary DPD/creatinine (CREA) ratio was significantly reduced (p < 0.0001) in the condensation stage and increased to slightly elevated values at the final stage (p = 0.05) when compared with that of the control group. Herring-C patients showed significantly lower median DPD/CREA ratios than Herring-B patients (p = 0.03). The significantly decreased median DPD/CREA ratio in early Perthes’ disease indicated a reduced bone turnover and supports the theory of a systemic aetiology. Urinary levels of DPD may therefore be used to monitor the course of Perthes’ disease.

We present the results of a prospective study about twenty-nine patients (thirty-two hips) with unstable slipped capital femoral epiphysis (SCFE), which were treated by indirect reduction and internal fixation of the epi- and metaphysis with 3–4 Kirschner-wires between 1990 – 1999.

Methods: The 29 patients with a mean age of 12,9 years were clinically and radiologically evaluated after a mean follow-up of 3 years applying the score of Heymann and Herndon and by different roentgenological parameters (CCD-angle, femoral head diameter, length of the femoral neck and sphericity of the femoral head). Compared to the uninvolved side in unilateral case, which all had prophylactic pinning, all patients showed overall a good subjective and objective outcome. The average slip angle of all 29 unstable SCFE patients (32 hips) was 31° with 19 (59,4%) mild SCFE (< 30°), 7 (21,9%) moderate forms (30–50°) and 6 (18,8%) severe slips (> 50°).

Results: According to the classification of Heyman and Herndon we had 18 excellent (62,1%), 9 good (31,1%), 1 fair (3,4%) and 1 poor (3,4%) results. None of the patients developed chondrolysis, but AVN occurred in one patient with complete and in one patient with partial involvement of the femoral head. The mean CCD-angle at the follow-up after skeletal maturity of the affected side was 133,3° in comparison to 135,9° of the non affected hips, indicating only a slight increase of varus position of the femoral neck of at average 2,6°. The mean length of the femoral neck of the affected hips was 64,5 mm in comparison to 70,8 mm of the not affected hips, thus a average difference of 6,3 mm. The neck/shaft-ratio between the affected and the not affected side was 0,88 (0,78 – 1,0). The mean femoral head diameter of the affected hips was 57,1 mm in comparison to 55,4 mm of the non affected hips. The radius quotient (RQ), measuring the relation of the femoral heads between the affected and the not affected hip was at average 103% (min 100 %, max. 114%). The sphericity according to Mose of the 58 hips (29 patients) treated by pinning with K-wires was normal (< 2mm) in 89,7% (52 hips), mild I°-aspheric (2–3mm) in 3,4% (2 hips), moderate II°-aspheric (3–4mm) in 3,4% (2 hips) and severe III°-aspheric (> 4mm) in 3,4% (2 hips).

Conclusion: As a standard in our institution we recommend the simultaneous transfixation of the epi- and metaphysis with Kirschner-wires in patients with unstable SCFE as therapeutic method for the involved as well as prophylactic for the uninvolved femoral epiphysis. Implants should not be placed in the anterosuperior quadrant of the femoral head and correct implant position has to be documented by the withdrawl maneouver using image intensifier during surgery. With this technique the slip could efficiently be stabilized, further slippage or any progression could be prevented and remodeling of the joint led to an optimal sphericity and improved femoral neck length at the end of growth, thus improving hip function. The rate of severe complications like AVN and chondrolysis was low in our prospective series (6,8% respectively 0%) compared to other series with different implants (screws, nails). There were no complications like implant failure or problems with hardware removal.

The goal of clubfoot management, regardless of the method applied, is still to improve function and form as close as possible to normal values. Since the final outcome of any therapy will only become evident at the end of growth, long-term follow-up studies are necessary to evaluate the results and methods. The aim of this study was to evaluate long-term results of corrective surgery for clubfoot deformity in a selected group of patients. Other congenital or acquired abnormalities like neuromuscular disease, arthrogryposis or others were excluded in order to identify the factors associated with the success or failure of the treatment.

