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Background: This study evaluated the osseointegration potential of functionalised high-performance oxide ceramics (HPOC) in isolation or coated with BMP-2 or RGD peptides in 36 New Zeeland female rabbits using micro-computed tomography (micro CT). The primary outcomes of interest were to assess the amount of ossification evaluating the improvement in the bone volume/ total volume (BV/TV) ratio and trabecular thickness at 6 and 12 weeks. The second outcome of interest was to investigate possible differences in osteointegration between the functionalised silanised HPOC in isolation or coated with Bone Morphogenetic Protein 2 (BMP-2) or RGD peptides., Methods: 36 adult female New Zealand white rabbits with a minimum weight of three kg were used. One-third of HPOCs were functionalised with silicon suboxide (SiOx), a third with BMP-2 (sHPOC-BMP2), and another third with RGD (sHPOC-RGD). All samples were scanned with a high-resolution micro CT (U-CTHR, MILabs B.V., Houten, The Netherlands) with a reconstructed voxel resolution of 10 µm. MicroCT scans were reconstructed in three planes and processed using Imalytics Preclinical version 2.1 (Gremse-IT GmbH, Aachen, Germany) software. The total volume (TV), bone volume (BV) and ratio BV/TV were calculated within the coating area., Results: BV/TV increased significantly from 6 to 12 weeks in all HPOCs: silanised (P = 0.01), BMP-2 (P < 0.0001), and RGD (P < 0.0001) groups. At 12 weeks, the BMP-2 groups demonstrated greater ossification in the RGD (P < 0.0001) and silanised (P = 0.008) groups. Trabecular thickness increased significantly from 6 to 12 weeks (P < 0.0001). At 12 weeks, BMP-2 promoted greater trabecular thickness compared to the silanised group (P = 0.07), although no difference was found with the RGD (P = 0.1) group., Conclusion: Sinalised HPOC in isolation or functionalised with BMP-2 or RGD promotes in vivo osteointegration. The sinalised HOPC functionalised with BMP-2 demonstrated the greatest osseointegration., (© 2024. The Author(s).)

Background: Neurological gait disorders are mainly classified based on clinical observation, and therefore difficult to objectify or quantify. Movement analysis systems provide objective parameters, which may increase diagnostic accuracy and may aid in monitoring the disease course. Despite the increasing wealth of kinematic movement and balance parameter data, the discriminative value for the differentiation of neurological gait disorders is still unclear. We hypothesized that kinematic motion and balance parameter metrics would be differently altered across neurological gait disorders when compared to healthy controls., Methods: Thirty one patients (9 normal pressure hydrocephalus < NPH > , 16 cervical myelopathy < CM > , 6 lumbar stenosis < LST >) and 14 healthy participants were investigated preoperatively in an outpatient setting using an inertial measurement system (MyoMotion) during 3 different walking tasks (normal walking, dual-task walking with simultaneous backward counting, fast walking). In addition, the natural postural sway of participants was measured by pedobarography, with the eyes opened and closed. The range of motion (ROM) in different joint angles, stride time, as well as sway were compared between different groups (between-subject factor), and different task conditions (within-subject factor) by a mixed model ANOVA., Results: Kinematic metrics and balance parameters were differently altered across different gait disorders compared to healthy controls. Overall, NPH patients significantly differed from controls in all movement parameters except for stride time, while they differed in balance parameters only with regard to AP movement. LST patients had significantly reduced ROMs of the shoulders, hips, and ankles, with significantly altered balance parameters regarding AP movement and passed center-of-pressure (COP) distance. CM patients differed from controls only in the ROM of the hip and ankle, but were affected in nearly all balance parameters, except for force distribution., Conclusion: The application of inertial measurement systems and pedobarography is feasible in an outpatient setting in patients with different neurological gait disorders. Rather than defining singular discriminative values, kinematic gait and balance metrics may provide characteristic profiles of movement parameter alterations in the sense of specific ´gait signatures´ for different pathologies, which could improve diagnostic accuracy by defining objective and quantifiable measures for the discrimination of different neurological gait disorders., Trial Registration: The study was retrospectively registered on the 27th of March 2023 in the 'Deutsches Register für Klinische Studien' under the number DRKS00031555., (© 2024. The Author(s).)

