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Horas K, Maier G, Rudert M, Jakuscheit A, Weißenberger M, Stratos I, Heinz T, Rak D, Anderson PM, Arnholdt J. Vitamin D Deficiency Is Frequent in Patients with Rapidly Destructive Osteoarthritis-Data from a Single-Center Analysis. J Clin Med 2024; 13:1296. [PMID: 38592156 PMCID: PMC10931965 DOI: 10.3390/jcm13051296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 01/30/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Rapidly destructive osteoarthritis (RDO) of the hip joint is characterised by the rapid destruction of the femoral head with or without acetabular involvement. There has been increasing interest in this disease over the past years; however, the entity is still poorly understood, and its pathophysiology remains unknown. Yet, there is ample evidence today that increased bone metabolism might play a role in the onset and progression of the disease. Vitamin D is of utmost importance to maintain a balanced bone metabolism. However, whether vitamin D deficiency is involved in disease development remains to be elucidated. Further, the vitamin D status of patients with RDO has not yet been analysed. For this reason, the objective of this study was to assess the vitamin D status of patients with RDO. Moreover, the aim was to clarify whether there is a difference in the vitamin D status of patients with RDO compared with patients with primary osteoarthritis (OA). METHODS In this single-centre analysis, the 25(OH)D, PTH, and calcium levels of 29 patients who presented with RDO between 2020 and 2022 were assessed. RESULTS Altogether, 97% of patients (28/29) were vitamin D deficient, a further 3% (1/29) were vitamin D insufficient, and not a single patient presented with a sufficient vitamin D status. Notably, the vitamin D levels of RDO patients (mean = 11.04 ng/mL) were significantly lower than the vitamin D levels of patients with OA (mean = 22.16 ng/mL, p = 0.001). CONCLUSION In conclusion, we found a widespread and high rate of vitamin D deficiency in patients with RDO. Hence, we believe that 25(OH)D status should routinely be analysed in these patients.
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Affiliation(s)
- Konstantin Horas
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
| | - Gerrit Maier
- Department of Orthopaedic Surgery, Pius-Hospital, Carl-von-Ossietzky-University, 26121 Oldenburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
| | - Manuel Weißenberger
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
- Orthopaedic Surgery Centre Wuerzburg (OCW), 97070 Wuerzburg, Germany
| | - Ioannis Stratos
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
| | - Dominik Rak
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
| | - Philip Mark Anderson
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany
| | - Jörg Arnholdt
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU University Hospital, 81377 Munich, Germany
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Anderson PM, Heinz T, Weißenberger M, Winter P, Rudert M, Jakuscheit A. Zirconium as a Promising Synovial Biomarker for Loose Cemented Knee Prosthesis. J Arthroplasty 2024:S0883-5403(24)00019-6. [PMID: 38244639 DOI: 10.1016/j.arth.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/21/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Aseptic loosening is the most common mode of failure after total knee arthroplasty. Despite this, the diagnosis often remains challenging and mainly relies on imaging modalities. Until today, no biomarker exists to aid in diagnosing loosening of the implants. As zirconium (Zr) is often found in bone cement, where it serves as radiopacifier, this study aimed to establish Zr as a synovial biomarker for loosened cemented knee prostheses. METHODS A total of 31 patients scheduled for revision of a cemented knee prostheses were included. In all patients, the initial used cement contained Zr. After arthrotomy, specimens of synovial fluid were taken and levels of Zr were measured by inductively coupled plasma mass spectrometry. Depending on the necessary amount of force for explantation, the implants were graded "loose" or "well-fixed". Preoperative radiographs were evaluated by 2 independent physicians. RESULTS The concentration of Zr in the synovial fluid differed significantly (P < .001) between the "loose" (mean 170.9 μg/L, range 0 to 1941 μg/L) and the "well-fixed" (mean 0.6 μg/L, range 0 to 6 μg/L) implants. The receiver operating characteristic analysis revealed 0.25 μg/l as an optimal cutoff value leading to a sensitivity of 0.84, a specificity of 0.92, a positive predictive value of 0.94, and a negative predictive value of 0.79. There was no significant difference in the diagnostic performance compared to radiographs (P = .66). CONCLUSIONS Zirconium proved to be a reliable novel synovial biomarker for diagnosing aseptic loosening of knee prothesis fixed with cement containing Zr. This biomarker should not be interpreted in isolation, but in combination with existing diagnostic tools.
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Affiliation(s)
- Philip M Anderson
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Tizian Heinz
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Manuel Weißenberger
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Philipp Winter
- Department of Orthopaedic Surgery, University of Saarland, Homburg, Germany
| | - Maximilian Rudert
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
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Weißenberger M, Heinz T, Rak D, Stratos I, Anderson PM, Lüdemann M, Horas K, Jakuscheit A, Rudert M. Does Body Mass Index (BMI) Affect the Reconstruction of Biomechanical Parameters in Patients Undergoing Total Hip Replacement (THR) through the Direct Anterior Approach (DAA)? J Clin Med 2024; 13:467. [PMID: 38256601 PMCID: PMC10816045 DOI: 10.3390/jcm13020467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/07/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE Direct anterior approach total hip replacement (DAA-THR) is gaining increased interest due to its tissue-sparing nature and rapid recovery. Obesity has been shown to be a significant parameter influencing cup positioning in DAA-THR. It was the intention of this retrospective study to examine how obesity would influence the restoration of native hip biomechanical parameters during DAA-THR. MATERIALS AND METHODS A total of 74 patients from a high-volume university orthopedic center after unilateral DAA-THA were included. Patients were retrospectively allocated to a study group (BMI > 30 kg/m2) and a control group (BMI < 30 kg/m2). Furthermore, propensity-score matching for baseline parameters was performed, leaving 30 patients in each group. Biomechanical parameters of the hip (i.e., femoral offset (FO), abductor lever arm (ABL), acetabular offset (AO), center of rotation (COR), stem alignment (SA), body weight lever arm (BWL), cup inclination (CI), and leg length discrepancy (LLD) were evaluated on standardized plain radiographs, and parameters were compared to the native contralateral hip. RESULTS Mean BMI in the study group was 35.07 ± 5.13 kg/m2 and 25.43 ± 2.64 kg/m2 in the control group. There was a significant decrease of the ABL only in the study cohort (p = 0.01). CI and SA did not differ between both cohorts. FO was slightly increased compared to the native hip in both groups. There was a marginally higher but non-significant proportion of improper FO restoration in the study group (19 vs. 16 patients, p = 0.60). CONCLUSIONS Obesity, as quantified by BMI, only has a limited impact on the adequate reconstruction of native biomechanical parameters of the hip during DAA-THR. ABL was the only parameter to be significantly decreased in the overweight patients after DAA-THR. Therefore, special care should be taken on proper acetabular reaming and consequent seating of the cup in the obese patient to avoid excessive lateral positioning.
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany (I.S.); (P.M.A.); (M.L.); (K.H.); (A.J.)
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Heinz T, Oberfeld J, Luetkens KS, Anderson PM, Stratos I, Horas K, Bley TA, Rudert M, Reppenhagen S, Weißenberger M. The AMADEUS score is not a sufficient predictor for functional outcome after autologous chondrocyte implantation (ACI) of the knee: data from the German Cartilage Registry (KnorpelRegister DGOU). Arch Orthop Trauma Surg 2023; 143:7097-7105. [PMID: 37639044 PMCID: PMC10635975 DOI: 10.1007/s00402-023-05037-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/13/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION The AMADEUS (Area Measurement And DEpth and Underlying Structures) score has advanced to a commonly used tool for MRI-based chondral defect severity grading prior to cartilage knee surgery. It was the intention of this study to assess the AMADEUS for a potential correlation with clinical data by patient-reported outcome measures (PROMs). METHODS A total of 51 patients undergoing ACI (autologous chondrocyte implantation) between 2016 and 2022 were found eligible and retrospectively analyzed. All patients were registered in the German Cartilage Registry prior to surgery and follow-up data were collected using the Knee Osteoarthritis Outcome score (KOOS), the International Knee Documentation Committee (IKDC) Form and the numeric rating scale (NRS). Pre-operative MRI images were scored by three raters using the AMADEUS classification system, and an overall AMADEUS score was calculated which was subsequently correlated with pre- and post-operative PROMs. RESULTS Mean patient age was 32.67 ± 8.37 years and mean defect size area 343.04 mm2 ± 139.45 mm2. No correlative capacity of the pre- and postoperative IKDC, KOOS or NRS scores was found with the AMADEUS final score or any of its subscores. From the pre- to postoperative visit, a significant improvement of the PROMs (IKDC: 45.53 ± 21.00 vs. 59.83 ± 17.93, p = 0.04; KOOS Pain: 58.00 ± 16.70 vs. 76.06 ± 19.20, p = 0.03; KOOS ADL: 64.17 ± 18.76 vs. 82.11 ± 16.68, p < 0.01; KOOS Sports: 26.11 ± 18.52 vs. 50.56 ± 23.94, p = 0.01; KOOS QOL: 25.50 ± 14.26 ± 45.28 ± 19.03, p = 0.00) was found. Intraclass correlation coefficients showed an overall good interrater agreement for the AMADEUS total score (ICC = 0.75). CONCLUSIONS Study results suggest no correlative capacity of the AMADEUS with routinely used PROMs in patients undergoing ACI. Therefore, radiographically assessed cartilage defect characteristics poorly translate to pre- and postoperative patient-reported outcome data.
