[Spondylolisthesis]

Spondylolisthesis is a frequent disease that is found in 20% of the adult population and is particularly accompanied by lumbar back pain. Degenerative spondylolisthesis develops in adulthood and is most often found in the L4/5 segment, in contrast to nondegenerative spondylolisthesis which is most often situated in the L5/S1 segment. Prior to every treatment the heterogeneous disease pattern has to be classified according to the severity grade of the olisthesis and to the Spinal Deformity Study Group (SDSG) classification. High-grade spondylolisthesis should preferably be surgically treated and low-grade spondylolisthesis should preferably be treated conservatively. In approximately 50% of all recently acquired spondylolistheses healing of the lysis can be achieved by a consequently carried out conservative treatment.

[Spondylolisthesis]

Spondylolisthesis is a frequent disease that is found in 20% of the adult population and is particularly accompanied by lumbar back pain. Degenerative spondylolisthesis develops in adulthood and is most often found in the L4/5 segment, in contrast to nondegenerative spondylolisthesis which is most often situated in the L5/S1 segment. Prior to every treatment the heterogeneous disease pattern has to be classified according to the severity grade of the olisthesis and to the Spinal Deformity Study Group (SDSG) classification. High-grade spondylolisthesis should preferably be surgically treated and low-grade spondylolisthesis should preferably be treated conservatively. In approximately 50% of all recently acquired spondylolistheses healing of the lysis can be achieved by a consequently carried out conservative treatment.

[Femoral neck fractures]

Femoral neck fractures (FNF) are the most frequent fractures in the older population and are also of high socioeconomic importance due to the high risk of mortality. The diagnostics are based on the clinical examination and imaging procedures. The classification systems used in the routine clinical practice are oriented towards the prognosis and are therefore a valuable aid in making decisions for the selection of the treatment procedure. Early surgery is decisive for the success of treatment. Older patients (> 60 years) with arthritically damaged hips and a high degree of fracture dislocation benefit from prompt hip replacement (bipolar systems, total hip arthroplasty, dual mobility systems). In contrast, joint-preserving surgery by osteosynthesis is indicated in younger patients with a low degree of dislocation. This article summarizes the clinically relevant aspects of FNF and gives an overview of current treatment strategies with inclusion of the scientific literature.

Unloader bracing in osteoarthritis of the knee - Is there a direct effect on the damaged cartilage?

BACKGROUND

Unloading knee braces represent a conservative treatment option for non-pharmalogical management of unicompartmental osteoarthritis of the knee. Though there is consensus on the clinical effectiveness of unloading, the effect mechanism of bracing remains part of a debate. Our study was designed to assess the effect of unloader bracing on damaged cartilage via MRI cartilage mappings.

METHODS

Fourteen patients (7 female, 7 male, mean age 43.1 ± 9.4 years) with unicompartmental cartilage wear in knees with varus or valgus malalignment were enrolled. Clinical scores, radiographs and MR-graphic properties (T2/T2* mapping, T1 Delayed Gadolinium Enhanced MRI of the cartilage (dGEMRIC) mapping, high-resolution PDw sequences) of knee cartilage were recorded before and three months after brace use.

RESULTS

Bracing the knees for a mean of 14.4 ± 2.0 weeks (range 11 to 18 weeks) resulted in significant pain reduction (VAS changed from 5.9 ± 2.0 to 2.0 ± 1.3, p < 0.001) and improvement in knee function (KOOS increased from 42.1 ± 22.7 to 64.8 ± 18.7, p < 0.001). In the affected cartilage regions T2 relaxation times significantly decreased from 56.1 ± 11.4 ms to 46.5 ± 11.2 ms (p < 0.05). No changes in T1-dGEMRIC and T2* relaxation times, thickness or the extent of the damaged cartilage area could be detected.

CONCLUSIONS

Our results suggest, that unloader bracing improves the biochemical properties of the damaged cartilage by increasing collagen and proteoglycan concentration as well as decreasing the cartilage edema.

Bioactivation of scaffolds in osteonecrosis

Avascular osteonecrosis (AVN) due to local ischemia leads to an inhomogeneous osseous defect, which can be treated by resection and with bone substitute materials in a joint-preserving treatment. Due to the underlying risk profile of AVN, the mostly subchondral localization and the size of the local bone defect, bone regeneration is impaired. Therefore, bioactivation of the applied bone substitute materials prior to application is highly desirable. Apart from the use of growth factors and other soluble substances, the autologous application of location-typical cells and tissue is a useful alternative to support the bone healing properties of scaffolds. This article presents various methods to activate scaffolds for bone stimulation and discusses these techniques with respect to recent data from the literature.

[Post-traumatic necrosis of the humeral head-Endoprosthesis or joint preservation]

BACKGROUND

Humerus fractures play a major role in daily clinical routine, and subsequent osteonecrosis is common after osteosyntheses.