Introduction: The management of periprosthetic joint infections (PJI) of the lower limb is challenging, and evidence-based recommendations are lacking. The present clinical investigation characterized the pathogens diagnosed in patients who underwent revision surgery for  PJI of total hip arthroplasty (THA) and total knee arthroplasty (TKA)., Methods: The present study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The institutional databases of the RWTH University Medical Centre of Aachen, Germany, were accessed. The OPS (operation and procedure codes) 5-823 and 5-821 and the ICD (International Statistical Classification of Diseases and Related Health Problems) codes T84.5, T84.7 or T84.8 were used. All patients with PJI of a previous THA and TKA who underwent revision surgery were retrieved and included for analysis., Results: Data from 346 patients were collected (181 THAs and 165 TKAs). 44% (152 of 346 patients) were women. Overall, the mean age at operation was 67.8 years, and the mean BMI was 29.2 kg/m2. The mean hospitalization length was 23.5 days. 38% (132 of 346) of patients presented a recurrent infection., Conclusion: PJI remain a frequent cause for revisions after total hip and knee arthroplasty. Preoperative synovial fluid aspiration was positive in 37%, intraoperative microbiology was positive in 85%, and bacteraemia was present in 17% of patients. Septic shock was the major cause of in-hospital mortality. The most common cultured pathogens were Staph. epidermidis, Staph. aureus, Enterococcus faecalis, and Methicillin-resistant Staph aureus (MRSA). An improved understanding of PJI pathogens is important to plan treatment strategies and guide the choice of empirical antibiotic regimens in patients presenting with septic THAs and TKAs., Level of Evidence: Level III, retrospective cohort study., (© 2023. The Author(s).)

Background: This in vitro study investigated the osseointegration and implant integration of high performance oxide ceramics (HPOC) compared to titanium implants in rabbits., Methods: Histomorphometry was conducted around the distal, proximal, medial, and lateral aspects of the HPOC to quantify the amount of mature and immature ossification within the bone interface. Histomorphometry was conducted by a trained musculoskeletal pathologist. The region of interest (ROI) represented the percentage of surrounding area of the implant. The percentage of ROI covered by osteoid implant contact (OIC) and mature bone implant contact (BIC) were assessed. The surrounding presence of bone resorption, necrosis, and/or inflammation were quantitatively investigated., Results: All 34 rabbits survived the 6- and 12-week experimental period. All HPOC implants remained in situ. The mean weight difference from baseline was + 647.7 mg (P < 0.0001). The overall OIC of the ceramic group was greater at 6 weeks compared to the titanium implants (P = 0.003). The other endpoints of interest were similar between the two implants at all follow-up points. No difference was found in BIC at 6- and 12-weeks follow-up. No bone necrosis, resorption, or inflammation were observed., Conclusion: HPOC implants demonstrated a greater osteoid implant contact at 6 weeks compared to the titanium implants, with no difference found at 12 weeks. The percentage of bone implant contact of HPOC implants was similar to that promoted by titanium implants., (© 2023. The Author(s).)

