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Background: Diagnostic accuracy of periprosthetic joint infection still remains controversial and an unsolved problem with respect to clinical signs and laboratory measures. Influencing factors of diagnosis like age, sex, abnormal physical findings and comorbidities are published with different results. The aim of our study was to find factors strengthening the diagnosis., Methods: We therefore retrospectively investigated all revision surgeries of total knee arthroplasty and total hip arthroplasty in the years 2019 and 2020 in a tertiary hospital with special regard to diagnostic accuracy of periprosthetic joint infection and switch in diagnosis to aseptic mechanical loosening or vice versa. All patients were divided into 4 non-hierarchical groups: suspected and discharge diagnosis periprosthetic joint infection (P1), suspected and discharge diagnosis mechanical loosening (P2), suspected diagnosis mechanical loosening and discharge diagnosis periprosthetic joint infection (P3), suspected diagnosis PJI and discharge diagnosis mechanical loosening (P4)., Results: In the years 2019-2020, 106 patients underwent revision surgery of total knee arthoplasty and total hip arthroplasty. 33 patients showed periprosthetic joint infection (31.1%) according to Infectious Diseases Society (IDSA) criteria, 73 patients showed mechanical loosening (68.9%). Of the periprosthetic joint infection -patients, 15 were men (46%) and 18 were women (54%). The patients with mechanical loosening were 27 men (37%) and 46 women (63%). In group P1 (25 patients), 22 could be classified according to the histopathological classification Krenn and Morawietz grade 2 and grade 3, 2 patients to grade 4 and one patient could not be classified. In group P3 (8 patients) all could be classified according to the classification Krenn and Morawietz grade 2 and 3. Groups P1 - P4 were correlated with categorial basic data: All Groups P1 - P4 showed a statistical correlation towards American Society of Anesthesiologists (ASA) categorization 3-4 versus ASA 2 (p = 0.01). In the pairwise comparison in the exact Fisher´s exact test P1 and P2 showed a statistical correlation towards ASA categorization 3-4 versus ASA 2 (p = 0.01). Charlson Comorbidity Index (CCI) categories 5-7 versus 0,1-2 and 3-4 showed a statistical correlation towards groups P1-P4 (p = 0.007) and in the pairwise comparison in the exact Fisher´s exact test a discrimination of P1 and P2 (p = 0.001) and P1 and P3 (p = 0.007). The preoperative corticoid therapy showed a statistical correlation to groups P1-P4 (p = 0.05) and in the pairwise comparison in the exact Fisher test a discrimination of P1 and P4 (p = 0.02)., Conclusion: We therefore conclude that diagnosis of periprosthetic joint infection still remains difficult. Switches in diagnosis during hospital stay from periprosthetic joint infection to aseptic mechanical loosening and vice versa are not unusual and the role of different diagnostic tools needs further investigation. Patients categorized according to ASA and CCI as severely ill might be more likely to be diagnosed correctly with periprosthetic joint infection., Competing Interests: Declarations. Ethics approval and consent to participate: According to the statutes of the ETHICS COMMISSION OF THE MEDICAL FACULTY OF THE RUHR UNIVERSITY BOCHUM, the following applies: Retrospective studies are characterized by the fact that all data are already available at the time the study begins and are now being systematically evaluated. Since this is a retrospective study based on the files and without further examination or questioning of the patients, an ethics vote was not required and informed consent could not be obtained retrospectively. The work was according to the rules registered with the doctoral committee of the Ruhr University Bochum and no objections were raised by the doctoral committee. https://www.Ruhr-uni-bochum.de/ethik/antragsformulare . Ruhr-uni-bochum.de/ethik/antragsformulare – last accessed September 6, 2024) Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Purpose: Up to 20% of all patients are not satisfied with the result after total knee arthroplasty (TKA). To improve patient satisfaction manufacturers have modified prosthesis design. The ATTUNE prosthesis is a modified version of the PFC Sigma. Aim of this study was to evaluate the outcome at 6 months and 5 years after TKA with ATTUNE compared to PFC Sigma., Methods: Sixty patients were included prospectively (30 ATTUNE vs. 30 PFC Sigma). Knee Society Score and Hospital for Special Surgery Score were recorded preoperatively, at 6 months and at least 5 years postoperatively. At 5-years follow-up X-rays in two planes were evaluated, radiolucent lines were documented., Results: Patient characteristics were similar in both groups. Both ATTUNE and PFC Sigma provided good to excellent clinical results. There were no statistically significant differences based on the overall scores and patient rated outcome measures. Nevertheless, patients in the ATTUNE group tended to be symptom-free earlier and to achieve better clinical results after 5 years., Conclusion: Even with the scores not being significantly different here, the modified design of ATTUNE could increase long-term satisfaction with the implant and reduce the need for revision surgery. However, long-term results are required to prove this., (© 2022. The Author(s).)