OBJECTIVES

The current paper highlights the incidence and cause of osteonecrosis after proximal humerus fractures, with respect to presentation of anatomy and risk factors.

METHODS

Display of the literature and therapy options for humerus fracture and subsequent necrosis.

RESULTS

Humerus fractures are the seventh most frequent fractures in humans. The complication rate is 40%, and the described rate of necrosis is up to 34%. Accordingly, the surgical revision rate is at 19% according to recent literature.

CONCLUSION

The treatment of humerus head fracture must consider numerous variables. The individual type of fracture and the current individual situation of the patient must be included in the process of choosing the right treatment. Modern implants with screw locking features should be used, and for certain circumstances the direct implantation of a prosthesis should be considered. Thereby the expectations of the patient with respect to the postoperative activity level play a major role.

[Chorioretinal atrophy in pediatric cerebral folate deficiency-a preventable disease?]

Cerebral folate deficiency (CFD) results in neurological alterations and a massive degeneration of the choroid/retina if left untreated, which limit the visual field and visual acuity. This article reports the case of a female patient with CFD, who developed autistic personal characteristics prior to reaching school age and first started to speak at the age of 3 years. At the age of 6 years she was presented because of unclear reduced visual acuity in the right eye. At that time mild bilateral peripheral chorioretinal atrophy was present, which subsequently became more pronounced. Additionally, a centrally emphasized chorioretinal atrophy further developed. Visual acuity of both eyes progressively deteriorated until stagnating at 0.1 at the age of 14 years. The causal assignment of the findings of the patient was not possible for many years. Choroideremia was excluded by molecular genetic testing (CHM gene with no mutations) and gyrate atrophy was ruled out by a normal ornithine level. The existence of a mitochondrial disease was almost completely excluded by exome sequencing. After the onset of further nonocular symptoms, e.g. neuromuscular disorders, electroencephalograph (EEG) alterations and autistic disorder, intensified laboratory diagnostics were performed in the treating pediatric hospital. Finally, an extremely low level of the folic acid metabolite 5‑methyltetrahydrofolate was detected in the cerebrospinal fluid (CSF) leading to the diagnosis of CFD. High-dose substitution treatment with folic acid was subsequently initiated. After excluding the presence of a pathogenic mutation of the FOLR1 gene for the cerebral folate receptor 1, a high titer blocking autoantibody against cerebral folate receptor 1 was detected as the cause.

From research to practice: Implementing an experimental home treatment model into routine mental health care

Background

In line with previous findings, in a recent randomized controlled trial (RCT), we found that home treatment (HT) for acute mental health care can reduce (substitute) hospital use among severely ill patients in crises. This study examined whether the findings of the RCT generalize to HT services provided under routine care conditions.

Methods

We compared patients who received HT during the RCT study phase with patients who received the same HT service after it had become part of routine mental health services in the same catchment area. Sociodemographic and clinical characteristics as well as service use (HT and hospital bed days) were compared between the RCT and the subsequent routine care study period.

Results

Compared to patients who received HT during the RCT, routine care HT patients were more often living with others, less often admitted compulsorily, more often diagnosed with anxiety and stress-related disorders (ICD-10 F4) and less often diagnosed with schizophrenia spectrum disorders (F2). When compared to patients who were exclusively treated on hospital wards, involvement of the HT team in patients’ care was associated with a clear-cut reduction of hospital bed days both during the RCT and under routine care conditions. However, unlike during the RCT study period, involvement of HT was associated with longer overall treatment episodes (inpatient + HT days) under routine care conditions.

Conclusions

HT seems to reduce the use of hospital bed days even under routine care conditions but is at risk of producing longer overall acute treatment episodes.

The learning curve of patient-specific unikondylar arthroplasty may be advantageous to off-the-shelf implants: A preliminary study

Introduction

Introducing a new arthroplasty system into clinical routine is challenging and could have an effect on early results. Since UKA are known to have failure mechanisms related to technical factors, reliable results and easy adoption are ideal. The question remains whether there are differences in objective procedure parameters in the early learning curve of different UKA systems.

Methods

two different UKA implants (Biomet Oxford[BO] followed by Conformis iuni[CI]) were introduced consecutively into clinical routine. We retrospectively analyzed the first 20 cases of each implant for one arthroplasty surgeon regarding operating time, correction of the mechanical axis, learning curve parameters, and revision rate of implants for 1.5 years postoperatively.