Introduction: Potential advantages of the Extreme Lateral Interbody Fusion (XLIF) approach are smaller incisions, preserving anterior and posterior longitudinal ligaments, lower blood loss, shorter operative time, avoiding vascular and visceral complications, and shorter length of stay. We hypothesize that not every patient can be safely treated at the L4/5 level using the XLIF approach. The objective of this study was to radiographically (CT-scan) evaluate the accessibility of the L4/5 level using a lateral approach, considering defined safe working zones and taking into account the anatomy of the superior iliac crest., Methods: Hundred CT examinations of 34 female and 66 male patients were retrospectively evaluated. Disc height, lower vertebral endplate (sagittal and transversal), and psoas muscle diameter were quantified. Accessibility to intervertebral space L4/5 was investigated by simulating instrumentation in the transverse and sagittal planes using defined safe zones., Results: The endplate L5 in the frontal plane considering defined safe zones in the sagittal and transverse plane (Zone IV) could be reached in 85 patients from the right and in 83 from the left side. Through psoas split, the safe zone could be reached through psoas zone II in 82 patients from the right and 91 patients from the left side. Access through psoas zone III could be performed in 28 patients from the right and 32 patients from the left side. Safe access and sufficient instrumentation of L4/5 through an extreme lateral approach could be performed in 76 patients of patients from the right and 70 patients from the left side., Conclusion: XLIF is not possible and safe in every patient at the L4/5 level. The angle of access for instrumentation, access of the intervertebral disc space, and accessibility of the safe zone should be taken into account. Preoperative imaging planning is important to identify patients who are not suitable for this procedure., (© 2022. The Author(s).)

Background: Leg length inequalities are a frequent condition in every population. It is common clinical practice to consider LLIs of 2 cm and more as relevant and to treat those. However, the amount of LLIs that need treatment is not clearly defined in literature and the effect of real LLIs on the musculoskeletal system above and below 2 cm have not been studied biomechanically before., Methods: By using surface topography, we evaluated 32 patients (10 females, 22 male) with real LLIs of ≥ 2 cm (mean: 2.72 cm; n = 10) and compared their pelvic position and spinal posture to patients with LLIs < 2 cm (mean: 1.24 cm; n = 22) while standing and walking. All patients were measured with a surface topography system during standing and while walking on a treadmill. To compare patient groups, we used Student t-tests for independent samples., Results: Pelvic obliquity was significantly higher in patients with LLI ≥ 2 cm during the standing trial (p = 0.045) and during the midstance phase of the longer leg (p = 0.023) while walking. Further measurements did not reveal any significant differences (p = 0.06-0.706)., Conclusions: The results of our study suggest that relevant LLIs of ≥ 2 cm mostly affect pelvic obliquity and do not lead to significant alterations in the spinal posture during a standing trial. Additionally, we demonstrated that LLIs are better compensated when walking, showing almost no significant differences in pelvic and spinal posture between patients with LLIs smaller and greater than 2 cm. This study shows that LLIs ≥ 2 cm can still be compensated; however, we do not know if the compensation mechanisms may lead to long-term clinical pathologies., (© 2022. The Author(s).)

Background: Symmetry is a sign of physiological and healthy movements, as pathologies are often described by increased asymmetries. Nevertheless, based on precisely measured data, even healthy individuals will show small asymmetries in their movements. However, so far there do not exist commonly accepted methods and reference values for gait symmetry in a healthy collective. Therefore, a comparison and presentation of reference values calculated by 3 different methods of symmetry indices for lower limb joint angles during walking, ascending, and descending stairs were shown., Methods: Thirty-five healthy participants were analyzed during walking, ascending, and descending stairs with the help of the inertial measurement system MyoMotion. Using the normalized symmetry index (SI norm ), the symmetry index (SI) as the integral of the symmetry function, and another normalized symmetry index (NSI), the symmetry of joint angles was evaluated. For statistical evaluation of differences, repeated measurement models and Bland-Altman-Plots were used., Results: Apart from a bias between the symmetry indices, they were comparable in the predefined limits of 5%. For all parameters, significantly higher asymmetry was found for ankle dorsi/-plantarflexion, compared with the hip and knee flexion. Moreover, the interaction effect of the joint and movement factors was significant, with an increased asymmetry of the hip and knee during descending stairs greater than while ascending stairs or walking, but a reduced symmetry of the ankle during walking when compared to descending. The movement only showed significant effects when analyzing the SI norm ., Conclusion: Even for healthy individuals, small asymmetries of movements were found and presented as reference values using 3 different symmetry indices for dynamic lower limb joint angles during 3 different movements. For the quantification of symmetrical movements differences between the joints, movements, and especially their interaction, are necessary to be taken into account. Moreover, a bias between the methods should be noted. The potential for each presented symmetry index to identify pathological movements or track a rehabilitation process was shown but has to be proven in further research., Trial Registration: DRKS00025878., (© 2021. The Author(s).)

