[Injection treatment for cervical and lumbar syndromes : Special infiltration techniques]

Minimally invasive injection treatment is indicated particularly in cases of treatment-resistant, painful degenerative alterations of the cervical and lumbar spine, intervertebral disc displacement and radicular syndrome. Through the injections and the supplementation with further conservative, e.g., physical therapy and activating measures, the vicious circle of neural irritation and muscle tension and sympathetic nerve reactions can be interrupted.

[Injection treatment for cervical and lumbar syndromes: principles, indications and general performance]

An intensive conservative treatment that exhausts all treatment options should fundamentally be carried out before every surgical intervention in the region of the spinal column. The therapeutic measures are determined by the extent of the cervical or lumbar syndrome. As a rule, in cases of local complaints symptomatic measures with physiotherapy or digital healthcare applications are indicated. In cases of referred cervical and lumbar syndromes targeted injections can be employed. Before targeted injection treatment a detailed orthopedic clarification with respect to the intensity of local, radicular or pseudoradicular complaints must be carried out. When carrying out minimally invasive injection treatment specific prerequisites with respect to spatial, personnel and technical conditions must be fulfilled. The indications and contraindications must be strictly controlled.

[Achilles tendon pathologies]

Achilles tendon pathologies are a frequent problem in the clinical practice. A distinction must be made between insertional and noninsertional tendinopathies. In addition to intrinsic risk factors, such as diabetes mellitus, there are also extrinsic risk factors, such as overuse and running. Sonography, X‑ray imaging and magnetic resonance imaging (MRI) are established imaging methods, depending on the question. The primary treatment includes a conservative approach. First-line treatment includes administration of nonsteroidal anti-inflammatory drugs (NSAID), physical rest and the use of assistive devices. Established conservative treatment procedures include eccentric stretching, shockwave therapy and infiltration with, e.g., platelet-rich plasma. There are numerous other conservative treatment options. After exhausting the conservative treatment options, a surgical approach can be considered. The surgical procedure depends on the clinical symptoms and findings. Established procedures are minimally invasive or endoscopic procedures or even open debridement.

[Update: endoprosthetics on the ankle joint]

The ankle joint has to bear the entire body weight on a relatively small joint surface. Incongruities, instabilities and deformities lead to painful arthrosis and considerable restrictions in everyday life. For many years, arthrodesis has proven to be the gold standard for end stage arthrosis; however, considering modern endoprostheses for the ankle joint it is no longer appropriate to offer only arthrodesis. The very good results of the 3rd generation 3‑component prostheses and the 4th generation 2‑component prostheses show how much the surgical treatment options for the ankle joint are currently changing. The simplified implantation techniques enable access to arthroplasty of the ankle joint for a broader spectrum of surgeons and explain the increasing implantation rates in recent years. Decisive for postoperative success are correct planning with knowledge of the leg axes and foot position, correct patient selection and exact surgical placement of the components.

[Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]

The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.

[Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]

The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.

[Infected endoprosthesis in patients with rheumatism]

Infections are a severe complication after an artificial joint replacement. The clinical symptoms are highly variable, particularly in patients with inflammatory rheumatic diseases, which often makes the diagnosis difficult. In addition to clinical and laboratory findings, joint puncture is an essential component of the diagnostics and enables the identification of pathogens. Treatment of periprosthetic infections in patients with rheumatism should be an interdisciplinary cooperation between surgeons, rheumatologists and specialists for infectious diseases. The two essential pillars of treatment are surgical intervention and antibiotics. For acute joint infections an attempt at preservation of the artificial joint can be carried out, whereas for chronic infection situations only replacement of the prosthesis is possible as a curative treatment. In order to reduce the probability of occurrence of a joint infection, modifiable risk factors should be preoperatively identified and specifically treated.

[Nerve compression syndromes of the upper extremities]

Nerve compression syndromes of the upper extremities are relatively frequent diseases, the timely detection and treatment of which can prevent irreversible damage in the sense of muscle atrophy and subsequent paresis. The medical history and clinical examination play an important role in determining the suspected diagnosis. The subsequent neurological examination then serves to confirm the suspected diagnosis. This article provides a comprehensive overview of the etiology, pathogenesis, symptoms and treatment of the disease.

[Application of image-guided injection for cervical and lumbar syndromes]

The X‑ray image-guided injection methods are an important tool for the treatment of cervical and lumbar pain syndromes. For the application of these methods it is necessary to have a differentiated consideration of cervical and lumbar pain syndromes. This leads to a decoding of complaints to assignable pain generators, which enables a targeted injection method. Depending on the origin of pain, injections are placed at the nerve root or the joints. Thus, the vicious cycle of pain can be stopped. A correct technical procedure is of enormous importance. Particular attention must be paid to the pharmacological effects and special complications. A monitoring and precautionary measures are mandatory.