Results

Operating time (BO:98.3 ± 26.3min, CI:83.85 ± 21.8min (p < 0.078)), and tourniquet time differed in favor of the CI implant (BO:97.5 ± 29.5min; CI:73.5 ± 33.2 min; p < 0.017)). Mechanical alignment was restored in boths (preop:BO:mean 2.9°varus, CI:2.7°varus, postop:BOmean1.3°varus, CI:1°varus), while one BO patient and two CI patients were overcorrected. Operating time decreased from the first five implants to implants 16-20 for CI (95.2 ± 18.5min to 69 ± 21.5min, p < 0.076) and BO (130.6 ± 27.6min to 78 ± 17.3min, p < 0.009). Within 18 months of follow-up, 2 BO and 1 CI implants were revised.

Conclusion

The introduction of an UKA implant was associated with longer surgery in both implants. Procedure time seems to differ between implants, while a learning curve was observed regarding instrumentation. CI implants seem to be reliable and adaptable in a medium-volume practice. The early results of this retrospective single-surgeon study were in favor of the individualized implant. Certainly, further studies encompassing larger cohorts with various implants are needed.

What are depressive symptoms in acutely ill patients with schizophrenia spectrum disorder?

Background:

Aim was to examine depressive symptoms in acutely ill schizophrenia patients on a single symptom basis and to evaluate their relationship with positive, negative and general psychopathological symptoms.

Methods:

Two hundred and seventy-eight patients suffering from a schizophrenia spectrum disorder were analysed within a naturalistic study by the German Research Network on Schizophrenia. Using the Calgary Depression Scale for Schizophrenia (CDSS) depressive symptoms were examined and the Positive and Negative Syndrome Scale (PANSS) was applied to assess positive, negative and general symptoms. Correlation and factor analyses were calculated to detect the underlying structure and relationship of the patient’s symptoms.

Results:

The most prevalent depressive symptoms identified were depressed mood (80%), observed depression (62%) and hopelessness (54%). Thirty-nine percent of the patients suffered from depressive symptoms when applying the recommended cut-off of a CDSS total score of > 6 points at admission. Negligible correlations were found between depressive and positive symptoms as well as most PANSS negative and global symptoms despite items on depression, guilt and social withdrawal. The factor analysis revealed that the factor loading with the PANSS negative items accounted for most of the data variance followed by a factor with positive symptoms and three depression-associated factors.

Limitations:

The naturalistic study design does not allow a sufficient control of study results for the effect of different pharmacological treatments possibly influencing the appearance of depressive symptoms.

Conclusion:

Results suggest that depressive symptoms measured with the CDSS are a discrete symptom domain with only partial overlap with positive or negative symptoms.

[Handball injuries and their prevention]

BACKGROUND

Handball is one of the most popular team sports in Germany, as well as one of the most dangerous ones. Injury rates in Germany are higher amongst handball professionals than in soccer, with the knee being the most commonly injured joint. To prevent injuries, a functional inert stability is necessary, but definitions and objective measures are lacking.

OBJECTIVES

Establishing valid reference data of functional knee stability in amateur handball players with use of an established test battery giving objective measures METHODS: 261 athletes (f:130; m:131), mean age 25.1 ± 5.8 y were screened during the preseason. The test battery consisted of double and single-leg counter movement jumps, balance tests, agility, parkour, quick feet test and plyometric jumps.

RESULTS

Significant differences between males and females were noted in regard to balance scores (favour for females p ≤ 0.001), as well as jump height, agility and speed tests (favour for males [p ≤ 0.002-0.001]).

CONCLUSION

The noted differences once again bring focus to the interindividual presence of risk factors, because female and male handball athletes have gender-specific ground levels. These attributes have to be considered in further screening and prevention programs, as well as in the context of the return-to-sports decision after injury. The given data may serve as objective reference measures.

[Current trends and injuries in cycling: faster, further, e-bike?]

During the past decade, technical innovations (e.g., carbon as a new material, disk brakes, hydraulic shock absorbers, electric transmissions) and lifestyle changes have significantly influenced recreational and professional cycling. In contrast to the past, where ambitious leisure cyclists were primarily interested in the recreational value of nature and landscape, cyclists of all ages are nowadays increasingly focused on performance and self-optimization. Simultaneously, manufacturers have adapted to differing customer requirements: besides the traditional extremities of road and mountain bikes, many specialized models have been designed for special applications: trekking, cyclocross, gravel, full-suspension, single-track, hardtail, downhill, fatbike, etc. For biking fans who are no longer able to meet their own demands due to individual physical restrictions or defined health problems, electric-assist bikes (pedelecs or "e-bikes") were recently introduced. While these are becoming increasingly popular, they have also increased the number of accidents and injuries. The current work provides an update on relevant sport medical and orthopaedic challenges brought on by these developments in cycling.