Background: Heterotopic ossifications (HO) are a common complication after total hip arthroplasty (THA). Nonsteroidal anti-inflammatory drugs have proven to reduce the occurrence of HO. It is still unclear when the formation of HO is finished. Aim of our study was to answer this question., Methods: In a prospective study, the occurrence of periarticular HO was checked during the follow-up (FU) examinations. In total, 75 consecutive patients who underwent THA were included. To ensure a high follow-up rate, only patients with a life expectancy of at least 10 years were included. A medical ossification prophylaxis with mostly etoricoxib (90 mg once daily) was administered. Follow-up examinations were performed at 3 months, 1 year, 3, 5, and 10 years postoperatively. Each time, a clinical and radiological examination was carried out. The HO was graded according to Brooker's method., Results: Low-grade HO classified by Brooker grade I and II occurred significantly more frequent than HO grade III. In patients with present HO, a possible increase in Brooker stage could further be observed within 3 years postoperatively. After 3 years, the formation of HO was completed in all patients., Conclusion: Three years after THA, the formation of HO is complete. After more than 3 years postoperatively, if HO occurs or increases, other triggering causes such as new trauma, periarticular infection, or implant loosening should be considered., (© 2022. The Author(s).)

Background: Heterotopic ossifications are a common complication after total hip arthroplasty. Low-dose radiation therapy and non-steroidal anti-inflammatory drugs have proven to effectively reduce the rate of heterotopic ossification after total hip arthroplasty. However, a low number of studies describe an equal efficiency of etoricoxib. This work shows first results on the examination of a larger group with 194 subjects to analyze efficiency and rate of side effects under treatment with etoricoxib., Methods: Clinical examinations were performed the day before surgery and after at least 12 months. The survey of clinical and functional outcome was done with Harris Hip Score (HHS). Conventional antero-posterior radiographs and second plane in frog leg position were assessed., Results: In total, 14 undesirable side effects (7.4%) and only four early terminations of therapy (2.1%) were documented. A complete 1-year follow-up examination including radiographs could be done in 143 subjects (79.4%). Only 28 subjects (19.6%) developed heterotopic ossifications from which 92.9% were classified in type 1 and 7.1% in type 2 using the method described by Brooker. The results do not show correlations with body mass index, extended treatment (more than ten days), or clinical and functional outcome (measured by "Harris Hip Score"). However, male subjects show a significantly higher rate of heterotopic ossifications., Conclusions: The investigations presented in this study confirm a good efficiency of etoricoxib for the prevention of heterotopic ossifications in comparison with classical methods such as radiation or drug therapy and show a low rate of undesirable side effects.

Background: The Polarstem (Smith & Nephew, Baar, Switzerland) is a tapered straight stem, an implant with an excellent survival rate. Although the most recent annual report of the National Joint Registry in the United Kingdom also reports excellent survivorship for the cementless Polarstem, no prospective studies have been published focusing on both its efficacy and clinical performance. Therefore, the present study was designed to prospectively evaluate its functional and radiographic outcomes at midterm., Methods: This prospective observational study conducted at 3 independent orthopaedic hospitals was designed to collect data in patients undergoing cementless primary total hip arthroplasty (THA). A total of 225 total hip arthroplasties (75 at each site) were performed. The predominant diagnosis was primary osteoarthritis. Anteroposterior and lateral radiographs were obtained at each follow-up (3 months, and 1, 3, and 5 years). Survivorship and the Harris Hip Score (HHS) and Western Ontario and McMaster Universities Index (WOMAC) were calculated., Results: Subjects experienced statistically significant improvements from baseline in mean HHS (48.5 to 88.0, P < .01) and WOMAC scores (58.6 to 9.3, P < .01) at all intervals through 5 years. The stem survivorship was 99.6% at 5 years with stem revision due to any reason. There were no observed cases of mechanical failure of the stem or signs of radiographic loosening., Conclusions: A revision rate of the femoral stem for any reason of 0.4%, as well as good clinical results based on HHS and WOMAC scores, was noted at 5-year follow-up. Therefore, safety and efficacy of the cementless Polarstem at midterm follow-up is confirmed., (© 2020 The Authors.)

