The Vega advanced third generation posterior stabilized total knee arthroplasty system enables the restoration of range of motion for high demanding daily activities - A 5-years follow-up study

BACKGROUND

The Vega System® PS (Aesculap AG, Tuttlingen, Germany) is an advanced, third generation fixed implant that aims to mimic natural knee kinematics by optimizing pivotal motion while reducing surface stress. This study evaluated mid-term survival and clinical outcomes, including range of motion (ROM) of the modern posterior stabilized implant in order to analyse whether this biomechanically successful implant reaches good results in situ.

METHODS

The first 100 patients to receive the Vega PS System for total knee arthroplasty were invited to take part in this single centre, single surgeon study. Of these, 84 patients were clinically assessed 5-6 years postoperatively. Data which was obtained during this follow-up examination included revision data, range of motion and clinical scores.

RESULTS

The 5-year survival rate for exchange of any component was 97.6%, whereby two patients required replacement of the polyethylene gliding surface. Secondary patella resurfacing was performed in 7 patients. Significantly improved results in comparison to the preoperative state could be obtained at the follow-up: KOOS improved from 39.4 to 78.8, SF-12 PCS improved from 32.1 to 42 SF-12 MCS improved from 46 to 53.8 and patella pain improved from 2.7 to 0.3. The mean ROM of the 84 patients after 5 years was 133.1° and mean total KSS was 189.9.

DISCUSSION & CONCLUSIONS

This study demonstrates a high survival rate of the Vega PS System® and significant improvements in clinical outcomes 5 years after implantation. The obtained mean ROM indicates that this implant provides good flexibility of the knee joint, allowing a high number of activities. However, due to the rate of secondary patella implantation, routine resurfacing of the patella for all PS TKA cases is highly recommended.

CLINICAL TRIALS REGISTRATION

The study was registered at clinicaltrials.gov (NCT02802085).

Topical Treatment Is Effective and Safe for Acute Ankle Sprains: The Multi-Center Double-Blind Randomized Placebo-Controlled TRAUMED Trial

BACKGROUND

Topical NSAIDs are widely used to treat ankle sprains. Traumed (Tr14) gel is a multicomponent formulation, demonstrating inflammation-resolution properties.

METHODS

This multicenter, double-blind trial investigated the efficacy and safety of Tr14 gel versus placebo gel and non-inferiority versus 1% diclofenac gel, applied 3×/day for 7 days after acute lateral ankle sprain (EudraCT Number: 2016-004792-50). The primary outcome was AUC for pain on passive movement, assessed by VAS from baseline to Days 4 and 7.

RESULTS

The trial population included 625 patients aged 18 to 78 years. The AUC scores were 187.88 and 200.75 on Day 4 (p = 0.02) and 294.14 and 353.42 on Day 7 (p < 0.001) for Tr14 and placebo, respectively. For Tr14 compared to diclofenac, the AUC scores were 187.50 and 197.19 on Day 4 (p = 0.3804) and 293.85 and 327.93 on Day 7 (p = 0.0017), respectively. On the FAAM-ADL subscale, Tr14 was superior to placebo and non-inferior to diclofenac at all time points. Time to 50% pain improvement was lowest for Tr14 (6.0 days), compared to placebo (7.1 days) and diclofenac (7.0 days). Adverse events were uncommon and minor.

CONCLUSIONS

Tr14 gel is effective and safe in acute ankle sprains, compared to placebo gel and diclofenac gel, and has faster pain resolution.

TRIAL REGISTRATION

The trial was registered in clinicaltrialsregister.eu, EudraCT number 2016-004792-50 on 07.06.2017.

Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the "GAIT" Study Group

Surgical repair of acute mid-substance Achilles tendon ruptures is performed in active patients, but the postoperative rehabilitation program is often based on the experience of the surgeon or therapist, rather than on evidence-based protocols. The aim of the study is to establish an evidence-based protocol for rehabilitation. This study is a consensus statement. The "GAIT" study group (German, American, and Italian Tendon), an informal collection of 4 experienced foot and ankle surgeons, met to address the question of what items they felt were important relative to rehabilitate a surgically repaired Achilles tendon acute rupture. Thirty-three statements were formulated. A value of 100% agreement by all the members was set to produce a proposed consensus statement. A value of 80% consensus was set to produce "strong recommendation." A systematic review of the literature was also performed. The GAIT group reach 100% agreement on the average postoperative non-weightbearing for 2.3 weeks, the foot in plantarflexion for the first 4 weeks, avoiding ROM exercises beyond neutral, and both stretching and eccentric exercise, not started before 12 weeks. Concentric bilateral heel raises should be performed after 6 weeks, and the average return to initiate sports, was 24.4 weeks. The use of a 1/8^th-1/4^th inch heel cushions in daily shoes after 8 weeks, the use of an antigravity treadmill for rehabilitation, and the return to sports based on heel raise repetitions is strongly recommended. Given lack of established verified protocols, the recommendations by our experienced panel should be considered. These proposed consensus statements could be used as a basis for larger controlled trials, and develop best practices.

Long-term Efficacy of Percutaneous Epidural Neurolysis of Adhesions in Chronic Lumbar Radicular Pain: 10 Year Follow-up of a Randomized Controlled Trial

BACKGROUND

No long-term follow-up data exist in any treatment for chronic radicular pain occurring with disc pathology and after failed back surgery. A previous randomized controlled trial (RCT) has proven efficacy in short-term follow-up as an evidence-based effective therapeutic option.

OBJECTIVES

Long term data is needed to determine the efficacy and cost- effectiveness of minimal invasive procedures. The present study reports 10 year follow-up results from the randomized trial.

STUDY DESIGN

A prospective, randomized, placebo-controlled, interventional clinical trial. A power calculation was based on a previous feasibility trial.

SETTING

University medical centers.

METHODS

After a 4 year enrollment phase, 381 patients with chronic radicular pain persisting beyond 4 months, who failed conservative treatments, were screened. Ninety patients were enrolled. Patients were randomly assigned to receive percutaneous epidural lysis of adhesions or placebo with concealed allocation in permuted blocks of 4 to 8 patients each, and stratified by treatment center. The primary outcomes were a mean change of the Oswestry Disability Index (ODI) scores and Visual Analog Scale (VAS), one and 10 years after intervention. For each rating scale an analysis of variance with the within-patient factor time (baseline, one year follow-up, 10 year follow-up) and the between-patient factor treatment (lysis, placebo) was used.

RESULTS

Homogeneity was shown at baseline between the groups. The ODI and VAS scores were significantly better one and 10 years in the lysis group vs the control group. The ODI in the lysis group improved from 55.3 ± 11.6 to 9.6 ± 9.3 after one year and to 11.7 ± 14.2 after 10 years. The placebo group also improved from 55.4 ± 11.5 to 30.7 ± 14.2 after one year and to 24.8 ± 12.0 after 10 years. The VAS improved from 6.7 ± 1.1 to 1.2 ± 1.1 after one year and to 1.5 ± 1.4 after 10 years in the lysis group and from 6.7 ± 1.1 to 2.8 ± 1.5 after one year and to 2.9 ± 1.3 after 10 years after placebo intervention. The statistical difference of the ODI and VAS between the treatment and control groups remain significant up to 10 years. No treatment-related severe adverse effects occurred within the 10 years, but minor transient neurological effects were seen directly after the intervention.