[Atraumatic fractures of the spine : Current strategies for diagnosis and treatment]

Atraumatic fractures of the spine are a common orthopedic disease condition that can be asymptomatic or associated with complaints of varying intensity and quality. The risk factors for such fracture forms are often metabolic and genetic diseases, which have a direct or indirect effect on bone metabolism and therefore secondarily affect the stability of the spinal vertebrae. Furthermore, benign and malignant tumors as well as infectious diseases can also be causative for atraumatic spinal fractures; however, those factors that are attributable to lifestyle habits should also not be underestimated. The treatment of affected patients is complex and nearly always interdisciplinary. In addition to purely symptom-oriented treatment concepts, orthoses in particular and when indicated surgical treatment procedures can be implemented. This article summarizes the important clinical, diagnostic and therapeutic aspects of atraumatic spinal fractures.

[Apps in clinical use in orthopedics and trauma surgery : The status quo in Germany]

In the course of digitalization the smartphone is penetrating more and more areas of life giving the user mobile and almost ubiquitous access to the internet and other web applications. The advantages of mHealth are an integral part in some areas of patient care but in contrast to other disciplines, routine integration of mobile devices into orthopedics and trauma surgery is still in its infancy. A survey among German orthopedists and trauma surgeons revealed which kind of apps have become established in everyday clinical practice to date. Apps published by representative institutions such as the AO Foundation demonstrated the highest usage rates. In summary, the number of regularly used apps is low; however, the causes of this lack of acceptance have not yet been conclusively clarified. The authors of this study proclaim a significant increase in the use of mHealth and mobile devices in daily clinical practice in the future.

The Refeeding Syndrome revisited: you can only diagnose what you know

BACKGROUND/OBJECTIVES

The Refeeding Syndrome (RFS) is a serious complication in patients receiving nutrition support after a period of severe malnutrition. We frequently recognize and diagnose the RFS due to increased awareness. Thus, we observe that many physicians do not know the RFS and that it is rarely diagnosed. The aim of the study was to determine whether physicians in Germany know the RFS.

SUBJECTS/METHODS

A questionnaire with a case vignette about an older person who developed the RFS after initiation of nutritional therapy was submitted to German physicians and fifth year medical students, who were participants of educational lectures.

RESULTS

Of the 281 participants who answered the respective question, 40 participants (14%) correctly diagnosed the RFS of the case vignette and 21 participants (8%) gave nearly correct answers. Indeed, the majority of the participants did not diagnose the RFS.

CONCLUSIONS

Although the RFS may lead to fatal complications, it is unknown to the majority of the queried physicians. Therefore, there is a call to implement the RFS in respective curricula and increase systematic education on this topic.

[Cell-based and future therapeutic strategies for femoral head necrosis]

BACKGROUND

The application of cell- and growth factor-based techniques in conjunction with conventional surgical approaches has great therapeutic potential for the treatment of avascular necrosis of the femoral head (AVNFH).

OBJECTIVES

This review provides an overview of new strategies for the treatment of AVNFH, with emphasis on cell and growth factor-based approaches.

MATERIALS AND METHODS

The results of a literature search are summarised, the most relevant publications are presented and discussed by the authors.

RESULTS

In the focus of new strategies for treatment of AVNFH are bone marrow-derived cell concentrates and ex vivo-expanded mesenchymal stem cells. Besides local application during core decompression, the systemic administration of cells via blood vessels supplying the femoral head is an interesting approach. The application of osteogenic and angiogenic growth factor-laden scaffold materials has also been clinically tested. Initial results of randomised clinical trials using cell- and growth factor-based approaches underline the potential of these innovative therapeutic strategies. Cell-based therapies are governed by EU law and generally require a manufacturing authorization.

CONCLUSION

To date, only few randomized controlled clinical trials are available which additionally display a considerable diversity concerning cell parameters, cell processing, adjuvant surgical techniques and the quality outcome parameters. Therefore, a final statement about the effectiveness of new cell and growth factor-based strategies is currently not possible.

TDM-controlled ring resonator arrays for fast, fixed-wavelength optical biosensing

A novel control concept for serial ring resonator arrays based on a time-division multiplex (TDM) approach is presented. It allows fast sampling rates in terms of biological kinetics. The novelty consists of using both thermal tuning of the effective refractive index and thermo-optical multiplexing for the silicon-on-insulator (SOI) ring resonator arrays, without the need for a tunable laser source. Using a fixed wavelength, fast read-out rates of 100 Hz are demonstrated for each ring.

[Big data and deep learning in preventive and rehabilitation medicine]

The digitalization in medicine has led to almost universal availability of information to different healthcare professionals and accelerated clinical pathways. Fast-track concepts and short hospital stays require intelligent and practicable systems in preventive and rehabilitation medicine. This includes optimization of movement analysis by innovative tools such as detectors sensing skin movements, portable feedback systems for monitoring, robot-assisted devices, and prevention programs based on reliable data. Finally, clinical structures are needed to exploit the maximal potential of artificial intelligence (AI) and deep learning. One example is the establishment of inter- and transdisciplinary professional teams such as a RehaBoard. In contrast to other cost-intensive disciplines such as oncology, the introduction of AI into rehabilitation orthopedics and trauma surgery with the support of cross-sectoral cooperation has great potential for performing well in patient benefit-orientated competition (value-based competition).