Background: Osteoporosis affects mostly postmenopausal women, leading to deterioration of the microarchitectural bone structure and low bone mass, with an increased fracture risk with associated disability, morbidity and mortality. This Bayesian network meta-analysis compared the effects of current anti-osteoporosis drugs on bone mineral density., Methods: The present systematic review and network meta-analysis follows the PRISMA extension statement to report systematic reviews incorporating network meta-analyses of health care interventions. The literature search was performed in June 2021. All randomised clinical trials that have investigated the effects of two or more drug treatments on BMD for postmenopausal osteoporosis were accessed. The network comparisons were performed through the STATA Software/MP routine for Bayesian hierarchical random-effects model analysis. The inverse variance method with standardised mean difference (SMD) was used for analysis., Results: Data from 64 RCTs involving 82,732 patients were retrieved. The mean follow-up was 29.7 ± 19.6 months. Denosumab resulted in a higher spine BMD (SMD -0.220; SE 3.379), followed by pamidronate (SMD -5.662; SE 2.635) and zoledronate (SMD -10.701; SE 2.871). Denosumab resulted in a higher hip BMD (SMD -0.256; SE 3.184), followed by alendronate (SMD -17.032; SE 3.191) and ibandronate (SMD -17.250; SE 2.264). Denosumab resulted in a higher femur BMD (SMD 0.097; SE 2.091), followed by alendronate (SMD -16.030; SE 1.702) and ibandronate (SMD -17.000; SE 1.679)., Conclusion: Denosumab results in higher spine BMD in selected women with postmenopausal osteoporosis. Denosumab had the highest influence on hip and femur BMD., Level of Evidence: Level I, Bayesian network meta-analysis of RCTs., (© 2021. The Author(s).)

Background: Leg length inequalities (LLI) are a common condition that can be associated with detrimental effects like low back pain and osteoarthritis. Inertial measurement units (IMUs) offer the chance to analyze daily activities outside a laboratory. Analyzing the kinematic effects of (simulated) LLI on the musculoskeletal apparatus using IMUs will show their potentiality to improve the comprehension of LLI., Methods: Twenty healthy participants with simulated LLI of 0-4 cm were analyzed while walking with an inertial sensor system (MyoMotion). Statistical evaluation of the peak anatomical angles of the spine and legs were performed using repeated measurement (RM) ANOVA or their non-parametric test versions (Friedman test)., Results: Lumbar lateral flexion and pelvic obliquity increased during the stance phase of the elongated leg and decreased during its swing phase. The longer limb was functionally shortened by higher hip and knee flexion, higher hip adduction, dorsiflexion, and lower ankle adduction. Finally, the shorter leg was lengthened by higher hip and knee extension, hip abduction, ankle plantarflexion, and decreased hip adduction., Conclusion: We found differing compensation strategies between the different joints, movement planes, gait phases, and amounts of inequality. Overall the shorter leg is lengthened and the longer leg is shortened during walking, to retain the upright posture of the trunk. IMUs were helpful and precise in the detection of anatomical joint angles and for the analysis of the effects of LLI.