LIMITATIONS

The long-term effects of single treatment components cannot be specified as no imaging examination was performed at 10 year follow-up. A large variety of unanalyzed noninvasive treatments were done within the 10 years. Some patients did not clearly remember the intervention after 10 years. Uncontrolled effects such as higher inhomogeneity of biometric properties, concomitant therapies, pain tolerance level, or just social effects could occur, but were not analyzed in the trial.

CONCLUSION

This is the first 10 year follow-up report of a placebo-controlled RCT showing efficacy of the minimally invasive percutaneous adhesiolysis procedure for patients with chronic lumbosacral radicular pain. No alternative evidence-based treatment modality with 10 year follow-up is available to be recommended. This procedure should be considered as the first treatment option for patients with chronic lumbosacral radicular pain.

Guided and Unguided Biopsy in the Diagnostic of Periprosthetic Infections of the Knee - Evaluation of an Evidence-based Algorithm

BACKGROUND

Periprosthetic joint infection (PPI) is one of the most common reasons for revision in total knee arthroplasty (TKA). Percutaneous synovial biopsy is considered as a well-established diagnostic tool in ambiguous cases of chronic pain after TKA. The exact number of undetected low-grade infections remains unclear.

OBJECTIVES

The aim of this prospective study was to compare the diagnostic accuracy of arthroscopically guided and unguided synovial biopsy. Additionally, the prevalence of initially undetected PPI during synovial biopsy and revision surgery was assessed.

MATERIALS AND METHODS

40 patients suffering from chronic pain after TKA and the clinical suspicion of PPI were included in the study. Synovial biopsies were collected in a standardized manner first without and then with arthroscopic visual control. Using both techniques, six samples were collected each (5 for microbiology, 1 for histology). 19 patients, initially classified aseptic, underwent revision surgery later.

RESULTS

The diagnosis of PPI was made in 10.0% of unguided biopsies (4 cases, 2× microbiologically, 2× histologically), 7.5% of arthroscopic biopsies (3 cases, 3× histologically) and 12.5% (5 cases, 3× histologically, 2× microbiologically) of all cases. Only histologic evaluation led to concordant positive findings using both techniques in two patients. The proportion of non-representative biopsies was twice as high after unguided tissue collection than after arthroscopic biopsy (30.0 vs. 15.0%). Microbiologic evaluation of arthroscopically collected biopsies did not lead to the diagnosis of PPI, which might have been essential to the selection of the appropriate antimicrobial therapy. During revision surgery the diagnosis of PPI was made in 22.2% of cases.

CONCLUSIONS

In patients suffering from chronic pain after TKA, periprosthetic low-grade infection was diagnosed in a relevant proportion of cases. Therefore, synovial biopsies for histological and microbiological evaluation should be collected whenever there's clinical suspicion of PPI. For histological evaluation, samples should be collected using arthroscopic control and ideally multiple biopsies should be taken. For microbiological evaluation, excessive joint lavage should be avoided.

A 30-Year Single-center Experience of Cementless Total Hip Arthroplasty With Spongy Metal Structured Implants: A Follow-up of a Previous Report

BACKGROUND/AIM

The aim of this study was to analyze survivorship and functional outcome of cementless spongy metal structured total hip arthroplasty (THA) after ultra-long-term follow-up.

PATIENTS AND METHODS

A total of 100 THAs in patients under 65 years at initial surgery were performed between 1985 and 1989 at our Department. Twenty patients (23 hips) were available for final follow-up. Implant survivorship and functional results (Merle d'Aubigné, SF-12) were assessed.

RESULTS

At a mean follow-up of 30 years (range=27.7-31.7 years), the overall stem survival rate was 82.6% (19/23 stems) and the overall cup survival rate was 52.2% (12/23 cups). Revision surgeries were performed for aseptic loosening in all cases. Functional evaluation revealed good to excellent results in 16 patients (80%) Conclusion: Spongy metal structured cementless THA provides remarkable survivorship and excellent functional results even after ultra-long-term follow-up. Further research regarding modern implants, bearing surfaces etc. is required to assess survivorship and clinical outcomes of different implant designs.

Distribution patterns of foot and ankle tumors: a university tumor institute experience

BACKGROUND

Bone and soft tissue masses of the foot and ankle are not particularly rare but true neoplasia has to be strictly differentiated from pseudotumorous lesions. Diagnosis is often delayed as diagnostic errors are more common than in other regions. Awareness for this localization of musculoskeletal tumors is not very high and neoplasia is often not considered. The purpose of this study is to provide detailed information on the incidence and distribution patterns of foot and ankle tumors of a university tumor institute and propose a simple definition to facilitate comparison of future investigations.

METHODS

As part of a retrospective, single-centre study, the data of patients that were treated for foot and ankle tumors between June 1997 and December 2015 in a musculoskeletal tumor centre were analyzed regarding epidemiologic information, entity and localization. Included were all cases with a true tumor of the foot and ankle. Exclusion criteria were incomplete information on the patient or entity (e.g. histopathological diagnosis) and all pseudotumoral lesions.

RESULTS

Out of 7487 musculoskeletal tumors, 413 cases (5,52%) of tumors of the foot and ankle in 409 patients were included (215 male and 198 female patients). The average age of the affected patients was 36 ± 18y (min.3y, max.92y). Two hundred sixty-six tumors involved the bone (64%), among them 231 (87%) benign and 35 (13%) malignant. There were 147 soft tissue tumors (36%), 104 (71%) were benign, 43 (29%) malignant. The most common benign osseous tumor lesions included simple bone cysts, enchondroma and osteochondroma. By far the most common malignant bone tumor was chondrosarcoma. Common benign soft tissue tumors included pigmented villo-nodular synovitis, superifcial fibromatosis and schwannoma whereas the most common malignant members were synovial sarcoma and myxofibrosarcoma. Regarding anatomical localization, the hindfoot was affected most often.

CONCLUSIONS

Knowledge of incidence and distribution patterns of foot and ankle tumors will help to correctly assess unclear masses and initiate the right steps in further diagnostics and treatment. Unawareness can lead to delayed diagnosis and inadequate treatment with serious consequences for the affected patient.

Treatment of Plantar Fasciitis With Radial Soundwave "Early" Is Better Than After 6 Months: A Pilot Study

Extracorporeal shock wave therapy/radial soundwave therapy has been predominantly used for chronic or recalcitrant plantar fasciitis with strong scientific evidence of reliable outcomes. Most of the studies included patients with plantar fasciitis with symptoms >6 months in duration. Only 2 known studies have investigated acute plantar fasciitis, which is <6 weeks in duration. They both found suboptimal results for the use of extracorporeal shock wave therapy. To the best of our knowledge, no studies have investigated radial soundwave therapy for the subacute stage or early stage of plantar fasciitis. Data were prospectively collected from 28 eligible patients who underwent radial soundwave therapy (RSWT) during a 9-month period in 2014. Of the 28 subjects, 14 were enrolled in the "early group" with a symptom duration of <3 months and 14 in the "standard/control" group with a symptom duration of >6 months. The pretreatment and posttreatment visual analog scale scores, Roles-Maudlsey scores, and activity level were recorded and compared. The early implementation of RSWT yielded comparable outcomes when compared with the standard group. RSWT is a valid treatment modality that can be implemented soon after the initial treatment options or first-phase treatment options have failed. Early treatment is more likely to allow for maintenance of patients' activity level. Also, waiting 6 months to treat plantar fasciitis with RSWT results in delays and inferior results. Early treatment is better for active and athletic patients.