ARTICULATION AND BACKSIDE WEAR ANALYSIS AFTER LONG-TERM IN VITRO WEAR SIMULATION OF VITAMIN E STABILIZED POLYETHYLENE ACETABULAR LINERS WITH A PRESS-FIT LOCKING MECHANISM

A previous retrieval study analyzed the backside wear of short-term implanted liners against in vitro tested liners of similar life in service and showed comparable results among both groups, with no significant backside wear due to micro-motion.

The purpose — to obtain a picture of the overall wear (articulation and backside surfaces) of 0.1% vitamin e blended polyethylene liners, with a locking mechanism based on a press-fit cone in combination with a rough titanium conical inner surface in the fixation area, under a 20 million cycles hip wear simulation.

Materials and Methods. A semi-quantitative method was used in order to assess the damage on the backside of the liners and a 3d measuring machine to assess the creep and wear at the articulation surface.

Results. The total average backside wear score was 22.00±2.59 from a maximum total score of 147 after 5 million cycles (mc), increased to 31.92±5.57 after 10 mc, but showed no further increment after 15 and 20 mc. The reference liners (subjected only to axial load) showed similar wear scores and modes as the liners under wear simulation (axial load and movement). Small scratches produced during insertion and removal were clearly seen at the rim (fixation) area and no considerable abrasion was observed. The machining marks on the convex surface were always visible. Regarding the articulation surface, a steady state wear rate of 7 µm/year was measured.

Conlusion. These results determined that most of the backside wear produced on the liners occurred during their insertion and removal rather than during their life in service. Moreover, the wear at the articulation surface was similar to that seen in vivo at short- and mid-term on highly cross-linked polyethylene liners with and without vitamin e content.

Tuberkulöse Spondylitis

Die Zahl der tuberkulösen Neuerkrankungen ist in Deutschland inzwischen gering. Bei nicht eingeschränkter Immunkompetenz kommt es nur in etwa 3–5 % aller Tuberkulosefälle zu einer skelettalen Manifestation. Bei immungeschwächten Patienten, wie HIV-Infizierten, Diabetikern oder bei medikamentös indizierter Immunsupression steigt der Anteil der ossären Manifestation einer Tuberkulose aber erheblich an. Deshalb sollte bei jedem immunsupprimierten Patienten mit Rückenschmerzen frühzeitig auch an eine tuberkulöse Infektion gedacht werden.

Medikamentöse Akutbehandlung schizophrener Ersterkrankungen

Atypische Neuroleptika werden heute für die Behandlung von Patienten mit schizophrenen Erkrankungen als Therapie der ersten Wahl empfohlen, da sie gegenüber den typischen Neuroleptika deutliche Vorteile hinsichtlich des Wirkungsspektrums und des Nebenwirkungsprofils aufweisen. Dies trifft insbesondere für ersterkrankte Patienten zu, da für diese Patientengruppe im Vergleich zu Mehrfacherkrankten ein höheres Risiko für extrapyramidal-motorische Nebenwirkungen beschrieben wurde. Ob die Vorteile der atypischen Neuroleptika aber auch nachweisbar sind, wenn typische Neuroleptika in niedrigen Dosierungen eingesetzt werden, ist bisher empirisch unzureichend geprüft. Vor diesem Hintergrund wurden im Rahmen einer multizentrischen, doppelblinden, randomisierten klinischen Studie des Kompetenznetz Schizophrenie die Effekte von Risperidon und Haloperidol im Niedrigdosisbereich (Tagesdosen von 2 mg bis maximal 8 mg für beide Medikamente) in der Akutbehandlung ersterkrankter Patienten verglichen.

Gelenkerhaltende Operationen bei atraumatischer Femurkopfnekrose

Neben nichtoperativen Behandlungsstrategien und dem endoprothetischen Gelenkersatz nehmen gelenkerhaltende Operationstechniken am Hüftgelenk eine Zwischenstellung in der Therapie der avaskulären Osteonekrose (AVN) ein. Die einzelnene Verfahren verfolgen hierbei verschiedene Ziele. Neben der seit vielen Jahren etablierten Entlastungsbohrung (Core Decompression), der Spongiosaplastik und aktueller innovativer Therapien (autologe Zelltherapie, Osteonekrosenagel, femoraler Teilgelenkersatz) besteht in ausgewählten Fällen die Indikation, ein betroffenes Osteonekroseareal durch eine Umstellungsosteotomie aus der Hauptbelastungszone zu schwenken. Die Entscheidung für hüftgelenknahe Osteotomien ist jedoch aufgrund eigener Erfahrungen sowie unter Berücksichtigung von umfangreichen Daten aus der wissenschaftlichen Literatur kritisch zu stellen, da bei bereits primär kritischer Durchblutung des Femurkopfes diese operationsbedingt zusätzlich beeinträchtigt werden können und sich das mittelfristige klinische Ergebnis im Einzelfall nur sehr schwer vorhersagen lässt. Ob minimalinvasive und regenerative Therapien zukünftig einen festen Stellenwert in der Behandlung der Femurkopfnekrose einnehmen werden, wird derzeit anhand experimenteller und klinischer Studien untersucht.