Background: We provide a meta-analysis for clinicians and researchers regarding the psychometric properties of the WOMET as a patient-reported outcome measure (PROM) for patients with meniscal pathologies., Methods: A comprehensive literature search identified 6 eligible papers evaluating WOMET measurement properties in patients with different meniscal injuries and meniscal treatments following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The quality of the included studies was evaluated using the four-point Consensus-based Standard for the selection of health Measurement Instruments (COSMIN) Checklist for good measurement properties. The checklist was specifically developed for studies on health-related PROMs., Results: Our meta-analysis suggests that the WOMET can be used to evaluate patients with different meniscal injuries and meniscal treatments, especially acute or chronic meniscal injuries and traumatic or degenerative meniscal injuries treated operatively or conservatively. The WOMET shows satisfactory internal consistency, test-retest reliability, and construct validity. Due to limitations in both sample sizes and methodologies of the included studies, no conclusions can be drawn regarding the WOMET's content validity, structure validity, cross-cultural validity, measurement error, or responsiveness. A further limitation of the studies included in this meta-analysis is the lack of cross-cultural validation, although recommended by the COSMIN Standards., Conclusions: The first meta-analysis on measurement properties of the WOMET demonstrates satisfactory internal consistency, test-retest reliability, and construct validity. Further studies are needed, focusing on the methodological deficiencies highlighted in this meta-analysis. To ensure that the WOMET adequately reflects the symptoms, functions, and quality of life of patients with meniscal tears based on COSMIN criteria, it is necessary to assess the structural validity and content validity of this PROM.

Background: Almost all epidemiological studies over the past 40 years have determined that the incidence of fragility fractures is increasing. Therefore, the assessment of postural stability and monitoring any progress during balance training for geriatric patients to prevent falls are becoming more important. The Nintendo ® Wii Fit Balance Board, with its integrated software and scoring system, might be a cheap and easily accessible tool for this purpose., Methods: This prospective study analyzed the diagnostic value of the Wii Fit Balance Board in 41 healthy subjects using two measurements: the yoga task "tree," which is performed in one-leg stance; and the balance game "table tilt." Our investigation compared these tasks to two established, regularly used systems, the MFT-S3 Check and the Posturomed, by looking for correlation and agreement, using Bland-Altman plots, as well as for differences to demographic data. All measurement tools were also compared to the Sensory Organization Test-the gold standard for detecting impaired balance., Results: We found a moderate correlation between the yoga exercise "tree" and the Sensory Organization Test (correlation coefficient r = 0.514, p = 0.001) as well as the MFT-S3 Check (r = 0.356-0.472, p = 0.002-0.022) and the Posturomed (r = 0.345, p = 0.027). However, results from the balance game "table tilt" did not show a significant correlation with those of the systems to which we compared it (p = 0.301-0.953)., Conclusions: According to the literature, the raw data from the Wii Fit Balance Board are comparable to that obtained by laboratory-grade force platforms. We have found, however, that the yoga pose "tree," as integrated into the Nintendo ® Wii Fit Balance Board with its own scoring system, also correlates with the gold-standard Sensory Organization Test. It also correlates with two frequently used diagnostic and therapeutic devices. We, therefore, conclude that the Wii Fit Balance Board is suitable for the evaluation of postural stability and may be useful in preventing falls among the geriatric population., Level of Evidence: 2b.

Background: Until recently, rasterstereographic analysis of the spine was limited to static measurements. However, understanding and evaluating the motion of the spine under dynamic conditions is an important factor in the diagnosis and treatment of spinal pathologies. The aim of this study was to study the spinal posture and pelvic position under dynamic conditions and compare it to static measurements using a dynamic rasterstereographic system., Methods: A total of 121 healthy volunteers (56 females; 65 males) were included in this observational study. The parameters trunk inclination, trunk imbalance, pelvic obliquity, kyphotic angle, lordotic angle, surface rotation, and lateral deviation were studied and compared under static and dynamic (1, 2, 4, 5 km/h) conditions using the system "Formetric 4D Motion®" (DIERS International GmbH, Germany)., Results: Female volunteers had a higher lordotic angle than males under static conditions (p < 0.001). Trunk inclination (5.31° vs. 6.74°), vertebral kyphotic angle (42.53° vs. 39, 59°), and surface rotation (3.35° vs. 3.81°) increase under dynamic conditions (p < 0.001). Trunk inclination and lordotic angle both show significant changes during walking compared to static conditions (p < 0.001)., Conclusion: The spinal posture differs between females and males during standing and during walking. Rasterstereography is a valuable tool for the dynamic evaluation of spinal posture and pelvic position, which can also be used to quantify motion in the spine and therefore it has the potential to improve the understanding and treatment of spinal pathologies., Trial Registration: Retrospectively registered.