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Affiliation(s)
- Tizian Heinz
- 1Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Würzburg, Germany
| | - Jan Oberfeld
- 1Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Würzburg, Germany
| | - Karsten Sebastian Luetkens
- 2Department of Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Oberduerrbacherstr. 6, 97080, Würzburg, Germany
| | - Philip Mark Anderson
- 1Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Würzburg, Germany
| | - Ioannis Stratos
- 1Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Würzburg, Germany
| | - Konstantin Horas
- 1Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Würzburg, Germany
| | - Thorsten Alexander Bley
- 2Department of Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Oberduerrbacherstr. 6, 97080, Würzburg, Germany
| | - Maximilian Rudert
- 1Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Würzburg, Germany
| | - Stephan Reppenhagen
- 1Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Würzburg, Germany
| | - Manuel Weißenberger
- 1Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Würzburg, Germany.
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Anderson PM, Heinz T, Rak D, Arnholdt J, Holzapfel BM, Dorsch S, Weißenberger M, von Eisenhart-Rothe R, Jaenisch M, Ertl M, Wagner M, Windhagen H, Rudert M, Jakuscheit A. Accuracy of Positioning and Risk Factors for Malpositioning Custom-Made Femoral Stems in Total Hip Arthroplasty-A Retrospective Multicenter Analysis. J Pers Med 2023; 13:1285. [PMID: 37763052 PMCID: PMC10532930 DOI: 10.3390/jpm13091285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023] Open
Abstract
Total hip arthroplasty (THA) is commonly performed using off-the-shelf implants. In the case of a severe mismatch between the anatomy of the proximal femur and the geometry of the stem, the use of custom-made stems might become necessary. The goal of this study was to investigate the precision of the implantation of custom-made stems of one manufacturer (CTX stem, AQ Implants) and to determine risk factors for malpositioning. All patients receiving a custom-made CTX stem between 2014 and 2020 at six high-volume academic centers were retrospectively recruited. The achieved position of the stem, as determined by stem version, stem coronal angle, and implantation depth on radiographs, was compared to the plan. The influence of radiographic and demographic parameters on the position was investigated. The results revealed a high variability of the achieved implant position in relation to the preoperative plan. While the stem coronal angle only differed slightly from the intended position, the stem version and the implantation depth showed a high frequency and amount of deviation. Right stems showed significantly higher positions than planned. Surgeons must be aware of this potential problem when implanting custom-made stems.
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Affiliation(s)
- Philip Mark Anderson
- Department of Orthopedics, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97070 Wuerzburg, Germany
| | - Tizian Heinz
- Department of Orthopedics, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97070 Wuerzburg, Germany
| | - Dominik Rak
- Department of Orthopedics, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97070 Wuerzburg, Germany
| | - Jörg Arnholdt
- Department of Orthopedic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Boris Michael Holzapfel
- Department of Orthopedic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Silke Dorsch
- Department of Orthopedics, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97070 Wuerzburg, Germany
| | - Manuel Weißenberger
- Department of Orthopedics, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97070 Wuerzburg, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675 Munich, Germany
| | - Max Jaenisch
- Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Max Ertl
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675 Munich, Germany;
| | - Michael Wagner
- Department of Orthopaedics and Trauma Surgery, Klinikum Nürnberg Campus Süd, Paracelsus Medical University, Breslauer Straße 201, 90472 Nürnberg, Germany;
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Annastift Hannover, Medical School Hannover, Borries Str. 1-6, 30625 Hannover, Germany;
| | - Maximilian Rudert
- Department of Orthopedics, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97070 Wuerzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopedics, König-Ludwig-Haus, University of Würzburg, Brettreichstraße 11, 97070 Wuerzburg, Germany
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Heinz T, Wild M, Eidmann A, Weißenberger M, Rak D, Nedopil AJ, Rudert M, Stratos I. Impact of COVID-19 on Fracture Incidence in Germany: A Comparative Age and Gender Analysis of Pre- and Post-Outbreak Periods. Healthcare (Basel) 2023; 11:2139. [PMID: 37570379 PMCID: PMC10418784 DOI: 10.3390/healthcare11152139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/16/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
In March 2020, Germany imposed a nationwide lockdown to curb the spread of COVID-19, prompting questions about the impact on the incidence of common fractures. This study examined 15 fracture types in pre-outbreak (2010-2019) and post-outbreak (2020-2021) periods, using data categorized by age (18-64 years, >65 years) and sex (male, female). Linear regression assessed annual growth rates, and mean fracture numbers were compared across periods for significant differences. Results indicated a positive correlation between fracture incidence rates and time for various types, such as cervical, thoracic, lumbar, and pelvic spine fractures, rib fractures, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures. Frequencies of proximal humerus, distal radius, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures in 2020 and 2021 were within predicted ranges from previous years. However, rib fractures and spinal fractures (cervical, thoracic, lumbar, and pelvic spine) occurred less frequently during this time. Notably, this study found a consistent decline in most fracture types for individuals aged 18-64 after the pandemic's onset, while the fracture incidence of hip fractures, often referred to as fragility fractures, for those over 65 remained unchanged. Fibula fractures showed the most considerable decrease in both age groups. In conclusion, the COVID-19 pandemic substantially impacted fracture incidence, with lower rates among individuals under 65 and unchanged fragility fractures in the elderly population.
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Affiliation(s)
- Tizian Heinz
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany (M.W.); (A.E.); (D.R.)
| | - Moritz Wild
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany (M.W.); (A.E.); (D.R.)
| | - Annette Eidmann
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany (M.W.); (A.E.); (D.R.)
| | - Manuel Weißenberger
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany (M.W.); (A.E.); (D.R.)
| | - Dominik Rak
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany (M.W.); (A.E.); (D.R.)
| | - Alexander Johannes Nedopil
- Department of Orthopedic Surgery, Orthopedic Surgeon Adventist Health Lodi Memorial, Lodi, CA 95240, USA;
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany (M.W.); (A.E.); (D.R.)
| | - Ioannis Stratos
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, 97074 Wuerzburg, Germany (M.W.); (A.E.); (D.R.)
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Eidmann A, Heinz T, Oberfeld J, Weißenberger M, Rudert M, Stratos I. Epidemiology and Trends in Cartilage Surgery of the Foot and Ankle in Germany: An Analysis of National Healthcare Billing and Reporting Data from 2006 to 2020. Medicina (Kaunas) 2023; 59:1256. [PMID: 37512067 PMCID: PMC10386157 DOI: 10.3390/medicina59071256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
Background and objectives: Cartilage surgery constitutes a standard intervention in foot and ankle procedures. Currently, there is a lack of epidemiological data on its frequency, age distribution, and surgical options for cartilage surgery. This study aimed to investigate the current landscape of cartilage surgery in Germany and identify the most common procedures from an epidemiological standpoint. Materials and methods: Medical billing and reporting data from the Federal Statistical Office of Germany, encompassing the period 2006-2020, was examined, including all foot and ankle cartilage surgical procedures (summarized under OPS codes 5-812 and 5-801). The dataset incorporated information on the affected joint, patient age and sex, and surgery type. Each surgical procedure was categorized as "debridement", "regeneration" or "refixation". Linear and nonlinear regression analyses were employed, with a statistical significance threshold of 0.05. Results: From the total of 136,501 procedures conducted during the study period, the most frequently performed interventions were microfracture (58,252) and chondroplasty (56,135), and thus, debridement procedures were in the leading position. The use of acellular membranes was the most used regenerative technique (n = 11,414). At the ankle joint, interventions were mostly arthroscopic and in men, while foot cartilage surgeries were preferably performed via open surgery and mostly in women. Age distribution analysis revealed two primary peaks: the first in the 20-25-year-old group (ankle and foot) and the second in the 45-50-year-old group (ankle) and 55-60-year-old group (foot). Refixation and regenerative procedures were more frequent among younger individuals, while debriding procedures were more frequent among older individuals. Regenerative procedures, particularly in the ankle, significantly increased over time. Conclusions: Cartilage surgery of the foot and ankle was common, with two primary age groups predominantly affected. Notably, recent years have witnessed a considerable rise in cartilage regenerative procedures.