[The intraarticular osteoid osteoma : A diagnostic and therapeutic challenge]

Intra- and, respectively, periarticular osteoid osteoma are accompanied by sympathical arthritis which itself can irreversibly destroy the cartilage of the joint. In contrast to other locations, intra- and periarticular osteoid osteoma are rare. Reactive and symptomatic accompanying arthritis may lead to irreversible cartilage destruction especially in chronic courses. Therefore early diagnosis and therapy is crucial. We present a case report and discuss these rare tumors by reviewing the literature.

[Endoprostheses in the elderly : Biomaterials, implant selection and fixation technique]

The replacement of hip and knee joints is one of the greatest success stories in orthopedics. Due to continuous improvement of biomaterials and implant design, patient-associated problems are now mostly multifactorial and only rarely caused by the implant. Abrasion was significantly reduced by the introduction of highly cross-linked polyethylene (PE), antioxidant stabilized PE, new ceramics and the development of ceramic and protective surfaces. It is assumed that further reduction of frictional resistance will not lead to a significantly better clinical result: however, the problem of periprosthetic infections and implant-related incompatibility is still unsolved and remains challenging for biomaterial research. For the knee joint PE will be irreplaceable for joint articulation even in the future due to the contact situation. Mobile bearings and fixed bearings are two established successful philosophies, which have shown comparably good clinical results. For the hip joint, it is forecasted that ceramic-on-ceramic will be the system of the future if the correct positioning and mounting of the components can be solved so that the problems, such as development of noise and breakage can be reduced to a minimum. An in-depth understanding and detailed knowledge of the biomaterials by the surgeon can prevent implant-related problems. For elderly patients it is assumed that the economic burden on the public healthcare system will have the strongest impact on implant selection.

[Hebephrenia - a viable psychopathological construct?]

Ewald Hecker was the first psychiatrist to describe the disease entity of hebephrenia in some detail, focusing mainly on disturbances of affect. Later Emil Kraepelin and Eugen Bleuler saw hebephrenia as a subtype of dementia praecox or schizophrenia. Willy Mayer-Gross and Karl Leonhard characterized hebephrenia with highly differentiated psychopathological descriptions, whereas this construct only played a minor role in the works of Klaus Conrad and Kurt Schneider. The International Classification of Diseases (ICD-10) lists hebephrenia as a subtype of schizophrenia but in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) no subtypes of schizophrenia are mentioned and the concept of hebephrenia is thus lost. Hebephrenia can be seen as an ideal type describing a psychopathological course pattern. This construct can be useful to conceptualize a group of disorders of affect which otherwise escape description, especially since these psychopathological alterations of affect are difficult to operationalize. To have a viable concept of these disorders is relevant for the prognosis and therapy planning. If the concept of hebephrenia is abolished, important psychopathological knowledge might be lost for future generations of psychiatrists.

Wave-optical modeling beyond the thin-element-approximation

The optical design and analysis of modern micro-optical elements with high index contrasts and large numerical apertures is still challenging, as fast and accurate wave-optical simulations beyond the thin-element-approximation are required. We introduce a modified formulation of the wave-propagation-method and assess its performance in comparison to different beam-propagation-methods with respect to accuracy, required sampling densities, and computational performance. For typical micro-optical components, the wave-propagation-method is found to be considerably faster and more accurate at even lower sampling densities compared to the different beam-propagation-methods. This enables realistic wave-optical simulations beyond the thin-element-approximation for micro-optical components. As an example, the modified wave-propagation-method is applied for in-line holographic measurements of strongly diffracting objects. From a direct comparison of experimental results and corresponding simulations, the geometric parameters of a test object could be retrieved with high accuracy.