Electromagnetic Transduction Therapy for Achilles Tendinopathy: A Preliminary Report on a New Technology

A parallel prospective feasibility study was performed on 53 patients with chronic mid-portion Achilles tendinopathy (age 44.7 ± 9.1 years). Of the 53 patients, 28 (active group) were treated using a new electromagnetic (pulsed electromagnetic field) transduction therapy device (Cellactor^® MT1) and heel cushions. The device produces an electromagnetic field of 80 milliTesla; a total of 8 treatments was performed within 4 weeks in an outpatient setting, without anesthesia, immobilization, or rest. A control group of 25 patients with a similar duration of symptoms was treated with heel cushions only. At the 12-week assessment point, the visual analog scale scores in both groups had significantly decreased, although the active group had significantly improved visual analog scale scores compared with those of the controls. The Role-Maudsley scores had also significantly improved in both the active and the control groups (p < .00001 and p = .0002, respectively). Electromagnetic transduction therapy could potentially be a useful modality for the treatment of Achilles tendinopathy. It should be compared with the current reference standard of extracorporeal shockwave therapy/radial soundwave therapy with similar level I, II, and III studies.

Treatment of Medial Tibial Stress Syndrome With Radial Soundwave Therapy in Elite Athletes: Current Evidence, Report on Two Cases, and Proposed Treatment Regimen

Two case reports of high-level athletes with medial tibial stress syndrome (MTSS), 1 an Olympian with an actual stress fracture, are presented. Successful treatment included radial soundwave therapy, pneumatic leg braces, relative rest using an antigravity treadmill, and temporary foot orthoses. Radial soundwave therapy has a high level of evidence for treatment of MTSS. We also present recent evidence of the value of vitamin D assessment. Both patients had a successful outcome with minimal downtime. Finally, a suggested treatment regimen for MTSS is presented.

The natural alpha angle of the femoral head-neck junction

Aims

Asphericity of the femoral head-neck junction is common in cam-type femoroacetabular impingement (FAI) and usually quantified using the alpha angle on radiographs or MRI. The aim of this study was to determine the natural alpha angle in a large cohort of patients by continuous circumferential analysis with CT.

Methods

CT scans of 1312 femurs of 656 patients were analyzed in this cross-sectional study. There were 362 men and 294 women. Their mean age was 61.2 years (18 to 93). All scans had been performed for reasons other than hip disease. Digital circumferential analysis allowed continuous determination of the alpha angle around the entire head-neck junction. All statistical tests were conducted two-sided; a p-value < 0.05 was considered statistically significant.

Results

The mean maximum alpha angle for the cohort was 59.0° (sd 9.4). The maximum was located anterosuperiorly at 01:36 on the clock face, with two additional maxima of asphericity at the posterior and inferior head-neck junction. The mean alpha angle was significantly larger in men (59.4°, sd 8.0) compared with women (53.5°, sd 7.4°; p = 0.0005), and in Caucasians (60.7°, sd 9.0°) compared with Africans (56.3°, sd 8.0; p = 0.007) and Asians (50.8°, sd 7.2; p = 0.0005). The alpha angle showed a weak positive correlation with age (p < 0.05). If measured at commonly used planes of the radially reconstructed CT or MRI, the alpha angle was largely underestimated; measurement at the 01:30 and 02:00 positions showed a mean underestimation of 4° and 6°, respectively.

Conclusion

This study provides important data on the normal alpha angle dependent on age, gender, and ethnic origin. The normal alpha angle in men is > 55°, and this should be borne in mind when making a diagnosis of cam-type morphology. Cite this article: Bone Joint J 2018;100-B:570–8.

Is total femoral replacement for non-oncologic and oncologic indications a safe procedure in limb preservation surgery? A single center experience of 22 cases

Background

Several surgical options for the reconstruction of massive bone defects have been described and include biologic methods with autografts and allografts, and the use of tumor endoprostheses (total femoral replacement, TFR). Several types of modular TFR are available, but nevertheless unpredictable outcomes and high complication rates have been described from most authors. The present study aims to compare results after TFR performed with modular total femur prosthesis MML (Fa. ESKA/Orthodynamics) in patients with and without malignant disease.

Methods

Retrospective chart review and functional investigation (Musculoskeletal Tumor Society (MSTS) score, Harris Hip Score (HHS), Oxford Knee Score (OKS), SF-12 Health Survey, and failure classification according to Henderson) of TFR cases from 1995 to 2011. Indications for TFR were malignant tumor resection from the femur (n = 9, Group A) or failure of a revision arthroplasty without history of malignant disease (n = 13, Group B).

Results

Thirty-six patients were treated during the study period, of whom 22 could be investigated clinically after a mean follow-up of 63 months. Overall failure rate for TFR was 59.1%, leading to 38 surgical revisions. The most common failure mechanisms were Type I (soft tissue), followed by Type IV (infection) and Type III (mechanical failure). Mean MSTS score out of 30 was 13 (range 1–25), with significantly higher scores in Group A (mean 19, range 3–25) than Group B (mean 9, range 1–15).

Conclusion

TFR is an established procedure to restore femoral integrity. However, complication rates are considerably high, and depend mainly on the age at initial reconstruction.

How to address ischiofemoral impingement? Treatment algorithm and review of the literature

Ischiofemoral impingement (IFI) is a rare cause of hip pain defined by a narrowing of the space between the lateral aspect of the os ischium and the lesser trochanter of the femur. Several underlying anatomic, functional and iatrogenic pathologies have been identified for symptomatic IFI in native hip joints and after total hip arthroplasty. Clinical symptoms vary but most commonly consist of pain of the lower buttock and groin including the inner thigh, and a snapping or clunking phenomenon is often reported. Symptoms may be provoked by a combined extension, adduction and external rotation during physical examination and during long-stride walking. Radiographs of the pelvis and an axial or false-profile-view of the hip as well as magnetic resonance imaging (MRI)-scans should be obtained to strengthen the diagnosis. On MRI, the quadratus femoris muscle signal and the space confined by the anatomic structures surrounding the muscle, the quadratus femoris space, are to be assessed. Targeted infiltration of the muscle can be helpful both diagnostically and therapeutically. The literature on differential diagnoses and treatment options for IFI is limited; therapeutic suggestions are offered only in case reports and series. With this work, we aim to give a systematic approach to the non-surgical and surgical treatment options for IFI based upon the current literature and the authors' personal experience.

Randomized Placebo-Controlled Placebo Trial to Determine the Placebo Effect Size

BACKGROUND

It is the gold standard to use a placebo treatment as the control group in prospective randomized controlled trials (RCTs). Although placebo-controlled trials can reveal an effect of an active treatment, the pure effect of a placebo treatment alone has never been presented or evaluated. No evidence-based, placebo-therapeutic options are currently available, and no placebo-controlled trials have been performed to elucidate the pure placebo effect.

OBJECTIVES

To analyze the pure placebo effect on clinical, chronic pain through a blinded RCT.

STUDY DESIGN

A prospective, randomized, placebo-controlled trial.

SETTING

Medical University centers.

METHODS

One-hundred eighty-two patients suffering from chronic plantar heel pain for over 6 months,who failed to respond to conservative treatments, were screened and 106 of these patients were enrolled into this study. The patients were randomly assigned to receive either a blinded placebo shockwave treatment or an unblinded placebo shockwave treatment. The primary outcome measure was the differences in percentage change of visual analogue scale (VAS) scores 6 weeks after the intervention. The secondary outcome measure was the differences in Roles and Maudsley pain score (RMS) 6 weeks after intervention. As an exploratory outcome, 2-sided group comparisons for baseline characteristics between active treatment and controls were done using the Mann-Whitney-U tests for group comparisons; treatment efficiency was calculated by the effect size coefficient and benchmarks for the Mann-Whitney estimator according to the t-test of 2 independent samples for quantitative data, as well as the Fisher's exact test for binary data.