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Affiliation(s)
- Annette Eidmann
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074 Wuerzburg, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074 Wuerzburg, Germany
| | - Jan Oberfeld
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074 Wuerzburg, Germany
| | - Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074 Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074 Wuerzburg, Germany
| | - Ioannis Stratos
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074 Wuerzburg, Germany
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Luetkens KS, Grunz JP, Kunz AS, Huflage H, Weißenberger M, Hartung V, Patzer TS, Gruschwitz P, Ergün S, Bley TA, Feldle P. Ultra-High-Resolution Photon-Counting Detector CT Arthrography of the Ankle: A Feasibility Study. Diagnostics (Basel) 2023; 13:2201. [PMID: 37443595 DOI: 10.3390/diagnostics13132201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/13/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
This study was designed to investigate the image quality of ultra-high-resolution ankle arthrography employing a photon-counting detector CT. Bilateral arthrograms were acquired in four cadaveric specimens with full-dose (10 mGy) and low-dose (3 mGy) scan protocols. Three convolution kernels with different spatial frequencies were utilized for image reconstruction (ρ50; Br98: 39.0, Br84: 22.6, Br76: 16.5 lp/cm). Seven radiologists subjectively assessed the image quality regarding the depiction of bone, hyaline cartilage, and ligaments. An additional quantitative assessment comprised the measurement of noise and the computation of contrast-to-noise ratios (CNR). While an optimal depiction of bone tissue was achieved with the ultra-sharp Br98 kernel (S ≤ 0.043), the visualization of cartilage improved with lower modulation transfer functions at each dose level (p ≤ 0.014). The interrater reliability ranged from good to excellent for all assessed tissues (intraclass correlation coefficient ≥ 0.805). The noise levels in subcutaneous fat decreased with reduced spatial frequency (p < 0.001). Notably, the low-dose Br76 matched the CNR of the full-dose Br84 (p > 0.999) and superseded Br98 (p < 0.001) in all tissues. Based on the reported results, a photon-counting detector CT arthrography of the ankle with an ultra-high-resolution collimation offers stellar image quality and tissue assessability, improving the evaluation of miniscule anatomical structures. While bone depiction was superior in combination with an ultra-sharp convolution kernel, soft tissue evaluation benefited from employing a lower spatial frequency.
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Affiliation(s)
- Karsten Sebastian Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Jan-Peter Grunz
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Andreas Steven Kunz
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Henner Huflage
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Würzburg, König-Ludwig-Haus, Brettreichstr. 11, 97074 Würzburg, Germany
| | - Viktor Hartung
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Theresa Sophie Patzer
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Philipp Gruschwitz
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Süleyman Ergün
- Institute of Anatomy and Cell Biology, University of Würzburg, Koellikerstraße 6, 97070 Würzburg, Germany
| | - Thorsten Alexander Bley
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Philipp Feldle
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
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Heinz T, Vasilev H, Anderson PM, Stratos I, Jakuscheit A, Horas K, Holzapfel BM, Rudert M, Weißenberger M. The Direct Anterior Approach (DAA) as a Standard Approach for Total Hip Arthroplasty (THA) in Coxa Profunda and Protrusio Acetabuli? A Radiographic Analysis of 188 Cases. J Clin Med 2023; 12:3941. [PMID: 37373635 DOI: 10.3390/jcm12123941] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION The direct anterior approach (DAA) represents a well-recognized soft tissue sparing technique for primary total hip arthroplasty (THA). The feasibility and suitability of the DAA in cases of complex acetabular deformities, namely coxa profunda (CP) and protrusio acetabuli (PA), remain to be determined. METHODS A total of 188 cases of CP (100 cases) and PA (88 cases) hips undergoing primary THA via the DAA were retrospectively analyzed. Surgical and radiographic parameters were evaluated and potential complications were assessed. Finally, successful implantation was defined if surgical and radiographic parameters were well within established values of non-complex primary THA. RESULTS In 159 hips, the medial border of the acetabular component was transferred laterally to the ilioischial line, corresponding to a fully treated acetabular protrusion. In 23 (12.23%) cases, mild, and in 5 (2.66%) cases, moderate residual acetabular protrusion remained after THA. Postoperatively, 11.40% (PA group) and 9.00% (CP group) had a leg length discrepancy (LLD) greater than 10 mm. The mean operative time was significantly less than 60 min. A linear relationship between the BMI and operative time was observed, with an additional 0.9 min of operative time per BMI unit. Overall, complications were rare and did not differ between the two groups. CONCLUSION The results of this study suggest that the DAA is a suitable approach for primary THA in patients with coxa profunda and acetabular protrusion if performed by experienced surgeons familiar with the DAA. Obese patients with acetabular protrusion may pose a significant limitation to the DAA and caution should be advised in cases of obesity.
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Affiliation(s)
- Tizian Heinz
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany
| | - Hristo Vasilev
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany
| | - Philip Mark Anderson
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany
| | - Ioannis Stratos
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany
| | - Konstantin Horas
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany
| | - Boris Michael Holzapfel
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15, 81377 Munich, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany
| | - Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr 11, 97074 Wuerzburg, Germany
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10
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Weißenberger M, Wagenbrenner M, Nickel J, Ahlbrecht R, Blunk T, Steinert AF, Gilbert F. Comparative in vitro treatment of mesenchymal stromal cells with GDF-5 and R57A induces chondrogenic differentiation while limiting chondrogenic hypertrophy. J Exp Orthop 2023; 10:29. [PMID: 36943593 PMCID: PMC10030724 DOI: 10.1186/s40634-023-00594-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/08/2023] [Indexed: 03/23/2023] Open
Abstract
PURPOSE Hypertrophic cartilage is an important characteristic of osteoarthritis and can often be found in patients suffering from osteoarthritis. Although the exact pathomechanism remains poorly understood, hypertrophic de-differentiation of chondrocytes also poses a major challenge in the cell-based repair of hyaline cartilage using mesenchymal stromal cells (MSCs). While different members of the transforming growth factor beta (TGF-β) family have been shown to promote chondrogenesis in MSCs, the transition into a hypertrophic phenotype remains a problem. To further examine this topic we compared the effects of the transcription growth and differentiation factor 5 (GDF-5) and the mutant R57A on in vitro chondrogenesis in MSCs. METHODS Bone marrow-derived MSCs (BMSCs) were placed in pellet culture and in-cubated in chondrogenic differentiation medium containing R57A, GDF-5 and TGF-ß1 for 21 days. Chondrogenesis was examined histologically, immunohistochemically, through biochemical assays and by RT-qPCR regarding the expression of chondrogenic marker genes. RESULTS Treatment of BMSCs with R57A led to a dose dependent induction of chondrogenesis in BMSCs. Biochemical assays also showed an elevated glycosaminoglycan (GAG) content and expression of chondrogenic marker genes in corresponding pellets. While treatment with R57A led to superior chondrogenic differentiation compared to treatment with the GDF-5 wild type and similar levels compared to incubation with TGF-ß1, levels of chondrogenic hypertrophy were lower after induction with R57A and the GDF-5 wild type. CONCLUSIONS R57A is a stronger inducer of chondrogenesis in BMSCs than the GDF-5 wild type while leading to lower levels of chondrogenic hypertrophy in comparison with TGF-ß1.
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, König-Ludwig-Haus, Würzburg, Germany.