Objective: Most patients suffering with rheumatic diseases who undergo surgical treatment are receiving immune-modulating therapy. To determine whether these medications affect their outcomes a national registry was established in Germany by the German Society of Surgery (DGORh). Data from the first 1000 patients were used in a pilot study to identify relevant corisk factors and to determine whether such a registry is suitable for developing accurate and relevant recommendations., Design and Participants: Data were collected from patients undergoing surgical treatments with their written consent. A second consent form was used, if complications occurred. During this pilot study, in order to obtain a quicker overview, risk factors were considered only in patients with complications. Only descriptive statistical analysis was employed in this pilot study due to limited number of observed complications and inhomogeneous data regarding the surgery and the medications the patients received. Analytical statistics will be performed to confirm the results in a future outcome study., Results: Complications occurred in 26 patients and were distributed equally among the different types of surgeries. Twenty one of these patients were receiving immune-modulating therapy at the time, while five were not. Infections were observed in 2.3% of patients receiving and in 5.1% not receiving immunosuppression., Conclusions: Due to the low number of cases, inhomogeneity in the diseases and the treatments received by the patients in this pilot study, it is not possible to develop standardised best-practice recommendations to optimise their care. Based on this observation we conclude that in order to be suitable to develop accurate and relevant recommendations a national registry must include the most important and relevant variables that impact the care and outcomes of these patients., Competing Interests: Competing interests: TK: Pharmaceutical or medical device companies may be involved in some of the included studies; however, the details are unknown to the author. SR: Has received speaker fees from the companies Abbvie/Grünenthal/MSD/implantcast/medac. CB: Has received speaker fees from the companies Link and Abbot. The remaining authors declare no conflicts of interest., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: To demonstrate non-inferiority of lumiracoxib 400 mg once daily (o.d.) compared with indomethacin 50 mg three times daily (t.i.d.) in the treatment of acute gout, and to compare the safety and tolerability of these treatments., Methods: In this 1-week, multicentre, randomized, double-blind, double-dummy, active-controlled, parallel-group study, patients with a clinical diagnosis of gout, an acute attack of gout in four or more joints within the 48 h prior to evaluation, and at least moderate pain intensity in the target joint were randomized to treatment with lumiracoxib 400 mg o.d. (n = 118) or indomethacin 50 mg t.i.d. (n = 117). The primary efficacy endpoint was the mean change in pain intensity from baseline over days 2-5, assessed on a 5-point Likert scale, where non-inferiority could be claimed if the lower limit of the confidence interval (CI) was greater than -0.5. The patient's and physician's global assessment of response to treatment, and physician's assessment of tenderness, swelling and erythema of the study joint were also assessed., Results: The estimated difference between treatments for the change from baseline in pain intensity over days 2-5 was -0.004 (95% CI -0.207 to 0.199, P > 0.05), indicating that lumiracoxib 400 mg o.d. had comparable efficacy to indomethacin 50 mg t.i.d. for the primary efficacy variable. There was no significant difference between treatments in any of the secondary efficacy variables. Adverse events were reported by 10.2% of patients treated with lumiracoxib and 22.2% of those receiving indomethacin., Conclusions: Lumiracoxib is as effective as indomethacin for treatment of acute gout and may have a better safety and tolerability profile.

Objectives: To investigate the relative contribution of the cyclooxygenase (COX) isoenzymes COX-1 and COX-2 to prostaglandin E2 (PGE2) release from inflamed synovial tissue in N=10 patients with primary osteoarthritis (OA) in vitro and to determine possible effects of COX inhibitors on the gene expression of synovial COX-1 and COX-2., Design: The effects of a COX-unspecific nonsteroidal anti-inflammatory drug (NSAID; diclofenac), a selective COX-1 inhibitor (SC-560) and a selective COX-2 inhibitor (SC-58125) on PGE2 release from inflamed synovial tissue (0.1-10 microM, 3 and 6 h incubation time) were compared. Release of PGE2 into the incubation media was measured by means of the enzyme-linked immunosorbent assay. Expression of synovial COX-1/-2 was quantified by means of real-time reverse transcriptase polymerase chain reaction (RT-PCR)., Results: All agents inhibited synovial PGE2 release dose-dependently. Compared to short-term incubations, the inhibitory potency of diclofenac, SC-58125 and SC-560 was increased (0.1-10 microM) and decreased (0.1-1 microM), respectively, during 6 h: At 10 microM, SC-560 and SC-58125 had obviously lost their specificity for COX-1 and COX-2, respectively, indicated by a comparable inhibitory potency of the selective COX-1 inhibitor (86.6%) and the selective COX-2 inhibitor (96.6%) within identical tissue specimens. In contrast, at 1 microM, 83% and 62.8% inhibition was seen for diclofenac and SC-58125, respectively. SC-560 showed 30.6% inhibition (P<0.05). In contrast to synovial COX-1, RT-PCR revealed a significant induction of COX-2 through PGE2., Conclusions: With respect to the concentrations studied, the data suggest that in inflamed synovial tissue in OA, up to 30% of PGE2 might be generated via the COX-1 pathway. In therapy of OA, the relative contribution of COX-1 in synovial inflammation should be considered, weighing the potency of COX-unspecific NSAID against the assumed superior gastrointestinal safety profile of selective COX-2 inhibitors.