RESULTS

Patients from both groups did not differ with respect to heel pain ratings at baseline, for both the VAS (P = .476) and RMS (P = .810) scores. After 6 weeks, patients receiving the blinded placebo treatment reported less heel pain on both scales (VAS: P = .031; RMS: P = .004). Change scores of pain ratings were significantly higher in the blinded placebo group than in the un-blinded placebo group (VAS: P = .002; RMS: P = .002).

LIMITATIONS

As the study represents the first to use an inverse placebo RCT (IPRCT), further conceptual and methodological issues need to be addressed to describe detailed, underlying mechanisms. Specific contextual, intrapersonal, and interpersonal factors modulating the placebo effects should be addressed in future IPRCTs.

CONCLUSIONS

The present study indicated that true placebo effect sizes can be analyzed through a proper IPRCT design. Instead of treating high numbers of patients with placebos in a RCT, which increases the risk for subjects not receiving the active treatment, the IPRCT technique seems to be much more appropriate to analyze the effect sizes of any active treatment, in accordance with the Good Clinical Practice guidelines and Declarations of Helsinki.

KEY WORDS

Pain, randomized controlled trial, RCT, placebo, effect size, inverse placebo, study, pain therapy.

Electromagnetic transduction therapy in non-specific low back pain: A prospective randomised controlled trial

OBJECTIVES

A prospective randomised controlled trial to investigate the efficacy of electromagnetic transduction therapy (EMTT) for treatment of patients with non-specific low back pain.

DESIGN

Two groups with non-specific low back pain were either treated with conventional therapy alone over 6 weeks or in combination with 8 sessions of EMTT.

RESULTS

In both intervention groups the low back pain related pain and the degree of disability decreased significantly at follow-up visits. Combination of EMTT and conventional therapy proved significant superior to conventional therapy alone.

CONCLUSION

EMTT is a promising treatment in patients with non-specific low back pain.

Distal femoral replacement with the MML system: a single center experience with an average follow-up of 86 months

Background

The aim of this study was to compare the functional outcomes and complication rates after distal femoral replacement (DFR) performed with the modular Munich-Luebeck (MML) modular prosthesis (ESKA/Orthodynamics, Luebeck, Germany) in patients being treated for malignant disease or failed total knee arthroplasty.

Methods

A retrospective review of patient charts and a functional investigation (involving Musculoskeletal Tumor Society Score [MSTS], American Knee Society Score [AKSS], Oxford Knee Score [OKS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Toronto Extremity Salvage Score [TESS], the 12-Item Short-Form [SF-12] Health Survey, and a failure classification system developed by Henderson et al.) of DFR cases from 2002 to 2015 were conducted. The indications for DFR were malignant tumor resection in the femur (n = 20, group A) or failure of revision total knee arthroplasty without a history of malignant disease (n = 16, group B).

Results

One-hundred and twenty-nine patients were treated during the study period. Of these, 82 were analyzed for complications and implant-survival. Further, 36 patients were available for functional assessment after a mean follow-up of 86 months (range: 24–154). There were 75 complications in total. The overall failure rate for DFR was 64.6% (53/82 patients). The most common failure mechanisms were type III (mechanical failure), followed by type I (soft tissue) and type II (aseptic loosening). The mean MSTS score (out of 30) was 17 for group A and 12 for group B. All the clinical outcome scores revealed an age-dependent deterioration of function.

Conclusion

DFR is an established procedure to restore distal femoral integrity. However, complication rates are high. Post-procedure functionality depends mainly on the patient’s age at initial reconstruction.

Short- to long-term follow-up of total femoral replacement in non-oncologic patients

BACKGROUND

Compromised bone stock and heavily impaired structural integrity after multiple endoprosthetic revision surgeries can lead to a comparable condition as encountered in musculoskeletal tumor surgery. Total femoral replacement (TFR) can restore femoral integrity and allow patients to resume ambulation. Even though several authors reported their results of TFR, so far many questions are still on debate: Which patients are at risk to experience low functional outcome? Do complications and clinical outcome after TFR depend on the indication for the surgery (e.g. periprosthetic fractures or aseptic loosening) or the age of the patients? The purpose of the present study was to compare complication rates after TFR performed with modular total femur prosthesis MML (Fa. ESKA/Orthodynamics) in patients without malignant disease.

METHODS

We conducted a retrospective chart review and functional investigation of patients treated with a TFR for non-oncologic conditions from 1995 to 2015 and a minimum follow-up of 2 years. Complications were recorded according to the Henderson-Classification; outcome was evaluated with established clinical scores. The indication for TFR was periprosthetic fracture (Group A, n = 11) or aseptic loosening (Group B, n = 7) with massive bone defect of the femur deemed unsuitable for conventional arthroplastic or biologic reconstruction.

RESULTS

Eighteen patients matched the inclusion criteria and could be investigated clinically after a mean follow-up of 80 months (range: 28-132). Before TFA, all patients had previously undergone multiple operations (range: 1-8). The overall failure rate for any reason was 72% (n = 13/18), leading to a total of 37 surgical revisions with total exchange of TFR in 22% (n = 4/18). Most common failure mechanism was Type I (soft tissue), followed by Type IV (infection) and Type III (mechanical failure). According to Enneking's functional evaluation method (MSTS-Score), the function ranged from 1 to 15 with a mean of 10 ± 4 out of 30.

CONCLUSION

TFR is a salvage procedure to restore mechanical integrity and regain functional ability after extensive femoral bone loss. Outcome of the patients in the present study did mainly depend on the age at reconstruction and not on the indication for TFR.

19 years outcome after cementless total hip arthroplasty with spongy metal structured implants in patients younger than 65 years

Background

Cementless fixation of total hip arthroplasties (THAs) is often favored in young, high-demanding patients due to the conservation of valuable bone-stock and easier revision if loosening has occurred. Long-term outcome data of the spongy metal structured implant used in the present study in patients younger than 65 years are still lacking.

Methods

We conducted a retrospective chart review and functional investigation (Merle d’Aubigné score, SF-12) of patients younger than 65 years at implantation treated with a spongy metal structured THA (n = 79) from one orthopedic university center from 1985 to 1989.

Results

At a 19-year mean follow-up (range: 15.3 – 21.3 years), the overall stem survival rate was 93.7 %, and the overall cup survival rate was 82.3 %. Revision surgeries of the stem were performed in all cases for aseptic loosening at an average of 15.3 ± 3.5 years after implantation. Acetabular components were revised for aseptic loosening and recurrent dislocation after inlay revision on an average of 11.8 ± 4.7 years after implantation. No other device related complications occurred within the 19-year follow-up period. No correlation was found between time of revision and gender or age. Clinical outcome scores (Merle d’Aubigné score, SF-12) revealed excellent to good results of the implanted THAs in 87 % of patients.

Conclusions

We conclude that spongy metal structured cementless THAs implanted in young patients have an excellent survival and provide trustworthy clinical results at 19 years of follow-up.