- Department of Orthopedic Surgery, University of Wuerzburg, König-Ludwig-Haus, Brettreichstraße 11, 97074, Würzburg, Germany.
| | - Mike Wagenbrenner
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, König-Ludwig-Haus, Würzburg, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Joachim Nickel
- Department of Tissue Engineering and Regenerative Medicine, Julius-Maximilians-University Würzburg, University Hospital, Würzburg, Germany
| | - Rasmus Ahlbrecht
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, König-Ludwig-Haus, Würzburg, Germany
- Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, Julius-Maximilians-University Würzburg, University Hospital, Würzburg, Germany
| | - Torsten Blunk
- Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, Julius-Maximilians-University Würzburg, University Hospital, Würzburg, Germany
| | - Andre F Steinert
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, König-Ludwig-Haus, Würzburg, Germany
- Current address:, Department of Orthopaedic, Trauma, Shoulder and Arthroplasty Surgery, Rhön-Klinikum, Campus Bad Neustadt, Bad Neustadt, Germany
| | - Fabian Gilbert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Trauma-, Hand-, Plastic- and Reconstructive Surgery, Julius-Maximilians-University Würzburg, University Hospital, Würzburg, Germany
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Heinz T, Meller F, Luetkens KS, Anderson PM, Stratos I, Horas K, Rudert M, Reppenhagen S, Weißenberger M. The AMADEUS score is not a sufficient predictor for functional outcome after high tibial osteotomy. J Exp Orthop 2023; 10:9. [PMID: 36705820 PMCID: PMC9883369 DOI: 10.1186/s40634-023-00575-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/19/2023] [Indexed: 01/28/2023] Open
Abstract
PURPOSE The Area Measurement And Depth Underlying Structures (AMADEUS) classification system has been proposed as a valuable tool for magnetic resonance (MR)-based grading of preoperatively encountered chondral defects of the knee joint. However, the potential relationship of this novel score with clinical data was yet to determine. It was the primary intention of this study to assess the correlative relationship of the AMADEUS with patient reported outcome scores in patients undergoing medial open-wedge high tibial valgus osteotomy (HTO). Furthermore, the arthroscopic ICRS (International Cartilage Repair Society) grade evaluation was tested for correlation with the AMADEUS classification system. METHODS This retrospective, monocentric study found a total of 70 individuals that were indicated for HTO due to degenerative chondral defects of the medial compartment between 2008 and 2019. A preoperative MR image as well as a pre-osteotomy diagnostic arthroscopy for ICRS grade evaluation was mandatory for all patients. The Knee Osteoarthritis Outcome Score (KOOS) including its five subscale scores (KOOS-ADL, KOOS-QOL, KOOS-Sports, KOOS-Pain, KOOS-Symptoms) was obtained preoperatively and at a mean follow-up of 41.2 ± 26.3 months. Preoperative chondral defects were evaluated using the AMADEUS classification system and the final AMADEUS scores were correlated with the pre- and postoperative KOOS subscale sores. Furthermore, arthroscopic ICRS defect severity was correlated with the AMADEUS classification system. RESULTS There was a statistically significant correlation between the AMADEUS BME (bone marrow edema) subscore and the KOOS Symptoms subscore at the preoperative visit (r = 0.25, p = 0.04). No statistically significant monotonic association between the AMADEUS total score and the AMADEUS grade with pre- and postoperative KOOS subscale scores were found. Intraoperatively obtained ICRS grade did reveal a moderate correlative relation with the AMADEUS total score and the AMADEUS grade (r = 0.28, p = 0.02). CONCLUSIONS The novel AMADEUS classification system largely lacks correlative capacity with patient reported outcome measures in patients undergoing HTO. The MR tomographic appearance of bone marrow edema is the only parameter predictive of the clinical outcome at the preoperative visit.
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Affiliation(s)
- Tizian Heinz
- grid.8379.50000 0001 1958 8658Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Felix Meller
- grid.8379.50000 0001 1958 8658Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Karsten Sebastian Luetkens
- grid.411760.50000 0001 1378 7891Department of Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany
| | - Philip Mark Anderson
- grid.8379.50000 0001 1958 8658Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Ioannis Stratos
- grid.8379.50000 0001 1958 8658Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Konstantin Horas
- grid.8379.50000 0001 1958 8658Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Maximilian Rudert
- grid.8379.50000 0001 1958 8658Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Stephan Reppenhagen
- grid.8379.50000 0001 1958 8658Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Manuel Weißenberger
- grid.8379.50000 0001 1958 8658Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
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12
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Anderson PM, Rudert M, Holzapfel BM, Meyer JS, Weißenberger M, Bölch SP. Conversion total hip arthroplasty following proximal femur fracture: A retrospective analysis. Technol Health Care 2023; 31:507-516. [PMID: 36404561 DOI: 10.3233/thc-220136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The incidence of conversion total hip arthroplasty (cTHA) following reduction and fixation for proximal femur fractures will increase in parallel to the aging population worldwide. OBJECTIVE The goal of this study is to report the frequency of bacterial detection and the outcome of cTHA at the authors' institution and to analyze preoperative factors that correlate with higher rates of bacterial growth and septic revision. METHODS 48 patients who had been converted to THA after osteosynthesis of a proximal femur fracture either by a one- or two-stage procedure were included. Septic failure rate and the frequency of bacterial detection at the time of fixation device removal were calculated. The influence of different preoperative factors was examined by the odds ratio. A receiver operating characteristic curve of c-reactive protein (CRP) for detection of bacterial growth at the time of fixation device removal was calculated. RESULTS 18.8% patients showed positive bacterial cultures, with Staph. epidermidis being the most frequent pathogen (33.3%). Septic failure after cTHA occurred in 4.2%. Fixation with cephalomedullary nails and complications with the internal fixation showed higher odds for bacterial growth at time of cTHA. CRP for predicting bacterial growth had an area under the curve of 0.661. Implant survival was worse when temporary spacers were used. CONCLUSION Bacterial detection rate at the time of cTHA is high, whereas septic failure rates are low. Isolated evaluation of inflammatory blood markers without other diagnostic modalities for infection is not decisive and does not justify a two-stage approach with implantation of a temporary spacer.
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Affiliation(s)
- Philip Mark Anderson
- Department of Orthopedics, Orthopädische Klinik, König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Maximilian Rudert
- Department of Orthopedics, Orthopädische Klinik, König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Boris Michael Holzapfel
- Department of Orthopedic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | | | - Manuel Weißenberger
- Department of Orthopedics, Orthopädische Klinik, König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Sebastian Philipp Bölch
- Department of Orthopedics, Orthopädische Klinik, König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
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13
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Anderson PM, Vollmann P, Weißenberger M, Rudert M. Total hip arthroplasty in geriatric patients – a single-center experience. SICOT J 2022; 8:12. [PMID: 35380534 PMCID: PMC8982179 DOI: 10.1051/sicotj/2022011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/07/2022] [Indexed: 11/15/2022] Open
Abstract
Background: As advanced age often leads to accumulating comorbidities, geriatric patients are endangered by serious events during total hip arthroplasty. This study was conducted to explore whether or not the benefit in terms of health-related quality of life (HRQoL) was comparable to younger patients. Methods: At a single academic center, 100 patients meeting the following inclusion criteria were retrospectively recruited: (1) primary arthritis of the hip leading to THA; (2) age 80 years or older at the time of surgery; (3) follow up of at least 12 months. For comparison, two further groups were recruited in the same manner, differing only in the age criterion: 100 patients aged 60–69 and 100 patients aged 70–79 at the time of hip replacement. The primary outcome was compared using the WOMAC and the EQ-5D score. The secondary outcome was determined by rates of orthopedic and non-orthopedic complications. Intragroup comparisons of the PROMS were performed by the non-parametric Wilcoxon test for paired samples. For intergroup comparisons of the PROMS, the Kruskal–Wallis-test was performed. Concerning categorial data, intergroup comparisons were performed by the Chi-Square test. The level of significance was set at 0.05. Results: Concerning the WOMAC score, neither the absolute values at 12 months after THA (p = 0.176) nor the amount of change relative to the values before surgery (p = 0.308) differed significantly between the 3 groups. Concerning the EQ-5D index the absolute values at 12 months after THA differed significantly (p = 0.008). Rates of orthopedic complications did not differ significantly (p = 0.631). Rates of non-orthopedic complications increased significantly with rising age (p = 0.033). Conclusions: Compared to younger patients, geriatric patients after THA have an equal improvement in hip-specific and general HRQoL. While rates of orthopedic complications are comparable too, non-orthopedic complications occur more frequently.