[Consequences of the Foundation of a University Centre for Orthopaedics and Accident Surgery]

Background: Since the combination of orthopaedic and traumatology surgery as a single speciality, an extremely wide variety of orthopaedic and trauma surgery centres have been founded in Germany. The present investigation analysed the degree to which additional value has been generated by merging two previously independent university departments - one for orthopaedics, the other for trauma surgery - into a single orthopaedics and trauma surgery centre. Material and Methods: The centre, merged in 1 June 2013, is led by two equal co-chairs (a full professor for orthopaedics and a full professor for trauma surgery). It consists of an acute division and five other divisions for specific parts of the body. The pre-existing certifications (level 1 trauma- and joint arthroplasty centre) were maintained in the new merged entity. Data from patient and employee questionnaires, as well as key economic indicators, were compared before and after the merger. Results: 11 % of the patients rated the medical treatment as mediocre or bad before the merger. After the merger, 5.7 % of the patients were moderately satisfied or unsatisfied; 92 % would recommend the merged centre to others and would return for further treatment. The evaluation of patient complaints before and after the merger showed no change. The evaluation of the employee questionnaires showed heterogeneous results. Overall, positive evaluations predominated, but in areas where there had been major changes, negative aspects were occasionally reported. The merger did not bring about any essential change in the number of in-patients (2012: 6693; 2014: 6649) or in the severity of the medical cases (CMI in 2012: 1.41; in 2014: 1.45). But in 2015, there was an increase in the number of in-patients (6837) and in the CMI (1.54). In the out-patient clinic, the merger led to a reduction in the material costs per patient (2012: 3.53 €/patient; 2014: 3.07 €/patient) and in the staff costs. The material costs for the entire centre were also reduced by 14 %. Conclusion: By merging the university orthopaedic and trauma surgery centres, transdisciplinary and transdepartmental improvements in patient care were achieved for musculoskeletal illnesses and injuries, and a sustainable structure was established for the advanced training for the joint specialist title of orthopaedics and trauma surgery. The merger also led to additional economic synergies, with a mid-term potential for increases in the number of patients and in CMI. To improve or at least maintain the level of employee satisfaction, staff must be actively included in the process.

A Single Dose of the Anti-Resorptive Peptide Human Calcitonin Paradoxically Augments Particle- and Endotoxin-Mediated Pro-Inflammatory Cytokine Production In Vitro

The peptide hormone calcitonin (CT) is known to inhibit bone resorption and has previously been shown also to prevent particle-induced osteolysis, the leading cause of revision arthroplasty. In the present study, the influence of human CT on the initial inflammatory response to particulate wear debris or bacterial endotoxins, ultimately leading to osteoclast-mediated bone resorption, was analysed in human THP-1 macrophage-like cells. The cells were activated with either ultra-high molecular weight polyethylene (UHMWPE) particles or bacterial lipopolysaccharides (LPS) in order to simulate an osteolysis-associated inflammatory response. The cells were simultaneously treated with human CT (10(-9) M). Cytokine production of tumour necrosis factor (TNF)-α was quantified on both RNA and protein levels while interleukins (IL)-1β and IL-6 were measured as secreted protein only. Stimulation of the cells with either particles or LPS led to a dose- and time-dependent increase of TNF-α mRNA production and protein secretion of TNF-α, IL-1β, and IL-6. Application of CT mostly enhanced cytokine production as elicited by UHMWPE particles while a pronounced transient inhibitory effect on LPS-induced inflammation became evident at 24 h of incubation. Human CT displayed ambivalent effects on the wear- and LPS-induced production of pro-inflammatory cytokines. Thereby, the peptide primarily upregulated particle-induced inflammation while LPS-induced cytokine secretion was temporarily attenuated in a distinct manner. It needs to be evaluated whether the pro- or anti-inflammatory action of CT contributes to its known anti-resorptive effects. Thus, the therapeutic potential of the peptide in the treatment of either particle- or endotoxin-mediated bone resorption could be determined.

Treating onychomycosis with the short-pulsed 1064-nm-Nd:YAG laser: results of a prospective randomized controlled trial

BACKGROUND

The role of the short-pulsed 1064-nm-Nd:YAG laser in treating onychomycosis has been the subject of controversial discussion ever since it received FDA approval in 2010. Research to date provides no valid conclusions supporting its use from an evidence-based perspective.

OBJECTIVE

In this prospective randomized controlled pilot study, we analysed the effect of the short-pulsed 1064-nm-Nd:YAG laser on the rate of mycological remission and clinical improvement after excluding relevant confounders with regard to our previous studies.

PATIENTS AND METHODS

Twenty patients with a total of 82 mycotic toenails were randomized to the treatment group (short-pulsed 1064-nm-Nd:YAG laser) or control group (no laser treatment). We conducted four laser treatments at 4- to 6-week intervals. In both groups, a local antimycotic agent was applied to the sole of the foot, the area between the toes and the skin directly surrounding the nails. The primary endpoint was complete remission of the onychomycosis after 12 months (fungal culture and histology); secondary endpoints included clinical improvement (Onychomycosis Severity Index, OSI) and the occurrence of pain or other adverse events.