Radial Soundwave for Sesamoidopathy in Athletes: A Pilot Study

The purpose of the present study was to evaluate the efficacy of radial soundwave therapy (RSW) for the management of sesamoiditis, symptomatic bipartite sesamoids, and avascular necrosis in athletic patients. The data from 10 patients undergoing RSW for sesamoiditis were retrospectively studied. Three treatments at 2.4 Bar and 13 Hz, for a total of 2500 pulses in each session, were administered to the affected sesamoid approximately 1 week apart. The Roles and Maudsley score and the visual analog scale (VAS) were used to assess disability and pain. An overall improvement was seen in reported pain after RSW. The pretreatment VAS score was 5.9 ± 1.7 and the post-treatment VAS score improved to 2.3 ± 2.4 (p = .0001). The activity pretreatment Roles and Maudsley score was 3.1 ± 0.3 and the post-treatment score was 1.5 ± 0.7 (p = .00003). All but 1 of the patients (90%) reported some or complete relief of pain. The mean time to return to activity was 10.1 ± 15.6 weeks, although this value was biased by 1 patient requiring 1 year to return to activity. Eliminating this patient, the average time to return to activity was 5.4 ± 5.6 weeks. Three patients in the cohort did not have to stop their desired activity at all, including 1 gymnast and 1 runner. Of these 3 patients, 2 (20% of all patients) reported complete relief of pain (VAS score of 0) after treatment. The third patient experienced a significant decrease in pain, with the VAS score, improving from 7 to 1. The results of the present study have demonstrated that RSW can be a viable treatment of certain symptomatic sesamoid pathologies and can be considered a valid alternative to surgery.

Percutaneous and Endoscopic Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis

BACKGROUND

Chronic refractory low back and lower extremity pain is frustrating to treat. Percutaneous adhesiolysis and spinal endoscopy are techniques which can treat chronic refractory low back and lower extremity pain.Percutaneous adhesiolysis is performed by placing the catheter into the tissue plane at the ventrolateral aspect of the foramen so that medications can be injected. Adhesiolysis is used both for pain caused by scarring which is not resistant to catheter placement and other sources of pain, including inflammation in the absence of scarring.Mechanical lysis of scars with a catheter may or may not be necessary for percutaneous adhesiolysis to be effective. Spinal endoscopy allows direct visualization of the epidural space and has the possibility to use laser energy to treat pathology.

STUDY DESIGN

A systematic review of the effectiveness of percutaneous adhesiolysis and spinal endoscopic adhesiolysis to treat chronic refractory low back and lower extremity pain.

OBJECTIVE

To evaluate and update the effectiveness of percutaneous adhesiolysis and spinal endoscopic adhesiolysis to treat chronic refractory low back and lower extremity pain.

METHODS

The available literature on percutaneous adhesiolysis and spinal endoscopic adhesiolysis in treating persistent low back and leg pain was reviewed. The quality of each article used in this analysis was assessed. The level of evidence was classified on a 5-point scale from strong, based upon multiple randomized controlled trials to weak, based upon consensus, as developed by the U.S. Preventive Services Task Force (USPSTF) and modified by ASIPP. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2015, and manual searches of the bibliographies of known primary and review articles.

OUTCOME MEASURES

Pain relief of at least 50% and functional improvement of at least 40% were the primary outcome measures. Short-term efficacy was defined as improvement of 6 months or less; whereas, long-term efficacy was defined more than 6 months.

RESULTS

For this systematic review, 45 studies were identified. Of these, for percutaneous adhesiolysis there were 7 randomized controlled trials and 3 observational studies which met the inclusion criteria. For spinal endoscopy, there was one randomized controlled trial and 3 observational studies. Based upon 7 randomized controlled trials showing efficacy, with no negative trials, there is Level I or strong evidence of the efficacy of percutaneous adhesiolysis in the treatment of chronic refractory low back and lower extremity pain. Based upon one high-quality randomized controlled trial, there is Level II to III evidence supporting the use of spinal endoscopy in treating chronic refractory low back and lower extremity pain.

CONCLUSION

The evidence is Level I or strong that percutaneous adhesiolysis is efficacious in the treatment of chronic refractory low back and lower extremity pain. Percutaneous adhesiolysis may be considered as a first-line treatment for chronic refractory low back and lower extremity pain. The evidence is Level II to III that spinal endoscopy is effective in the treatment of chronic refractory low back and lower extremity pain.

KEY WORDS

Spinal pain, chronic low back pain, post lumbar surgery syndrome, epidural scarring, adhesiolysis, endoscopy, radicular pain.

Extracorporeal shockwave therapy (ESWT)--First choice treatment of fracture non-unions?

Fracture non-unions are still a challenging problem in orthopedics. The treatment of non-unions remains highly individualized, complex, and demanding. In most countries the surgical approach with debridement of the non-union gap, anatomical reduction and appropriate osteosynthesis along with autologous bone grafting is considered as the standard of care. One of the very first non-urologic applications of extracorporeal shockwave treatment (ESWT) concerned non-healing fractures. Since the early 1990ties the knowledge of the working mechanism has increased enormously. The purpose of this review article is to demonstrate by peer-reviewed literature in conjunction with our own experiences that ESWT can be an efficient, non-invasive, almost complication-free and cost effective alternative to surgical treatment of non-healing fractures.

Adult osteochondritis dissecans and focussed ESWT: A successful treatment option

Extracorporeal shockwave therapy (ESWT) has gained acceptance in the medical field and in the treatment of non-unions and delayed bone healing. ESWT has been used effectively for many years as a noninvasive surgical procedure. The idea of treating Osteochondritis dissecans of knee and talus arose in the middle of the 1990's. OCD is known as a pre-arthritic factor in the long-term and still there is no consistent treatment. In the literature there is still only a small number of publications but international societies for shockwave treatment are convinced that ESWT on OCD shows to be an effective and safe method in the treatment of OCD in the early stages. We want to summarize the actual data on the treatment of OCD by ESWT.

Lateral epicondylitis: This is still a main indication for extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) is used in a number of indications in the medical field. A number of tendinopathies show good and excellent results due to evidence based medicine. The treatment of lateral epicondylitis is known to show conflicting results. This overview of the published RCT's on ESWT for lateral epicondylitis tries to show the reasons for this conflicting data-base and point out, why we think that this is still a main indication for extracorporeal shockwave therapy.

Current evidence of extracorporeal shock wave therapy in chronic Achilles tendinopathy

Chronic Achilles tendinopathy has been described as the most common overuse injury in sports medicine. Several treatment modalities such as activity modification, heel lifts, arch supports, stretching exercises, nonsteroidal anti-inflammatories, and eccentric loading are known as standard treatment mostly without proven evidence. After failed conservative therapy, invasive treatment may be considered. Extracorporeal shock wave therapy (ESWT) has been successfully used in soft-tissue pathologies like lateral epicondylitis, plantar fasciitis, tendinopathy of the shoulder and also in bone and skin disorders. Conclusive evidence recommending ESWT as a treatment for Achilles tendinopathy is still lacking. In plantar fasciitis as well as in calcific shoulder tendinopathy shock wave therapy is recently the best evaluated treatment option. This article analysis the evidence based literature of ESWT in chronic Achilles tendinopathy. Recently published data have shown the efficacy of focused and radial extracorporeal shock wave therapy.

Clinically relevant effectiveness of focused extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: a randomized, controlled multicenter study

BACKGROUND

The effectiveness of extracorporeal shock wave therapy in the treatment of plantar fasciitis is controversial. The objective of the present study was to test whether focused extracorporeal shock wave therapy is effective in relieving chronic heel pain diagnosed as plantar fasciitis.