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Affiliation(s)
- Philip Mark Anderson
- University of Wuerzburg, Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus Brettreichstraße 11 97074 Würzburg Germany
- Corresponding author:
| | - Peter Vollmann
- University of Wuerzburg, Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus Brettreichstraße 11 97074 Würzburg Germany
| | - Manuel Weißenberger
- University of Wuerzburg, Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus Brettreichstraße 11 97074 Würzburg Germany
| | - Maximilian Rudert
- University of Wuerzburg, Department of Orthopedics, Orthopädische Klinik König-Ludwig-Haus Brettreichstraße 11 97074 Würzburg Germany
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14
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Weißenberger M, Wagenbrenner M, Schote F, Horas K, Schäfer T, Rudert M, Barthel T, Heinz T, Reppenhagen S. The 3-triangle method preserves the posterior tibial slope during high tibial valgus osteotomy: first preliminary data using a mathematical model. J Exp Orthop 2022; 9:29. [PMID: 35322320 PMCID: PMC8943089 DOI: 10.1186/s40634-022-00466-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Despite much improved preoperative planning techniques accurate intraoperative assessment of the high tibial valgus osteotomy (HTO) remains challenging and often results in coronal over- and under-corrections as well as unintended changes of the posterior tibial slope. Noyes et al. reported a novel method for accurate intraoperative coronal and sagittal alignment correction based on a three-dimensional mathematical model. This is the first study examining preliminary data via the proposed Noyes approach for accurate intraoperative coronal and sagittal alignment correction during HTO. METHODS From 2016 to 2020 a total of 24 patients (27 knees) underwent HTO applying the proposed Noyes method (Noyes-Group). Radiographic data was analyzed retrospectively and matched to patients that underwent HTO using the conventional method, i.e., gradual medial opening using a bone spreader under fluoroscopic control (Conventional-Group). All operative procedures were performed by an experienced surgeon at a single orthopaedic university center. RESULTS From the preoperative to the postoperative visit no statistically significant changes of the posterior tibial slope were noted in the Noyes-Group compared to a significant increase in the Conventional-Group (p = 0.01). Regarding the axial alignment no significant differences between both groups were observed pre- and postoperatively. The number of over- and under-corrections did not differ significantly between both groups. Linear regression analysis showed a significant correlation of the postoperative medial proximal tibial angle (MPTA) with the position of the weightbearing line on the tibial plateau. CONCLUSION The 3-triangle method by Noyes seems to be a promising approach for preservation of the posterior tibial slope during HTO.
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Mike Wagenbrenner
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Fritz Schote
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany.,Department of Orthopaedic Surgery and Traumatology, University of Salzburg, University Hospital Salzburg SALK, Müllner Haupstraße 48, 5020, Salzburg, Austria
| | - Konstantin Horas
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Thomas Schäfer
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Thomas Barthel
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Stephan Reppenhagen
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
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15
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Rak D, Weißenberger M, Horas K, von Hertzberg-Bölch S, Rudert M. [Mega-prostheses in revision knee arthroplasty]. Orthopade 2021; 50:1011-1017. [PMID: 34739569 DOI: 10.1007/s00132-021-04187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Due to a predicted increase in primary total knee arthroplasty (TKA), revision TKA will gain importance over the following years. Because the average age of patients receiving a TKA is decreasing the possible need for multiple revisions might increase as well. Despite efforts to minimize bone and soft tissue damage, the resulting bone and soft-tissue loss increases with each revision and will make the use of megaprostheses indispensable in the future. COMPLICATIONS The implantation of a mega-prosthesis must be carefully considered and planned, since mega-prostheses in particular are associated with an increased risk of infection and loosening. Mechanical complications, patient-specific problems and periprosthetic infections can be either the cause for or the result of revision surgery of a mega-prosthesis. In the case of a complication, only a salvage procedure, namely an arthrodesis, amputation or-if necessary-the installation of a permanent fistula is commonly recommended.
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Affiliation(s)
- D Rak
- Klinik König-Ludwig-Haus Würzburg, Lehrstuhl für Orthopädie, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland
| | - M Weißenberger
- Klinik König-Ludwig-Haus Würzburg, Lehrstuhl für Orthopädie, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland
| | - K Horas
- Klinik König-Ludwig-Haus Würzburg, Lehrstuhl für Orthopädie, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland
| | - S von Hertzberg-Bölch
- Klinik König-Ludwig-Haus Würzburg, Lehrstuhl für Orthopädie, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland
| | - M Rudert
- Klinik König-Ludwig-Haus Würzburg, Lehrstuhl für Orthopädie, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland.
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16
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Weißenberger M, Klug A, Heinz T, Rueckl K, Kollenda H, Rudert M, Hoffmann R, Schmidt-Horlohé K. No functional differences in anatomic reconstruction using a one- versus a two-point fixation for distal biceps tendon rupture through a single-incision anterior approach: A prospective randomized trial. Technol Health Care 2021; 29:575-588. [PMID: 33492254 DOI: 10.3233/thc-202476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The distal biceps brachii tendon rupture is a rare injury of the musculoskeletal system. Multiple surgical techniques have been described for distal biceps brachii tendon repairs including suture anchors. OBJECTIVE The aim of this study was to evaluate the outcome of anatomical distal biceps tendon refixation using either one or two suture anchors for reattachment and to determine whether there are significant clinically important differences on the number of anchors used for refixation. METHODS A monocentric, randomized controlled trial was conducted, including 16 male patients with a mean age of 47.4 years (range, 31.0 to 58.0) in Group 1 (two suture anchors for refixation) and 15 male patients with a mean age of 47.4 (range, 35.0 to 59.0) in Group 2 (one suture anchor for refixation). All surgeries were performed through an anterior approach. The outcome was assessed using the Oxford Elbow Score (OES), the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Andrews Carson Score (ACS) and by isokinetic strength measurement for the elbow flexion after six, twelve, 24 and 48 weeks. Radiographic controls were performed after 24 and 48 weeks. RESULTS No significant differences between both groups were evident at any point during the follow-up period. A continuous improvement in outcome for both groups could be detected, reaching an OES: 46.3 (39.0 to 48.0) vs. 45.5 (30.0 to 48.0), MEPS: 98.0 (85.0 to 100.0) vs. 99.0 (85.0 to 100.0), DASH: 3.1 (0.0 to 16.7) vs. 2.9 (0.0 to 26.7), ACS: 197.0 (175.0 to 200.0) vs. 197.7.
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Affiliation(s)
- Manuel Weißenberger
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany.,Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Germany.,Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany
| | - Alexander Klug
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany.,Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Germany
| | - Kilian Rueckl
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Germany
| | - Hans Kollenda
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany.,Supervisory Center North for Public Law Tasks of the Bundeswehr Medical Service, Kronshagen, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Germany
| | - Reinhard Hoffmann
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany
| | - Kay Schmidt-Horlohé
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Department of Trauma and Orthopaedic Surgery, Frankfurt am Main, Germany.,Orthopaedicum Wiesbaden, Wiesbaden, Germany
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Heinz T, Reppenhagen S, Wagenbrenner M, Horas K, Ohlmeier M, Schäfer T, Rudert M, Barthel T, Weißenberger M. Focal cartilage defects of the lateral compartment do influence the outcome after high tibial valgus osteotomy. SICOT J 2021; 7:44. [PMID: 34431783 PMCID: PMC8386396 DOI: 10.1051/sicotj/2021044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/27/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION High tibial medial open-wedge valgus osteotomy (HTO) is a well-established procedure for unicompartimental medial osteoarthritis of the young and active patient. However, the influence of cartilage defects of the lateral compartment on the total outcome remains obscure. METHODS From 2005 to 2012, a total of 63 patients underwent HTO for medial osteoarthritis of the knee at a single university orthopaedic center. Baseline data as well as intraoperative findings, including the grade and location of cartilage lesions, were evaluated retrospectively. Two groups were formed regarding the integrity of the lateral tibiofemoral compartment as measured by the Outerbridge score (group A: no lateral cartilage defects, group B: mild to moderate lateral cartilage defects). Functional outcome was assessed using the Knee and Osteoarthritis Outcome Score (KOOS), including its five subscores. RESULTS Comparing pre- and postoperative data, we identified an overall benefit of the HTO procedure as measured by the KOOS. Group A (no lateral cartilage defects) showed an increase in all five KOOS subscores (p = 0.00-0.01), whereas for group B (mild to moderate lateral cartilage defects), only two KOOS subscores revealed a significant increase (p = 0.03-0.04). There was also a statistically significant difference in the total KOOS score with higher values for group A at the postoperative visit. Cartilage defects with a higher Outerbridge score were associated with lower postoperative KOOS subscores. DISCUSSION Mild to moderate cartilage defects of the lateral compartment humble the total outcome after HTO procedure. Thus, indication for HTO should be made very carefully if any degree of lateral cartilage degeneration is present.