[Discrepancy between radiographic and true cup position after total hip arthroplasty : Are we interpreting our radiographic quality indicators correctly? Video article]

BACKGROUND

After total hip arthroplasty (THA), objective postoperative quality control is done via X‑rays by as component position assessment. The cup position is defined by its version and inclination. However, there is a discrepancy between radiographically measured and true (anatomic) cup position, which may lead to misinterpretation.

METHODS

To visualize the discrepancy between true and radiographically measured cup position, in this video, a cup holder was used to set the angular cup version and inclination. Hereby, the cup position (anteversion and inclination) can be characterized in its radiographic and anatomic definition in greater detail. The viewer of this video should receive an impression as to when radiographically measured cup angles must be considered with caution.

RESULTS

In a simultaneous X‑ray and image sequence, this video shows decreased radiographic inclination measurement with increasing anterior rotation of the cup exceeding 20° of anteversion, yet with unchanged true inclination on the cup holder. Isolated consideration of the radiographic angles of anteversion and inclination may cause misinterpretation of true cup position. In pectoral illustration we show that variations in cup version and inclination may remain undetected when considering isolated the radiographic cup parameters.

CONCLUSION

True cup position in its anatomical definition can be calculated from the radiographically measured position. For this purpose, both cup parameters (radiographic anteversion and radiographic inclination) have to be taken into account.

[Biomechanical aspects of preoperative planning: What is really important?]

BACKGROUND

Sagittal balance is dependent on a complex interplay of the spinal curves, shape and setting of the pelvis, but also the position of the joints of the lower limb. Degenerative processes such as stiffening of the spine, aging of musculature, or reduction of the range of motion of the joints lead to imbalance of the spine after all compensatory mechanisms have been exhausted.

OBJECTIVES

Based on standardized imaging, compensation mechanisms must be identified within a biomechanical analysis of the spine, the original sagittal spine profile anticipated and included in the planning of the corrective intervention.

RESULTS

This review presents the most important global and spinopelvic parameters for the biomechanical analysis of the spine. In addition, normal variations of the sagittal alignment are discussed, compensation mechanisms are shown, and the planning of the rebalancing of the sagittal alignment is shown according to the full balance integrated model.

[Degenerative forefoot : Diagnostics and treatment]

The hallux valgus deformity is the most common toe deformity of the forefoot and is often associated with a splayfoot. Malpositioning of the small toes may be isolated but are more common in other foot deformities. The understanding of the complex pathoanatomy of the foot is necessary for orthopedic treatment. Conservative treatment is reserved for the early stages. The indications for surgery should be based on clinical and radiographic findings. Countless surgical procedures are available and minimally invasive surgical techniques are also increasingly being used.

[Ankle cartilage repair : Therapeutic options, results and technical aspects]

BACKGROUND

Therapeutic strategies for cartilage repair of the talus are varied. With the use of biologic scaffolds and biologic agents new cell-based therapies have become the focus of attention.

OBJECTIVES

Ankle cartilage repair techniques are presented and assessed by current data. In addition, technical notes for each technique are given.

MATERIAL AND METHODS

Currently, the following established ankle cartilage repair procedures exist: microfracturing, AMIC (autologous matrix-induced chondrogenesis), OCT (osteochondral transplantation, mosaicplasty), allograft transplantation.

DISCUSSION

The success of each repair technique is dependent on the proper indication, addressing of co-morbidities like axis deviation or ligament instabilities, the experience of the surgeon and the appropriate rehabilitation. Mid- and long-term results are often good or excellent. Best results are seen in isolated cartilage defects without co-morbidities in patients younger than 40 years of age and non-smokers with normal BMI and early intervention. New cell-based therapies utilize scaffolds and biologic agents. They offer promising perspectives, although current data is inconsistent.

[Rheumatism operations in a state of flux-"Foot"]

Surgical management of rheumatic feet has dramatically changed over the last decades influenced by the development of new pharmacological drugs and tissue-preserving surgical procedures. It has switched from joint resection to joint-sparing procedures as the method of choice. Nevertheless, the surgical interventions commonly used for non-rheumatic patients cannot be applied to rheumatic patients without reflection: in addition to the basic treatment, comorbidities, degree of mobilization of the patient, orthopedic shoe engineering and orthotic treatment play a major role. Due to the decreasing incidence of the classical rheumatic foot, it has become even more important for physicians, physiotherapists and ergotherapists to recognize the development of such a disease as early as possible and immediately start the appropriate treatment.

Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios

INTRODUCTION

In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs.

METHODS

Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°.

RESULTS

No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen.