METHODS

Two hundred and fifty subjects were enrolled in a prospective, multicenter, double-blind, randomized, and placebo-controlled U.S. Food and Drug Administration trial. Subjects were randomized to focused extracorporeal shock wave therapy (0.25 mJ/mm(2)) or placebo intervention, with three sessions of 2000 impulses in weekly intervals. Primary outcomes were both the percentage change of heel pain on the visual analog scale composite score (pain during first steps in the morning, pain with daily activities, and pain with a force meter) and the Roles and Maudsley score at twelve weeks after the last intervention compared with the scores at baseline.

RESULTS

Two hundred and forty-six patients (98.4%) were available for intention-to-treat analysis at the twelve-week follow-up. With regard to the first primary end point, the visual analog scale composite score, there was a significant difference (p = 0.0027, one-sided) in the reduction of heel pain in the extracorporeal shock wave therapy group (69.2%) compared with the placebo therapy group (34.5%). Extracorporeal shock wave therapy was also significantly superior to the placebo therapy for the Roles and Maudsley score (p = 0.0006, one-sided). Temporary pain and swelling during and after treatment were the only device-related adverse events observed.

CONCLUSIONS

The results of the present study provide proof of the clinically relevant effect size of focused extracorporeal shock wave therapy without local anesthesia in the treatment of recalcitrant plantar fasciitis, with success rates between 50% and 65%.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

[Greater trochanteric pain syndrome]

Greater trochanteric pain is one of the common complaints in orthopedics. Frequent diagnoses include myofascial pain, trochanteric bursitis, tendinosis and rupture of the gluteus medius and minimus tendon, and external snapping hip. Furthermore, nerve entrapment like the piriformis syndrome must be considered in the differential diagnosis. This article summarizes essential diagnostic and therapeutic steps in greater trochanteric pain syndrome. Careful clinical evaluation, complemented with specific imaging studies and diagnostic infiltrations allows determination of the underlying pathology in most cases. Thereafter, specific nonsurgical treatment is indicated, with success rates of more than 90 %. Resistant cases and tendon ruptures may require surgical intervention, which can provide significant pain relief and functional improvement in most cases.

Percutaneous Epidural Lysis of Adhesions in Chronic Lumbar Radicular Pain: A Randomized, Double-Blind, Placebo-Controlled Trial

Background: Chronic radicular pain can occur after disc pathology and failed back surgery. An evidence-based effective therapeutic option is not available nor does a gold standard exist. Objectives: A randomized controlled trial to analyze the clinical efficacy of percutaneous epidural lysis of adhesions in chronic radicular pain. Study Design: Prospective randomized placebo controlled interventional trial. Power calculation based on a feasibility trial. Setting: Medical university centers. Methods: Within 4 years a total of 381 patients with chronic radicular pain lasting longer than 4 months which failed to respond to conservative treatments were screened and 90 patients were enrolled. They were randomly assigned to receive either percutaneous neurolysis or placebo with concealed allocation in permuted blocks of 4 to 8, stratified by treatment center. The primary outcome measure was the differences in percent change of Oswestry Disability Index (ODI) scores 3 months after intervention. Secondary outcome measures were difference in percent change of ODI scores and Visual Analog Scale (VAS) 6 and 12 months after intervention and success rates defined as at least 50% reduction in ODI scores and VAS scores (mean change from baseline) at 3, 6, and 12 months after treatment. Explorative, 2-sided group comparisons for baseline characteristics between active treatment and controls were done using the t-test for 2 independent samples for quantitative data and Fisher’s exact test for binary data. Results: The ODI and VAS scores as well as the success rates for ODI vs VAS were significantly better 3, 6, and 12 months in the lysis group vs the control group. The ODI in the lysis group improved from 55.3 ± 11.6 to 26.4 ± 10.8 after 3 months. The placebo group improved from 55.4 ± 11.5 to 41.8 ± 14.6 (P < 0.01). VAS improved from 6.7 ± 1.1 to 2.9 ± 1.9 in the active group and from 6.7 ± 1.1 to 4.8 ± 2.2 (P < 0.01) after placebo. Twelve month follow-up shows further improvement, the differences remain significant. In multiple linear regression, forward and backward variable selection methods resulted in the same covariate model confirming the univariate result for group comparison in the primary analysis. No severe side effects occurred but minor transient neurological effects such as partial sensomotoric deficits did. One dura puncture and one catheter displacement were found. Limitations: Specific effects of single treatment components cannot be specified because there was no imaging examination after treatment. Conclusion: Based on the findings of our study as well as other studies, we believe the minimally invasive percutaneous adhesiolysis procedure should be the first choice treatment option for patients with chronic lumbosacral radicular pain who present with clinical history and findings similar to those of the patients enrolled in our study. Key words: Lysis, low back pain, randomized controlled trial (RCT), placebo, epidural, radiculopathy, outcome, evidence-based medicine

Percutaneous epidural lysis of adhesions in chronic lumbar radicular pain: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Chronic radicular pain can occur after disc pathology and failed back surgery. An evidence-based effective therapeutic option is not available nor does a gold standard exist.

OBJECTIVES

A randomized controlled trial to analyze the clinical efficacy of percutaneous epidural lysis of adhesions in chronic radicular pain.

STUDY DESIGN

Prospective randomized placebo controlled interventional trial. Power calculation based on a feasibility trial.

SETTING

Medical university centers.

METHODS

Within 4 years a total of 381 patients with chronic radicular pain lasting longer than 4 months which failed to respond to conservative treatments were screened and 90 patients were enrolled. They were randomly assigned to receive either percutaneous neurolysis or placebo with concealed allocation in permuted blocks of 4 to 8, stratified by treatment center. The primary outcome measure was the differences in percent change of Oswestry Disability Index (ODI) scores 3 months after intervention. Secondary outcome measures were difference in percent change of ODI scores and Visual Analog Scale (VAS) 6 and 12 months after intervention and success rates defined as at least 50% reduction in ODI scores and VAS scores (mean change from baseline) at 3, 6, and 12 months after treatment. Explorative, 2-sided group comparisons for baseline characteristics between active treatment and controls were done using the t-test for 2 independent samples for quantitative data and Fisher's exact test for binary data.

RESULTS

The ODI and VAS scores as well as the success rates for ODI vs VAS were significantly better 3, 6, and 12 months in the lysis group vs the control group. The ODI in the lysis group improved from 55.3 ± 11.6 to 26.4 ± 10.8 after 3 months. The placebo group improved from 55.4 ± 11.5 to 41.8 ± 14.6 (P < 0.01). VAS improved from 6.7 ± 1.1 to 2.9 ± 1.9 in the active group and from 6.7 ± 1.1 to 4.8 ± 2.2 (P < 0.01) after placebo. Twelve month follow-up shows further improvement, the differences remain significant. In multiple linear regression, forward and backward variable selection methods resulted in the same covariate model confirming the univariate result for group comparison in the primary analysis. No severe side effects occurred but minor transient neurological effects such as partial sensomotoric deficits did. One dura puncture and one catheter displacement were found.

LIMITATIONS

Specific effects of single treatment components cannot be specified because there was no imaging examination after treatment.

CONCLUSION

Based on the findings of our study as well as other studies, we believe the minimally invasive percutaneous adhesiolysis procedure should be the first choice treatment option for patients with chronic lumbosacral radicular pain who present with clinical history and findings similar to those of the patients enrolled in our study.