RESULTS

Mycological remission was not achieved in either study group. A comparison of both groups yielded no difference in the OSI score, both at the beginning of the trial (P = 0.9873) and after 12 months (P = 0.4317). In the treatment group, the OSI score worsened by a mean 2.0 points, and in the control group, by a mean 3.5 points. On a visual analogue scale (0 = 'no pain' to 10 = 'most intense pain'), pain in the treatment group was indicated at a mean score of five. Other adverse events were not reported.

CONCLUSIONS

The short-pulsed 1064-nm-Nd:YAG laser shows no long-term efficacy as a monotherapy. Its role as an adjuvant therapy should be investigated in upcoming trials.

[The Concept of Typology in Psychiatry in the Context of Historical Contributions of Max Weber and Karl Jaspers]

Against the background of Max Weber's and Karl Jaspers' outstanding historical contributions to the conceptual development of different typologies, the importance of a psychiatric typology is examined. The term "ideal type" was introduced into social science by Weber as an analytical construct to describe and classify cultural phenomena. This concept was adopted for the psychiatric context by Jaspers who proposed to establish a typological system in the field of psychotic disturbances without an organic correlate. He emphasized the importance of the course of psychopathological symptoms for such a typological system. The concept of typology can be regarded as a promising heuristic approach in psychiatry, providing a classification system for complex psychopathological symptoms. Even though several historic typologies exist in psychopathology, their usefulness in the fields of therapy and prognosis needs to be critically assessed. Also, new typologies will have to be developed, taking into account neurobiological knowledge now available.

Effect of the stiffness of bone substitutes on the biomechanical behaviour of femur for core decompression

Core decompression is the most common procedure for treatment of the early stages of osteonecrosis of the femoral head. The purpose of this study was to compare the biomechanical performance of four different bone graft substitutes combined with core decompression. Subject-specific finite element models generated from computed tomography (CT) scan data were used for a comprehensive analysis. Two different contact conditions were simulated representing states of osseointegration at the interface. Our results showed that the use of a low-stiffness bone substitute did not increase the risk of femoral fracture in the early postoperative phase, but resulted in less micromotion and interfacial stresses than high-stiffness bone substitutes.

S3-Guideline non-traumatic adult femoral head necrosis

INTRODUCTION

The treatment of adult non-traumatic avascular necrosis of the femoral head (AVN; N-ANFH) within an estimated incidence of 5000-7000 cases per annum in Germany remains a challenge. Risk factors include steroids, alcohol abuse, chemotherapy and immunosuppressive medication, but a genetic predisposition has been suggested. Early diagnosis of this often bilateral disease process is essential for successful conservative or joint preserving surgical management. In this review, we present the update German consensus S3 guideline "diagnosis and management for N-ANFH" as a concise summary.

MATERIALS AND METHODS

This systematic review is based on the published literature from January 1, 1970 to April 31, 2013 (German and English language). Inclusion criteria were systematic reviews, meta-analyses and relevant peer review publications. We identified a total of 3715 related publications, of which 422 were suitable according to the SIGN criteria, but only 159 fulfilled our inclusion criteria.

RESULTS AND CONCLUSIONS

Clinical suspicion of N-ANFH mandates radiographic evaluation. If radiographs are normal MRI scans are recommended, which should be evaluated according to the ARCO-classification. Differential diagnoses include transient osteoporosis, bone bruise, insufficiency fracture and destructive arthropathy. Untreated, subchondral fractures commonly occur within 2 years, during which the risk for contralateral involvement is high-thereafter unlikely. Conservative management with Ilomedin and Alendronat can be tried, but other pharmacological or physical treatments are inappropriate. No specific joint preserving procedure can be recommended, but core decompression should be considered in early stages if necrosis is <30 %. In ARCO stages IIIc or IV total hip arthroplasty (THA) should be contemplated, which offers similar outcome compared to osteoarthritis. Young age is the main risk factor for higher revision rates after THA for N-ANFH.

[Psychiatry as a practical science : Considerations following Wolfgang Wieland (1933-2015)]

In the light of historical and modern criticism of the discipline of psychiatry and psychotherapy as a medical subspecialty, this paper deals with aspects of the theory of medicine as postulated by the physician and philosopher Wolfgang Wieland. According to his contributions medicine is a practical science aiming at establishing rational action. Central to this model is a diagnosis, which helps to subsume individual cases under general principles from which essential therapeutic options can be derived. Hence, psychiatry and psychotherapy become a medical subspecialty by adopting the basic model of medical reasoning and action as described by Wieland. Nevertheless, the limits of such an approach must be taken into consideration. Especially in a psychiatric and psychotherapeutic context it is of particular importance that even when being guided by general principles the responsibility for the personality of each individual patient should be adequately met. Furthermore, attention should be paid to the limits of the subspecialty of psychiatry and psychotherapy as a medical discipline, which also requires a critical analysis of the concept of psychiatric illness.