Introduction: Systemic capillary leak syndrome is a rare and life threatening disease characterized by periodic episodes of hypovolemic shock due to leakage of plasma from the intravascular to the extravascular space. It is associated with hemoconcentration, hypoalbuminemia, and generalized edema. We report the case of a patient with idiopathic systemic capillary leak syndrome who developed an unexpected and potentially fatal abdominal and four-limb compartment syndrome. This was successfully treated with fasciotomies and medical treatment including terbutaline, theophylline, and corticosteroids. To the best of our knowledge this is the first report of this kind in the literature., Case Presentation: A previously healthy 54-year-old Caucasian man presented to the emergency department of our internal medicine ward with a medical history of aggravation of general health related to dizziness, weight gain, and two syncopal attacks. Due to a massive emission of fluids and proteins from the intravascular to the extracellular compartments, he developed compartment syndromes in his upper and lower limbs and the abdominal compartment. The abdomen and all four limbs required decompression by a fasciotomy of both forearms, both thighs, both lower legs, and the abdomen within 24 hours after admission. After 60 days of treatment he was dismissed from the clinic. He was able to return to his previous occupation and reached the same level of athletic activity as before the illness., Conclusions: Systemic capillary leak syndrome is a very rare disease that can lead to a fatal clinical outcome. It is important to be aware of the fatal complications that can be caused by this disease. Despite the fact that systemic capillary leak syndrome represents a very rare disease it is still important to be aware of life threatening complications, like compartment syndromes, which need surgical intervention. However, early diagnosis and interdisciplinary treatment can lead to a good clinical outcome.

Objective: Modified anterior tension wiring with K-wires and cannulated lag screws with anterior tension wiring are currently the fixation of choice for patellar fractures. Failure of fixation, migration of the wires, postoperative pain and resulting revision surgery, however, are not uncommon. After preliminary biomechanical testing of a new fixed-angle plate system especially designed for fixation of patella fractures the aim of this study was to evaluate the surgical and anatomical feasibility of implanting such a plate-device at the human patella., Methods: In six fresh unfixed female cadavers without history of previous fractures around the knee (average age 88.8 years) a bilateral fixed-angle plate fixation of the patella was carried out after previous placement of a transverse central osteotomy. Operative time, intraoperative problems, degree of retropatellar arthritis (following Outerbridge), quality of reduction and existence of any intraarticular screw placement have been raised. In addition, lateral and anteroposterior radiographs of all specimens were made., Results: Due to the high average age of 88.8 years no patella showed an unimpaired retropatellar articular surface and all were severely osteoporotic, which made a secure fixation of the reduction forceps during surgery difficult. The operation time averaged 49 minutes (range: 36-65). Although in postoperative X-rays the fracture gap between the fragments was still visible, the analysis of the retropatellar surface showed no residual articular step or dehiscence > 0.5 mm. Also in a total of 24 inserted screws not one intraarticular malposition was found. No intraoperative complications were noticed., Conclusions: Osteosynthesis of a medial third patella fracture with a bilateral fixed-angle plate-device is surgically and anatomically feasible without difficulties. Further studies have to depict whether the bilateral fixed-angle plate-osteosynthesis of the patella displays advantages over the established operative procedures.