Radial extracorporeal shock wave therapy (rESWT) induces new bone formation in vivo: results of an animal study in rabbits

The aim of this study was to investigate if radial extracorporeal shock wave therapy (rESWT) induces new bone formation and to study the time course of ESWT-induced osteogenesis. A total of 4000 impulses of radial shock waves (0.16 mJ/mm²) were applied to one hind leg of 13 New Zealand white rabbits with the contralateral side used for control. Treatment was repeated after 7 days. Fluorochrome sequence labeling of new bone formation was performed by subcutaneous injection of tetracycline, calcein green, alizarin red and calcein blue. Animals were sacrificed 2 weeks (n = 4), 4 weeks (n = 4) and 6 weeks (n = 5) after the first rESWT and bone sections were analyzed by fluorescence microscopy. Deposits of fluorochromes were classified and analyzed for significance with the Fisher exact test. rESWT significantly increased new bone formation at all time points over the 6-week study period. Intensity of ossification reached a peak after 4 weeks and declined at the end of the study. New bone formation was significantly higher and persisted longer at the ventral cortex, which was located in the direction to the shock wave device, compared with the dorsal cortex, emphasizing the dose-dependent process of ESWT-induced osteogenesis. No traumata, such as hemorrhage, periosteal detachment or microfractures, were observed by histologic and radiologic assessment. This is the first study demonstrating low-energy radial shock waves to induce new bone formation in vivo. Based on our results, repetition of ESWT in 6-week intervals can be recommended. Application to bone regions at increased fracture risk (e.g., in osteoporosis) are possible clinical indications.

Comparison between extracorporeal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete

Plantar fasciitis can be a chronic and debilitating condition affecting athletes of all levels. The aim of this study is to compare treatment outcomes for the treatment of chronic plantar fasciitis in athletes, comparing focused extra corporeal sound wave therapy (ESWT) and the surgical endoscopic plantar fasciotomy (EPF). A total of 37 eligible patients were enrolled in the study between May 2006 and December 2008 at a single institution. Patients were either enrolled in the surgical group, or to the ESWT group which included a placebo controlled, randomized group (P-ESWT). Pre and post Visual Analog Scores (VAS) and Roles and Maudlsey (RM) scores were recorded and compared between the three groups. The patient's return to activity (RTA) was also documented. The results showed statistical improvement within the EPF and ESWT groups with both VAS & RM scores, with EPF being significantly better than both ESWT and P-ESWT in terms of treatment outcomes. Patients enrolled in the ESWT were able though to continue with their exercise regimen, while the EPF group was able to return to their athletic activity in an average of 2.8 months. In conclusion, EPF and ESWT are both effective forms of treatment for chronic plantar fasciitis; EPF being superior in outcomes yet ESWT treatment could be preferable since the athlete can remain active during treatment.

LEVEL OF EVIDENCE

II.

[Calcific tendinitis of the shoulder]

Calcific tendinitis of the shoulder is a process involving crystal calcium deposition in the rotator cuff tendons, which mainly affects patients between 30 and 50 years of age. The etiology is still a matter of dispute. The diagnosis is made by history and physical examination with specific attention to radiologic and sonographic evidence of calcific deposits. Patients usually describe specific radiation of the pain to the lateral proximal forearm, with tenderness even at rest and during the night. Nonoperative management including rest, nonsteroidal anti-inflammatory drugs, subacromial corticosteroid injections, and shock wave therapy is still the treatment of choice. Nonoperative treatment is successful in up to 90% of patients. When nonsurgical measures fail, surgical removal of the calcific deposit may be indicated. Arthroscopic treatment provides excellent results in more than 90% of patients. The recovery process is very time consuming and may take up to several months in some cases.

Cementless total hip arthroplasty using the Spongiosa-I fully coated cancellous metal surface: a minimum twenty-year follow-up

BACKGROUND

We present the results of cementless total hip arthroplasty performed with use of an anatomically adapted femoral stem and hemispherical cup with a fully coated Spongiosa-I metal surface, which was designed to achieve a surface similar to human cancellous bone. The purpose of the present retrospective case series was to determine the long-term outcomes of this hip arthroplasty system after a minimum of twenty years of follow-up.

METHODS

Between 1983 and 1985, 209 consecutive total hip arthroplasty procedures (199 patients) were performed with use of the first-generation Spongiosa metal-surface chromium-cobalt total hip implant with an articulating surface consisting of a ceramic head and an ultra-high-molecular-weight polyethylene liner. We report the clinical and radiographic outcomes, the rates of and reasons for revision, and the influence of sex and age on outcome and complications.

RESULTS

At the time of the latest follow-up, twenty-seven patients had died and thirteen patients had been lost to follow-up; none of these forty patients had had revision surgery. The outcomes for 159 patients (169 prostheses) were reviewed. The mean duration of follow-up was 262 months (range, 242 to 275 months). There were nineteen revisions, including fourteen revisions of the femoral stem, two revisions of the acetabular cup, and three revisions of both components. The mean Harris hip score for patients who did not undergo revision surgery was 82 points. The probability of survival of both components at twenty years, with revision for any reason as the end point, was 97%. The probability of survival of the acetabular component was 98%, and the probability of survival of the femoral component only was 86%. The probability of component survival was significantly increased among older patients.

CONCLUSIONS

The results of cementless hip arthroplasty with use of the first-generation Spongiosa implant were excellent at a minimum of twenty years of follow-up. The probability of survival of the acetabular component exceeded that of the femoral stem.

Extra-corporeal pulsed-activated therapy ("EPAT" sound wave) for Achilles tendinopathy: a prospective study

Achilles tendinopathy is common and extracorporeal shockwaves have become a popular treatment for this condition, even though previous research has not provided conclusive results regarding its efficacy in cases of Achilles tendinopathy. Our aim was to evaluate 3 weekly shockwave treatments in patients with Achilles tendinopathy, as quantified by the Roles and Maudsley score. A total of 74 tendons in 60 patients were assessed at baseline and at least 1 year posttreatment, including 32 (43.24%) paratendinoses, 23 (31.08%) proximal tendinoses, and 19 (25.68%) insertional tendinoses. The mean age of the participants was 48.6 ± 12.94 years, and patients with paratendinosis (41.44 ± 14.01 years) were statistically significantly younger than those with proximal (53 ± 8.9 years) and insertional (54.26 ± 9.74 years) tendinopathy, and these differences were statistically significant (P = .0012 and P = .0063, respectively). Overall, 58 (78.38%) tendons improved by at least 1 year posttreatment, including 75% in the paratendinosis, 78.26% in the proximal tendinosis, and 84.21% in the insertional tendinosis groups, and no adverse effects were observed. The Roles and Maudsley score improved from 3.22 ± 0.55 to 1.84 ± 1.05 (P < .0001) in the paratendinosis group, 3.39 ± 0.5 to 1.57 ± 0.66 (P < .0001) in the proximal tendinopathy group, and 3.32 ± 0.58 to 1.47 ± 0.7 (P = .0001) in the insertional tendinopathy group. Based on these results, we believe that shockwave therapy serves as a safe, viable, and effective option for the treatment of Achilles tendinopathy.

8-year follow-up after cementless hip arthroplasty with a second generation spongy metal total hip replacement

We studied a consecutive series of 81 cementless total hip arthroplasties in 80 patients using the second generation ESKA cementless spongy metal hip replacement. The study end-point was implant revision and both function as well as satisfaction with treatment outcome were assessed.Mean age at the time of surgery was 50.9 years [range 23-73]. No patient was lost to follow-up and 75 patients (76 hips) could be included in the final analysis at a mean follow-up of 7.9 years [range 7.0-10.0]. Survival rate without loosening as the end-point was 100% for the femoral component and 99% for the acetabular component (one cup revision). Two cups and one stem had to be revised for recurrent dislocation, resulting in a total implant survival at follow-up of 99% for the femoral component and 96% for the acetabular component. Very good functional results were obtained with a mean Merle d' Aubigné score of 15.5 +/- 2.9 at 7.9 years after surgery. Satisfaction with treatment outcome was reported in 88%. 95% of patients would recommend the performed procedure to a friend. Peri-operative complications without revision occurred in eleven patients (14%).We report excellent survival rates of the cementless spongy metal hip arthroplasty at a mean follow-up of eight years, particularly considering the young age of many of the patients.