A retrospective clinical and radiological study of 64 patients with 104 treated feet with a follow-up of 8 to 35 years (mean: 19.2 years) is presented. All of the patients were operated on by Scheel′s technique. In this technique the Achilles tendon was lengthened and combined with a dorsal arthrolysis. In some cases medial structures such as the tibialis posterior, long-toe flexors tendon sheaths and the medial ligaments of the talonavicular joint were released. A calcaneal traction was applied for four weeks and a plaster cast for six weeks.

The patients were grouped according to the duration of follow-up (< 10, 10–20 and > 20 years) and the results were compared. Clinical evaluation followed the criteria according to the McKay Score, a score of 180 from which points for sequela (either morphologic or functional) are subtracted.

There was an inverse relationship between the functional rating score and the length of follow-up. Acceptable results decrease over time as the patient approaches skeletal maturity. In the group with a follow-up of > 20 years, only 5% were rated as good, 34% as satisfactory, 28% as poor and 33 % as failure.

Radiographic evaluation of the last group showed marked deformities of the talus and navicular bones, as well as advanced osteoarthritis. The degree of bone deformity of the talus (flat-top-talus) and navicular seems to depend on the degree of persistent residual joint subluxation after surgery and contribute to the development of secondary osteoarthritis of the ankle and subtalar joint over time. Considering the goal of treatment is to restore form and function, assessment and approach of all the components of the individual deformity is required.

A complete subtalar release to realign the calcaneus to an externally rotated position is followed by a reduction of the talonavicular joint. To achieve full reduction, release of the calcaneocuboid joint is necessary because it is linked with the talonavicular joint.

Preliminary results of 89 congenital clubfeet treated with a complete subtalar release with an average follow- up of five years show 12.4% excellent, 41.6% good and 39.3% satisfactory according to the McKay-Score. The results of this series underlines the importance of careful and complete derotation and anatomic realignment of the talocalcaneonavicular joint complex in order to have a lifelong functional foot with the least amount of deformity and disability. The results of any treatment for clubfoot deformity should be judged after skeletal maturity, making a follow-up of at least 20 years necessary.

The objective of our research is to elucidate the pathogenesis of soft-tissue contracture. Here we present a comparison of collagens isolated from deltoid ligament of 23 clubfeet classified according to the Dimeglio-classification and of 14 matched controls of normal feet.

Collagens were isolated by acetic acid extraction and by limited pepsin-solubilisation and analysed by SDS-PAGE. Ligaments and solubilised collagens were analysed for their extent of hydroxylation of prolyl- and lysyl-residues, their content of galactosyl-hydroxylysine and glucosyl-galacto-syl-hydroxylysine and their content of lysyl-oxidase dependent cross-links histidinohydroxylysino-norleucine (HHL), hydroxylysylpyridinoline (HP) and lysylpyridinoline (LP). Analysis were carried out using an amino acid analyser (Bio-chrom 20, Amersham Pharmacia Biotech) and a reverse-phase HPLC system (Gynkothek).

Percentage of collagen of total protein decreases in club-foot as compared to controls. SDS-PAGE of solubilised collagens shows a high content of type I, less of type III and small amounts of type V collagen in both groups. The extent of hydroxylation of proline appears to be very similar, whereas the degree of hydroxylation of lysine follows the Dimeglio-classification. In addition, glycosylation of hydroxylysine increases parallelly to the classification. However, the increase is found solely in the amount of disac-charides. Total content of HHL, the most important collagen cross-link in soft tissues, was increased significantly in club-feet as compared to controls. HP, the hard tissue specific collagen cross-link was increased slightly in clubfeet. Levels of LP were too low to detect differences precisely.

The data presented show distinct differences in the post-translational modifications of collagen (hydroxylation of lysyl-residues, glycosylation and lysyl-oxidase dependent cross-links) isolated from congenital idiopathic clubfeet and from controls.