CONCLUSION

The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

[Examination of the wrist and hand]

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

Different Kinematics of Knees with Varus and Valgus Deformities

Few data exist of kinematics of knees with varus and valgus deformities combined with osteoarthritis. The purpose of this study was to reveal different (1) tibiofemoral kinematics, (2) medial and lateral gaps, and (3) condylar liftoff of osteoarthritic knees with either varus or valgus deformity before and after total knee arthroplasty (TKA). For this purpose, 40 patients for TKA were included in this study, 23 knees with varus deformity and 17 knees with valgus deformity. All patients underwent computer navigation, and kinematics was assessed before making any cuts or releases and after implantation. Osteoarthritic knees with valgus deformity showed a significant difference in tibia rotation relative to the femur with flexion before and after TKA, whereas knees with varus deformity did not. Knees with a valgus deformity showed femoral external rotation in extension and femoral internal rotation in flexion, whereas knees with a varus deformity revealed femoral internal rotation in extension and femoral external rotation in flexion. In both groups, gaps increased after TKA. Condylar liftoff was not observed in the varus deformity group after TKA. In the valgus deformity group, condylar liftoff was detected after TKA at knee flexion of 50 degrees and more. This study revealed significant differences in tibiofemoral kinematics between osteoarthritic knees with a varus or valgus deformity before and after TKA. Valgus deformities showed a paradoxic movement pattern. These in vivo intraoperative results need to be confirmed using fluoroscopic or radiographic three-dimensional matching before and after TKA.

Regarding loads after spinal fusion, every level should be seen separately: a musculoskeletal analysis

INTRODUCTION

The number of spinal fusion surgeries is steadily increasing and biomechanical consequences are still in debate. The aim of this study is to provide biomechanical insights into the sagittal balance of the spine and to compare spinal load before and after spinal fusion.

METHOD

The joint reaction forces of 52 patients were analyzed in proximo-distal and antero-posterior direction from the levels T12-L1 to L5-S1 using musculoskeletal simulations.

RESULTS

In 104 simulations, pre-surgical forces were equal to post-surgical. The levels L4-L5 and T12-L1, however, showed increased spinal forces compression forces with higher sagittal displacement. Improved restauration of sagittal balance was accompanied by lower spinal load. AP shear stress, interestingly decreased with sagittal imbalance.

CONCLUSION

Imbalanced spines have a risk of increased compression forces at Th12-L1. L4-L5 always has increased spinal loads. These slides can be retrieved under Electronic Supplementary Material.

What is the optimal valgus pre-set for intramedullary femoral alignment rods in total knee arthroplasty?

PURPOSE

In total knee arthroplasty (TKA), intramedullary guides are often used for aligning the distal femoral cutting block. Because of the highly varying angles between the mechanical axis and the anatomical femoral axis (AMA), different valgus pre-sets have been recommended. The present study investigated the optimal valgus pre-set (measuring the AMA in long-leg radiographs or at 5°, 6°, 7° or 8° valgus) to align the cutting block perpendicularly to the mechanical axis.

METHODS

The AMA was preoperatively measured in weight-bearing long-leg radiographs. After alignment of the cutting block by means of an intramedullary rod, deviation of the block from the mechanical femoral axis was measured with a pinless navigation device. The true AMA (tAMA) was calculated by adding the valgus pre-set of the alignment rod to the deviation measured with the navigation device. Mean deviations between the tAMA and (a) the AMA measured by the surgeon, (b) the AMA calculated with the computer software, (c) 5°, (d) 6°, (e) 7° and (f) 8° valgus pre-sets were measured for each patient. The lowest mean differences were determined.

RESULTS

The 40 knees measured showed a mean tAMA of 7.2° valgus (1.7 SD) (range 4°-11.5°). The following mean differences and 95 % limits of agreement were calculated: 2.2 (-1.2, 5.5) to the tAMA for the 5° valgus pre-set, 1.2 (-2.2, 4.5) for 6°, 0.2 (-3.2, 3.5) for 7° and -0.8 (-4.2, 2.5) for 8°. AMA measurements by the surgeon and with the digital medical planning software yielded mean differences of 0.6 (-3.1, 4.3) and 0.4 (-4.1, 4.8), respectively.

CONCLUSION

In the present setting, the best mean distal femoral cutting block alignment perpendicular to the mechanical femoral axis could be achieved with a valgus pre-set of 7° and not by measuring the AMA. Nevertheless, we recommend conducting weight-bearing radiographs of the entire leg prior to TKA for easy detection of any anatomical varieties, old fractures, long stems of total hip arthroplasties or cement. However, surgeons must be aware that exact coronal component alignment can only be achieved by navigational devices.

LEVEL OF EVIDENCE

Diagnostic study, Level II.

[Total knee arthroplasty in the elderly]

BACKGROUND

The number of total knee arthroplasties in elderly patients is increasing in accordance with the demographic shift in the population.

OBJECTIVE

Analysis of the special situation in the elderly, conservative treatment options, perioperative risk factors, preoperative preparation, special intraoperative features and outcome.

METHODS

Analysis of currently available scientific data and presentation of own scientific study results.

RESULTS

Total knee arthroplasty in elderly patients is related to an increased perioperative risk of complications. A thorough interdisciplinary preparation is required to reduce risk factors. Ligament stability of the knee does not correlate with age. The postoperative outcome after total knee arthroplasty in elderly patients is decisively influenced by the preoperative function and psychosocial parameters.

CONCLUSION

Total knee arthroplasty in elderly patients is particularly challenging for orthopedic surgeons and requires close interdisciplinary cooperation.