The effect of antibacterial acting extracorporeal shockwaves on bacterial cell integrity

BACKGROUND

Antibacterial effects of extracorporeal shockwaves (ESWs) have been demonstrated in vitro against bacteria under static and dynamic growth conditions. This study assessed the effects of ESWs on the cell wall integrity of bacteria.

MATERIAL/METHODS

Standardized suspensions of Staphylococcus aureus were exposed to various shockwave impulses (2000-12,000) of different energy flux densities (EFD, 0.38-0.96 mJ/mm(2)). Bacterial suspensions of equal concentration that had been permeabilized (to >99%) with isopropanol were used as positive controls. The bacteria of all groups were stained with Sytox Green nucleic acid stain. The fluorescence of the shockwave-treated, permeabilized, and untreated suspensions was measured and compared for bacterial survival, quantified by colony-forming units after plating.

RESULTS

Although ESWs showed a significant energy-dependent antibacterial effect that reduced CFUs in the treated suspensions by between 56% and 99%, only maximum energies (4000 impulses at 0.96 mJ/mm(2) and 12,000 impulses at 0.59 mJ/mm(2)) were followed by a significant increase in fluorescence compared with the untreated control (p<0.05). However, the fluorescence of these treated groups was still far less than that of the alcohol-permeabilized positive control groups (p<0.05). Lower energies and impulse rates did not show increased intracellular uptake of the fluorescent dye (p>0.05).

CONCLUSIONS

This is the first study to assess bacterial cell wall permeability after ESW treatment. It was found that the permeabilization of bacterial cells after ESW treatment was far less than expected due to the corresponding antibacterial effect. Other mechanisms, such as intracellular effects, might be involved in bacterial killing after ESWs and still must be elucidated.

Energy-dependent stimulatory and inhibitory effects of extracorporeal shock waves on bacteria and on gentamicin activity

BACKGROUND

Local infection is considered a contraindication for extracorporeal shock wave (ESW) application, although the antibacterial effects of ESW have been clearly demonstrated in vitro. This study aimed to assess the effects of ESW on bacteria under growth-promoting conditions and to evaluate interactions with the activity of gentamicin.

MATERIAL/METHODS

Standardized suspensions of Staphylococcus aureus were exposed to 4000 shock wave impulses of various energy flux densities (EFD) both at 37 degrees C in growth medium and at 20 degrees C in saline. Bacterial viability of treatment groups and controls were quantified. Furthermore, the MICs of gentamicin against ESW-treated and untreated suspensions of S. aureus were compared. Finally, suspensions of S. aureus containing graded concentrations of gentamicin were exposed to ESW and bacterial growth was assessed.

RESULTS

Antibacterial effects of ESW (0.59-0.96 mJ/mm2) were confirmed with bacteria suspended in normal saline (20 degrees C, p<0.05). However, bacteria suspended in growth medium at 37 degrees C demonstrated significantly increased proliferation (p=0.009) after treatment with shock waves of lower EFD (0.59 mJ/mm2). At higher EFD a significant reduction of bacteria was observed (p=0.009). The MIC of gentamicin against S. aureus was not altered by ESW application. Furthermore, the combination of gentamicin and ESW did not alter gentamicin activity (p>0.05). Nevertheless, a growth-promoting effect of ESW at 0.59 mJ/mm(2) was demonstrated despite simultaneous administration of gentamicin.

CONCLUSIONS

This is the first study reporting energy-dependent stimulation of bacterial growth by ESW. Also important is that ESW did not alter the activity of gentamicin.

Safety and effectiveness of extracorporeal shockwave therapy: results of a rabbit model of chronic osteomyelitis

Extracorporeal shockwave therapy (ESWT) is applied successfully in various orthopedic disorders. Since shockwaves have demonstrated significant bactericidal effectiveness in vitro, safety and effectiveness of ESWT in vivo were evaluated in a rabbit model of osteomyelitis. Chronic osteomyelitis was induced by injecting sodium morrhuate and Staphylococcus aureus into the proximal tibia of 12 New Zealand white rabbits. Four and five wk after the initial operation, soft focused ESWT was applied twice to the infected limbs. Clinical parameters and laboratory values were followed and blood samples were taken for culture before and 30 min after ESWT. Following sacrifice after 8 wk, lungs, spleen and kidneys were studied histologically for signs of sepsis and secondary infection. Tibial osteomyelitis was assessed clinically, and by radiologic, microbiologic and histologic procedures. Signs of bacterial spreading were not detectable after ESWT, neither in blood cultures nor in histologic analyses of representative organs. Temperature, body weight, C-reactive protein and white blood cell levels also remained unchanged after ESWT. Of particular interest, histologic scores of osteomyelitis were significantly decreased in the ESWT-group compared to the untreated control (p = 0.019). However, S. aureus was still detectable in tissue samples of all animals. This is the first study investigating the effects of ESWT applied to infected target areas. ESWT of infected bone did neither induce bacterial spreading nor worsening of infection, and the results suggest the reported treatment protocol of ESWT to be beneficial in the treatment of chronic bone infections.

High hydrostatic pressure for disinfection of bone grafts and biomaterials: an experimental study

BACKGROUND

Autoclaving, heat, irradiation or chemical detergents are used to disinfect autografts, allografts and biomaterials for tissue reconstruction. These methods are often associated with deterioration of mechanical, physical, and biological properties of the bone grafts and synthetic implants. High hydrostatic pressure has been proposed as a novel method preserving biomechanical and biological properties of bone, tendon and cartilage. This is the first study to assess the inactivation of clinically relevant bacteria on biomaterials and human bone by high hydrostatic pressure.

METHODS

Bacterial suspensions of Staphylococcus aureus, Pseudomonas aeruginosa and Enterococcus faecium, implants covered with infected blood, human bone infected in vitro, and biopsies of patients with chronic osteomyelitis were subjected to different protocols of high hydrostatic pressure up to 600 MPa. Bacterial survival after high hydrostatic pressure treatment was determined and compared with bacterial growth in untreated controls.

RESULTS

S. aureus and P. aeruginosa in suspension were completely inactivated by high hydrostatic pressure (> 5log levels), whereas E. faecium showed barotolerance up to 600 MPa. Blood and adherence to metal implants did not significantly alter inactivation of bacteria, and complete disinfection was achieved with barotolerant bacteria (S. aureus and P. aeruginosa). However, osteoarthritic bone demonstrated a non-homogeneous baroprotective effect, with single bone samples resistant to treatment resulting in unaltered bacterial growth, and complete disinfection of artificially infected bone specimens was achieved in 66% for S. aureus, 60% for P. aeruginosa and 0% for E. faecium. Human bone samples of patients with chronic osteomyelitis could be completely disinfected in 2 of 37 cases.

CONCLUSION

High hydrostatic pressure offers new perspectives for disinfection of sensitive biomaterials and bone grafts, and contamination by blood did not significantly affect bacterial inactivation rates. However, a significant baroprotective effect was demonstrated in bone. Effectiveness is currently limited to colonization and / or infection with barosensitive micro-organisms.