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Affiliation(s)
- Tizian Heinz
- Department of Orthopaedic Surgery, University of Wuerzburg Koenig-Ludwig-Haus, Brettreichstr. 11 97074 Wuerzburg Germany
| | - Stephan Reppenhagen
- Department of Orthopaedic Surgery, University of Wuerzburg Koenig-Ludwig-Haus, Brettreichstr. 11 97074 Wuerzburg Germany
| | - Mike Wagenbrenner
- Department of Orthopaedic Surgery, University of Wuerzburg Koenig-Ludwig-Haus, Brettreichstr. 11 97074 Wuerzburg Germany
| | - Konstantin Horas
- Department of Orthopaedic Surgery, University of Wuerzburg Koenig-Ludwig-Haus, Brettreichstr. 11 97074 Wuerzburg Germany
| | - Malte Ohlmeier
- Department of Orthopaedic Surgery, HELIOS ENDO-Klinik Hamburg 22767 Hamburg Germany
| | - Thomas Schäfer
- Department of Orthopaedic Surgery, University of Wuerzburg Koenig-Ludwig-Haus, Brettreichstr. 11 97074 Wuerzburg Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg Koenig-Ludwig-Haus, Brettreichstr. 11 97074 Wuerzburg Germany
| | - Thomas Barthel
- Department of Orthopaedic Surgery, University of Wuerzburg Koenig-Ludwig-Haus, Brettreichstr. 11 97074 Wuerzburg Germany
| | - Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg Koenig-Ludwig-Haus, Brettreichstr. 11 97074 Wuerzburg Germany
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Weißenberger M, Heinz T, Boelch SP, Niemeyer P, Rudert M, Barthel T, Reppenhagen S. Correction to: Is debridement beneficial for focal cartilage defects of the knee: data from the German Cartilage Registry (KnorpelRegister DGOU). Arch Orthop Trauma Surg 2021; 141:1081-1082. [PMID: 33950276 PMCID: PMC8139924 DOI: 10.1007/s00402-021-03905-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A correction to this paper has been published: https://doi.org/10.1007/s00402-021-03905-0
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Sebastian P. Boelch
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Philipp Niemeyer
- OCM Clinic, Steinerstr. 6, 81369 Munich, Germany ,Department of Orthopaedics and Trauma Surgery, Freiburg University Hospital, Hugstetter Str. 55, 79106 Freiburg im Breisgau, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Thomas Barthel
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Stephan Reppenhagen
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
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Weißenberger M, Weißenberger MH, Wagenbrenner M, Heinz T, Reboredo J, Holzapfel BM, Rudert M, Groll J, Evans CH, Steinert AF. Different types of cartilage neotissue fabricated from collagen hydrogels and mesenchymal stromal cells via SOX9, TGFB1 or BMP2 gene transfer. PLoS One 2020; 15:e0237479. [PMID: 32790806 PMCID: PMC7425924 DOI: 10.1371/journal.pone.0237479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/27/2020] [Indexed: 11/18/2022] Open
Abstract
Objective As native cartilage consists of different phenotypical zones, this study aims to fabricate different types of neocartilage constructs from collagen hydrogels and human mesenchymal stromal cells (MSCs) genetically modified to express different chondrogenic factors. Design Human MSCs derived from bone-marrow of osteoarthritis (OA) hips were genetically modified using adenoviral vectors encoding sex-determining region Y-type high-mobility-group-box (SOX) 9, transforming growth factor beta (TGFB) 1 or bone morphogenetic protein (BMP) 2 cDNA, placed in type I collagen hydrogels and maintained in serum-free chondrogenic media for three weeks. Control constructs contained unmodified MSCs or MSCs expressing GFP. The respective constructs were analyzed histologically, immunohistochemically, biochemically, and by qRT-PCR for chondrogenesis and hypertrophy. Results Chondrogenesis in MSCs was consistently and strongly induced in collagen I hydrogels by the transgenes SOX9, TGFB1 and BMP2 as evidenced by positive staining for proteoglycans, chondroitin-4-sulfate (CS4) and collagen (COL) type II, increased levels of glycosaminoglycan (GAG) synthesis, and expression of mRNAs associated with chondrogenesis. The control groups were entirely non-chondrogenic. The levels of hypertrophy, as judged by expression of alkaline phosphatase (ALP) and COL X on both the protein and mRNA levels revealed different stages of hypertrophy within the chondrogenic groups (BMP2>TGFB1>SOX9). Conclusions Different types of neocartilage with varying levels of hypertrophy could be generated from human MSCs in collagen hydrogels by transfer of genes encoding the chondrogenic factors SOX9, TGFB1 and BMP2. This technology may be harnessed for regeneration of specific zones of native cartilage upon damage.
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research (OCMR), Julius-Maximilians-University Würzburg, Würzburg, Germany
- * E-mail:
| | - Manuela H. Weißenberger
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research (OCMR), Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Mike Wagenbrenner
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research (OCMR), Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research (OCMR), Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Jenny Reboredo
- Department of Tissue Engineering and Regenerative Medicine, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Boris M. Holzapfel
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research (OCMR), Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research (OCMR), Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Jürgen Groll
- Department of Functional Materials in Medicine and Dentistry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Christopher H. Evans
- Department of Physical Medicine and Rehabilitation, Musculoskeletal Gene Therapy Research Laboratory, Mayo Clinic, Rochester, MN, United States of America
| | - Andre F. Steinert
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research (OCMR), Julius-Maximilians-University Würzburg, Würzburg, Germany
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Wagenbrenner M, Heinz T, Horas K, Jakuscheit A, Arnholdt J, Herrmann M, Rudert M, Holzapfel BM, Steinert AF, Weißenberger M. The human arthritic hip joint is a source of mesenchymal stromal cells (MSCs) with extensive multipotent differentiation potential. BMC Musculoskelet Disord 2020; 21:297. [PMID: 32404085 PMCID: PMC7222515 DOI: 10.1186/s12891-020-03340-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/08/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND While multiple in vitro studies examined mesenchymal stromal cells (MSCs) derived from bone marrow or hyaline cartilage, there is little to no data about the presence of MSCs in the joint capsule or the ligamentum capitis femoris (LCF) of the hip joint. Therefore, this in vitro study examined the presence and differentiation potential of MSCs isolated from the bone marrow, arthritic hyaline cartilage, the LCF and full-thickness samples of the anterior joint capsule of the hip joint. METHODS MSCs were isolated and multiplied in adherent monolayer cell cultures. Osteogenesis and adipogenesis were induced in monolayer cell cultures for 21 days using a differentiation medium containing specific growth factors, while chondrogenesis in the presence of TGF-ß1 was performed using pellet-culture for 27 days. Control cultures were maintained for comparison over the same duration of time. The differentiation process was analyzed using histological and immunohistochemical stainings as well as semiquantitative RT-PCR for measuring the mean expression levels of tissue-specific genes. RESULTS This in vitro research showed that the isolated cells from all four donor tissues grew plastic-adherent and showed similar adipogenic and osteogenic differentiation capacity as proven by the histological detection of lipid droplets or deposits of extracellular calcium and collagen type I. After 27 days of chondrogenesis proteoglycans accumulated in the differentiated MSC-pellets from all donor tissues. Immunohistochemical staining revealed vast amounts of collagen type II in all differentiated MSC-pellets, except for those from the LCF. Interestingly, all differentiated MSCs still showed a clear increase in mean expression of adipogenic, osteogenic and chondrogenic marker genes. In addition, the examination of an exemplary selected donor sample revealed that cells from all four donor tissues were clearly positive for the surface markers CD44, CD73, CD90 and CD105 by flow cytometric analysis. CONCLUSIONS This study proved the presence of MSC-like cells in all four examined donor tissues of the hip joint. No significant differences were observed during osteogenic or adipogenic differentiation depending on the source of MSCs used. Further research is necessary to fully determine the tripotent differentiation potential of cells isolated from the LCF and capsule tissue of the hip joint.