Between 1995 and 2000, we performed 45 endoscopic bursectomies in 42 patients (average age 51, range 17-61 years). All patients had at least 6 months of failed conservative treatment, and all responded positively to a sonographic-guided injection with Mepivacaine 0.5%. The bursa was removed using a synovial resector. An additional tractopexie was performed in four cases. We followed 37 patients for 12-48 months. Pre-operatively, the mean modified Japanese Orthopaedic Association (JOA) disability hip score was 40.5 points. It improved to 72.6 points after a mean of 25 months. Severe complications did not occur. The minimally invasive technique requires only stab incisions, and immobilisation and hospitalisation are minimal.

Fifty patients with impingement syndrome refractory to long-term conservative treatment were randomized to three treatment groups. All patients received an injection of 10 ml 0.5% bupivacaine, in group 1 without corticosteroid, in group 2 with crystalline corticosteroid and in group 3 with lipoid corticosteroid. Treatment in group 1 had to be stopped because of inefficacy. In groups 2 and 3 favorable results were achieved in 19 out of 40 patients.

Our aim was to determine the amounts of eicosanoids in blood and synovial tissue of patients with knee arthrosis and to examine the effects of 2 doses of tepoxalin (50 mg twice, 200 mg twice), administered p.o. for 3.5 days. Concentrations of leukotriene B4 (LTB4, LTC4, and thromboxane B2 (TXB2) were measured in blood before and after oral administration of tepoxalin and release of prostaglandin E2 (PGE2), 6-keto-PGF1alpha, and LTC4 was measured in incubation media of synovial tissue, taken at surgery from patients treated with tepoxalin. Radioimmunoassay (RIA) was used to determine the levels of the eicosanoids. LT and TXB2 release was reduced by tepoxalin in both doses used. Under these conditions, PGE2, 6-keto-PGF1alpha, and LTC4 release from synovial tissue was detectable only after stimulation with calcium ionophore A23187. Washed synovial tissue, in which tepoxalin concentrations should be reduced, released higher amounts of all eicosanoids measured than directly incubated synovial tissue did. Pain after tepoxalin administration was significantly reduced. Relevant drug concentrations were detected in plasma and synovial fluid. Tepoxalin was well tolerated and had no marked adverse effects. At 400 mg, tepoxalin is a dual inhibitor of cyclooxygenase (CO) and 5-lipoxygenase (5-LO) in blood and synovial tissue.

Fifty-four consecutive patients were studied prospectively with magnetic resonance imaging before microdiscectomy, and the findings correlated with clinical symptoms before and after operation. A sequestrated fragment was found in 59% of cases, a subligamentous disc sequestration in 25% and a disc protrusion in 16%. The levels operated on were L4/5-36%, L5/S1-62.5%, and one at L3/4; 71% were laterally placed, 10% lay intraforaminal and 10% medial. The diameter of the protrusion was 4 mm to 13 mm for the craniocaudal extension, and 5 mm to 18 mm for the anteroposterior extension. No correlation could be found between a neurological deficit and the size of the prolapse. A positive correlation was present between the increasing degree of canal obstruction and the degree of disc degeneration determined by imaging for extrusions, subligamentous disc sequestrations and free sequestrations. Nerve root inflammation and enlargement was seen in 36% of the images, corresponding to an operative finding of 32%. Magnetic resonance imaging is a helpful pre-operative diagnostic investigation which shows structural changes in the disc and the correct localisation and size of the disc sequestration, but there was no correlation between the imaging findings and the clinical symptoms.

Objective: To determine the major source of eicosanoid release in arthritic joint tissues and to examine the modulation of this release by indomethacin and diclofenac., Methods: Release of prostaglandin E2 (PGE2), 6-keto-PGF1 alpha, leukotriene B4 (LTB4), and LTC4 was measured in supernatants of synovial tissue, cartilage, and bone incubates from patients with osteoarthritis, active rheumatoid arthritis (RA), inactive RA, and pseudogout. Radioimmunoassay (RIA) was used to determine the levels of the eicosanoids., Results: Addition of the divalent cation ionophore A23187 resulted in significant release of all eicosanoids measured from synovial tissue, but not from cartilage, cortical bone, or cancellous bone. PG release was significantly inhibited by the addition of indomethacin or diclofenac at either 10(-5) moles/liter or 10(-7) moles/liter. The amount of LTC4 released from cartilage and bone was only slightly above the detection limit of the RIA, whereas large amounts were released from synovial tissue. Neither indomethacin nor diclofenac had an effect on LTC4 release. LTC4 release from synovial tissue of patients with inactive RA was significantly decreased in comparison with the levels from synovial tissue of patients with the other joint diseases. There was no significant difference in PG release among patients in the various disease groups., Conclusion: Synovial tissue appears to be the major source of eicosanoids in synovial fluid. Indomethacin and diclofenac inhibit the release of PG, but not LT, from various joint tissues.