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Affiliation(s)
- Mike Wagenbrenner
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Konstantin Horas
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Axel Jakuscheit
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Joerg Arnholdt
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Marietta Herrmann
- Bernhard-Heine-Center for Locomotion Research, University of Wuerzburg, Wuerzburg, Germany.,IZKF Research Group Tissue Regeneration in Musculoskeletal Disease, University Clinics Wuerzburg, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Boris M Holzapfel
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Andre F Steinert
- Department of Orthopaedic, Trauma, Shoulder and Arthroplasty Surgery, Rhön-Klinikum Campus Bad Neustadt, Von-Guttenberg-Str. 11, 97616, Bad Neustadt, Germany
| | - Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany.
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Weißenberger M, Heinz T, Rueckl K, Rudert M, Klug A, Hoffmann R, Schmidt-Horlohé K. No functional differences in anatomic reconstruction with one vs. two suture anchors after non-simultaneous bilateral distal biceps brachii tendon rupture: a case report and review of the literature. BMC Musculoskelet Disord 2020; 21:270. [PMID: 32340623 PMCID: PMC7187509 DOI: 10.1186/s12891-020-03304-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 04/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical reattachment of the tendon is still the gold standard for ruptures of the distal biceps brachii tendon. Several fixation techniques have been described in the literature, with suture anchors being one of the most common fixation techniques. Currently, there is no data available on how many anchors are required for a safe and stable refixation. In this case report clinical data of a patient with non-simultaneous bilateral distal biceps tendon ruptures treated with a different number of suture anchors for each side (one vs. two) are demonstrated. CASE PRESENTATION A 47-year-old factory worker suffered a rupture of the distal biceps tendon on both arms following two different occasions. The left side was fixed using a single suture anchor, while refixation on the right side was performed with two anchors. The patient was prospectively followed for one year. Functional outcome was assessed using the Andrews Carson Score (ACS), the Oxford Elbow Score (OES), and the Disabilities of Arm, Shoulder and Hand (DASH) Score after six, twelve, 24 and 48 weeks. Furthermore, an isokinetic strength measurement for flexion strength was performed after 24 and 48 weeks. After 48 weeks the patient presented with excellent functional outcome scores and no follow-up complications. During the follow-up period, no differences in the functional scores nor in the isokinetic flexion strength measurement could be detected. Furthermore, no radiological complications (like heterotopic ossifications) could be detected in the postoperative radiographs after one year. CONCLUSIONS Anatomic reattachment of the distal biceps tendon is a successful operative treatment option for distal biceps tendon ruptures. Suture anchor fixation remains one of the most common techniques, as it allows fast surgery and provides good results with respect to range of motion (ROM) and functional scoring according to the current literature. However, the number of anchors required for a stable fixation remains unclear. As indicated by our presented case, we hypothesize, that there are no significant differences between a one-point or a two-point fixation. In the presented case report, no intraindividual differences between the usage of one versus two suture anchors were evident in the short-term follow-up.
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Brettreichstr. 11, D-97074, Wuerzburg, Germany. .,Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany.
| | - Tizian Heinz
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Brettreichstr. 11, D-97074, Wuerzburg, Germany
| | - Kilian Rueckl
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Brettreichstr. 11, D-97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, Julius-Maximilians-University, Wuerzburg, Brettreichstr. 11, D-97074, Wuerzburg, Germany
| | - Alexander Klug
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - Kay Schmidt-Horlohé
- Department of Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany.,Orthopaedicum Wiesbaden, Wiesbaden, Germany
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Weißenberger M, Petersen N, Bölch S, Rak D, Arnholdt J, Rudert M, Holzapfel BM. Revision of unicompartmental knee arthroplasty using the in situ referencing technique. Oper Orthop Traumatol 2020; 32:273-283. [PMID: 32140741 DOI: 10.1007/s00064-020-00656-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/25/2019] [Accepted: 10/09/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) with the in situ referencing technique aiming to preserve as much ligament function and epi-metaphyseal bone stock as possible. INDICATIONS Aseptic loosening, progression of osteoarthritis, periprosthetic fracture, periprosthetic infection, arthrofibrosis, polyethylene wear, malalignment, instability, femoro-tibial impingement. CONTRAINDICATIONS Unexplained pain, localized or systemic active infection (anywhere). SURGICAL TECHNIQUE Referencing for the tibia and the femur cuts is performed prior to implant removal. The tibial cutting jig and the initial tibial resection level is set in a way that the sawblade just fits under the tibial implant. In case too much bone needs to be removed to achieve flush implant sitting on both the medial and lateral tibia, a step cut needs to be performed to build up the medial defect with an augment. Prior to femoral component removal, rotational alignment is determined and intramedullary referencing for the distal femur osteotomy is performed. Level of constraint and additional tibial stem fixation is chosen according to the amount of bone resected and according to ligament stability. POSTOPERATIVE MANAGEMENT Sterile dressings and elastic compression bandaging. No limitation of active/passive range of motion. Full weight-bearing or partial weight-bearing for 2 weeks postoperatively in the presence of bone or soft tissue defects. RESULTS Between 2008 and 2019, 84 patients underwent revision of unicompartmental knee arthroplasty. The mean follow-up was 64 months (range 3-132 months). Implant survival after revision of UKA to TKA was 92% (95% CI = 82-97%) at 5 years of follow-up and 86% (95% CI = 69-93%) at 10 years of follow-up. The mean Oxford knee score was 20.1 (6-39, SD ± 6.5) preoperatively and 30.2 (3-48, SD ± 11.3) postoperatively. The mean visual analogue scale was 6.9 (range 1-10, SD ± 1.8) preoperatively and 3.9 (range 0-9, SD ± 2.6) postoperatively.
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Nils Petersen
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Sebastian Bölch
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Dominik Rak
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Jörg Arnholdt
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany
| | - Boris Michael Holzapfel
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074, Wuerzburg, Germany. .,Regenerative Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, 4059, Brisbane, Australia.
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Weißenberger M, Heinz T, Boelch SP, Niemeyer P, Rudert M, Barthel T, Reppenhagen S. Is debridement beneficial for focal cartilage defects of the knee: data from the German Cartilage Registry (KnorpelRegister DGOU). Arch Orthop Trauma Surg 2020; 140:373-382. [PMID: 31970506 PMCID: PMC8079301 DOI: 10.1007/s00402-020-03338-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Focal cartilage defects of the knee are often treated with arthroscopic debridement. Existing literature discussing the benefit of debridement for small articular cartilage lesions is scarce, especially if the debridement was not part of a combined operative cartilage procedure including meniscal and ligament repair. The purpose of this study was to examine the patients´ benefit after arthroscopic debridement for the treatment of isolated focal chondral defects with or without partial meniscus resection. MATERIALS AND METHODS Baseline (preoperative data) and 12-month follow-up of the five Knee Osteoarthritis Outcome Score (KOOS) subscores and the Numeric Rating Scale (NRS) for pain were analyzed in 126 patients undergoing debridement for focal chondral defects of the knee from the German Cartilage Registry. Sub-analysis for patients receiving isolated debridement and debridement with concomitant partial resection of meniscal pathologies was performed. Thus, four subgroups were created according to the treated defect size and presence of meniscal pathologies: "debridement-only < 2 cm2", "debridement-only > 2 cm2", "debridement and partial meniscus resection < 2 cm2" and "debridement and partial meniscus resection > 2 cm2". RESULTS KOOS-subscores showed a significant increase from baseline to follow-up evaluation (p = 0.017-0.037) within the 126 patients. Sub-analysis showed significant improvement of all five KOOS-subscores in all three subgroups, except for the "debridement and partial meniscus resection > 2 cm2"-group: in this group the KOOS subscores symptoms and sports showed no significant improvement. The NRS scores revealed no significant changes from baseline to 12-month follow-up within the four subgroups. CONCLUSION An overall benefit of arthroscopic debridement for focal cartilage lesions of the knee could be conducted. Isolated cartilage defects seem to benefit from debridement irrespectively of size. In patients with large cartilage defects (> 2 cm2) and concurrent meniscal pathology expectation to improvement should be humbled. Effective reduction of pain by arthroscopic debridement remains unclear.
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Affiliation(s)
- Manuel Weißenberger
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Tizian Heinz
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Sebastian P. Boelch
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Philipp Niemeyer
- OCM Clinic, Steinerstr. 6, 81369 Munich, Germany ,Department of Orthopaedics and Trauma Surgery, Freiburg University Hospital, Hugstetter Str. 55, 79106 Freiburg im Breisgau, Germany
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Thomas Barthel
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
| | - Stephan Reppenhagen
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, Brettreichstr. 11, 97074 Wuerzburg, Germany
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Abstract
Elbow dislocations are frequent and present with a broad spectrum of subsequent ligamentous and soft tissue injuries. Beside clinical examination, fluoroscopy, ultrasound and magnetic resonance imaging (MRI) can specify the extent of the injuries and provide a foundation for decision-making between conservative and operative treatment. This article highlights the basic underlying biomechanics and anatomy, discusses the trauma mechanisms and presents clinical and imaging diagnostic procedures. Treatment algorithms for conservative and surgical treatment are presented in detail. In addition to acute instability, chronic instability of the elbow has recently been recognized as the cause of a large variety of symptoms, often resulting in significant functional impairment. The most commonly used techniques for reconstruction of the medial and lateral collateral ligaments and the rehabilitation protocols are described in detail.
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Affiliation(s)
- Kay Schmidt-Horlohé
- Zentrum für Ellenbogenchirurgie, Orthopaedicum Wiesbaden - Praxis für Orthopädie, Unfallchirurgie und Sportmedizin, Friedrichstr. 29, 65185, Wiesbaden, Deutschland.
| | - Alexander Klug
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Manuel Weißenberger
- Orthopädische Klinik König-Ludwig-Haus, Lehrstuhl für Orthopädie, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland
| | - Den Nis Wincheringer
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Reinhard Hoffmann
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
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Armbruster N, Krieg J, Weißenberger M, Scheller C, Steinert AF. Rescued Chondrogenesis of Mesenchymal Stem Cells under Interleukin 1 Challenge by Foamyviral Interleukin 1 Receptor Antagonist Gene Transfer. Front Pharmacol 2017; 8:255. [PMID: 28536528 PMCID: PMC5422547 DOI: 10.3389/fphar.2017.00255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 04/24/2017] [Indexed: 12/15/2022] Open
Abstract
Background: Mesenchymal stem cells (MSCs) and their chondrogenic differentiation have been extensively investigated in vitro as MSCs provide an attractive source besides chondrocytes for cartilage repair therapies. Here we established prototype foamyviral vectors (FVV) that are derived from apathogenic parent viruses and are characterized by a broad host range and a favorable integration pattern into the cellular genome. As the inflammatory cytokine interleukin 1 beta (IL1β) is frequently present in diseased joints, the protective effects of FVV expressing the human interleukin 1 receptor antagonist protein (IL1RA) were studied in an established in vitro model (aggregate culture system) of chondrogenesis in the presence of IL1β. Materials and Methods: We generated different recombinant FVVs encoding enhanced green fluorescent protein (EGFP) or IL1RA and examined their transduction efficiencies and transgene expression profiles using different cell lines and human primary MSCs derived from bone marrow-aspirates. Transgene expression was evaluated by fluorescence microscopy (EGFP), flow cytometry (EGFP), and ELISA (IL1RA). For evaluation of the functionality of the IL1RA transgene to block the inhibitory effects of IL1β on chondrogenesis of primary MSCs and an immortalized MSC cell line (TERT4 cells), the cells were maintained following transduction as aggregate cultures in standard chondrogenic media in the presence or absence of IL1β. After 3 weeks of culture, pellets were harvested and analyzed by histology and immunohistochemistry for chondrogenic phenotypes. Results: The different FVV efficiently transduced cell lines as well as primary MSCs, thereby reaching high transgene expression levels in 6-well plates with levels of around 100 ng/ml IL1RA. MSC aggregate cultures which were maintained in chondrogenic media without IL1β supplementation revealed a chondrogenic phenotype by means of strong positive staining for collagen type II and matrix proteoglycan (Alcian blue). Addition of IL1β was inhibitory to chondrogenesis in untreated control pellets. In contrast, foamyviral mediated IL1RA expression rescued the chondrogenesis in pellets cultured in the presence of IL1β. Transduced MSC pellets reached thereby very high IL1RA transgene expression levels with a peak of 1087 ng/ml after day 7, followed by a decrease to 194 ng/ml after day 21, while IL1RA concentrations of controls were permanently below 200 pg/ml. Conclusion: Our results indicate that FVV are capable of efficient gene transfer to MSCs, while reaching IL1RA transgene expression levels, that were able to efficiently block the impacts of IL1β in vitro. FVV merit further investigation as a means to study the potential as a gene transfer tool for MSC based therapies for cartilage repair.
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Affiliation(s)
- Nicole Armbruster
- Institute for Virology and Immunobiology, University of WuerzburgWuerzburg, Germany.,Department of Orthopaedic Surgery, Klinik König-Ludwig-Haus Würzburg - Center for Musculoskeletal Research, University of WuerzburgWuerzburg, Germany
| | - Jennifer Krieg
- Institute for Virology and Immunobiology, University of WuerzburgWuerzburg, Germany.,Department of Orthopaedic Surgery, Klinik König-Ludwig-Haus Würzburg - Center for Musculoskeletal Research, University of WuerzburgWuerzburg, Germany
| | - Manuel Weißenberger
- Department of Orthopaedic Surgery, Klinik König-Ludwig-Haus Würzburg - Center for Musculoskeletal Research, University of WuerzburgWuerzburg, Germany
| | - Carsten Scheller
- Institute for Virology and Immunobiology, University of WuerzburgWuerzburg, Germany
| | - Andre F Steinert
- Department of Orthopaedic Surgery, Klinik König-Ludwig-Haus Würzburg - Center for Musculoskeletal Research, University of WuerzburgWuerzburg, Germany
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27
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Sieker JT, Kunz M, Weißenberger M, Gilbert F, Frey S, Rudert M, Steinert AF. Direct bone morphogenetic protein 2 and Indian hedgehog gene transfer for articular cartilage repair using bone marrow coagulates. Osteoarthritis Cartilage 2015; 23:433-42. [PMID: 25463442 DOI: 10.1016/j.joca.2014.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 11/01/2014] [Accepted: 11/05/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Bone morphogenetic protein 2 (BMP-2, encoded by BMP2) and Indian hedgehog protein (IHH, encoded by IHH) are well known regulators of chondrogenesis and chondrogenic hypertrophy. Despite being a potent chondrogenic factor BMP-2 was observed to induce chondrocyte hypertrophy in osteoarthritis (OA), growth plate cartilage and adult mesenchymal stem cells (MSCs). IHH might induce chondrogenic differentiation through different intracellular signalling pathways without inducing subsequent chondrocyte hypertrophy. The primary objective of this study is to test the efficacy of direct BMP2 and IHH gene delivery via bone marrow coagulates to influence histological repair cartilage quality in vivo. METHOD Vector-laden autologous bone marrow coagulates with 10(11) adenoviral vector particles encoding BMP2, IHH or the Green fluorescent protein (GFP) were delivered to 3.2 mm osteochondral defects in the trochlea of rabbit knees. After 13 weeks the histological repair cartilage quality was assessed using the ICRS II scoring system and the type II collagen positive area. RESULTS IHH treatment resulted in superior histological repair cartilage quality than GFP controls in all of the assessed parameters (with P < 0.05 in five of 14 assessed parameters). Results of BMP2 treatment varied substantially, including severe intralesional bone formation in two of six joints after 13 weeks. CONCLUSION IHH gene transfer is effective to improve repair cartilage quality in vivo, whereas BMP2 treatment, carried the risk intralesional bone formation. Therefore IHH protein can be considered as an attractive alternative candidate growth factor for further preclinical research and development towards improved treatments for articular cartilage defects.
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Affiliation(s)
- J T Sieker
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University of Würzburg, Germany.
| | - M Kunz
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University of Würzburg, Germany.
| | - M Weißenberger
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University of Würzburg, Germany.
| | - F Gilbert
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University of Würzburg, Germany; Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius-Maximilians-University of Würzburg, Germany.
| | - S Frey
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius-Maximilians-University of Würzburg, Germany.
| | - M Rudert
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University of Würzburg, Germany.
| | - A F Steinert
- Department of Orthopaedic Surgery, König-Ludwig-Haus, Julius-Maximilians-University of Würzburg, Germany.
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