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Introduction Enhanced recovery after surgery (ERAS) leads to less morbidity, faster recovery, and, therefore, shorter hospital stays. The expected increment of primary total hip arthroplasty (THA) in the U.S. highlights the need for sufficient pain management. The favorable use of short-lasting spinal anesthesia enables early mobilization but may lead to increased opioid consumption the first 24 h (h) postoperatively. Methods In a retrospective study design, we compared conventional THA with postoperative immobilization for two days (non-ERAS) and enhanced recovery THA with early mobilization (ERAS group). Data assessment took place as part of the “Quality Improvement in Postoperative Pain Treatment project” (QUIPS). Initially, 2161 patients were enrolled, resulting in 630 after performing a matched pair analysis for sex, age, ASA score (American-Society-of-Anesthesiology) and preoperative pain score. Patient-reported pain scores, objectified by a numerical rating scale (NRS), opioid consumption and side effects were evaluated 24 h postoperatively. Results The ERAS group revealed higher activity-related pain (p = 0.002), accompanied by significantly higher opioid consumption (p p > 0.05). Conclusion This study is the first to analyze pain scores, opioid consumption, and side effects in a matched pair analyses at this early stage and supports the implementation of an ERAS concept for THA. Taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Although opioid consumption appeared to be higher in ERAS group, occurrence of side effects ranged among comparable percentages.

Treatment of coccygodynia is still a challenging entity. Clear surgical selection criteria are still lacking. The aim of the investigation was to establish a novel radiological classification for surgical decision-making in coccygodynia cases. Retrospective analysis of standing and sitting X-rays of coccygodynia patients referred to a single centre from 2018 to 2020. The sacro-coccygeal angle (SCA), the intra-coccygeal angle (ICA) and the difference of the intervertebral disc height (∆IDH) were measured. All coccyges were distributed in subtypes and correlated with the patients’ treatment. In total, 138 patients (female/male: 103/35) with a mean age of 45.6 ± 15.4 years were included in the study. In total, 49 patients underwent coccygectomy. Four different subtypes of displaced coccyges were identified: Type I with a non-segmented coccyx, anterior pivot, increased SCA and ICA from standing to sitting, ∆IDH = 1.0 ± 1.5 mm. Type II with a multisegmented coccyx, anterior pivot, increased SCA and ICA standing/sitting, ∆IDH = 1.1 ± 1.6 mm. Type III showed a posterior pivoted coccyx, negative SCA and ICA, ∆IDH = 0.6 ± 1.6 mm. Type IV is characterized by an anterior–posterior dissociation of the tail bone with a positive SCA, and the ICA shifted from a posterior to an anterior orientation. ∆IDH was − 0.6 ± 1.8 mm. The presented radiological classification could help to facilitate the surgical decision-making for patients with displaced os coccyx. In addition, lateral and sitting X-rays were easy to perform and did not need unnecessary ionizing radiation like in CT scans and were more cost-effective than MRI investigations. The subtypes III and especially IV were more likely leading to surgery.

The aim of the present work is an overview of current concepts in the treatment of osteoporotic vertebral fractures, risk factors, clinical presentation and conservative and operative management. Osteoporotic vertebral fractures are a widespread problem, affecting between 700,000 and 1.5 million adults annually in the USA alone. Osteoporotic vertebral fractures can cause severe physical impairment, including back pain, dysfunction, and progressive thoracic kyphosis. Mortality after osteoporotic vertebral fractures is still increased compared to age-matched controls. In the reality of care, advocates of purely conservative therapy as well as advocates of surgical treatment can be found all over the world. In summary, understanding the risk factors, appropriate clinical evaluation and treatment strategies are crucial. When surgery is indicated, balloon kyphoplasty shows significantly better pain reduction and lower mortality compared to nonsurgical treatment.Ziel der vorliegenden Arbeit ist ein Überblick über aktuelle Konzepte in der Behandlung von osteoporotischen Wirbelkörperfrakturen, über Risikofaktoren, über das klinische Erscheinungsbild und das konservative und operative Management. Osteoporotische Wirbelkörperfrakturen sind ein weit verbreitetes Problem, allein in den USA sind jährlich zwischen 700.000 und 1,5 Mio. Erwachsene betroffen. Osteoporotische Wirbelkörperfrakturen können schwere körperliche Einschränkungen verursachen, einschließlich Rückenschmerzen, Funktionsstörungen und fortschreitender Kyphose der Brustwirbelsäule. Immer noch ist die Sterblichkeit nach osteoporotischen Wirbelkörperfrakturen im Vergleich zu gleichaltrigen Kontrollen erhöht. In der Versorgungsrealität über den Erdball verteilt finden sich die Verfechter der rein konservativen Therapie genauso wie die Befürworter der operativen Behandlung. Zusammenfassend kann man sagen, dass das Verständnis der Risikofaktoren, eine angemessene klinische Bewertung und Behandlungsstrategien von entscheidender Bedeutung sind. Wenn eine Operation indiziert ist, dann zeigt die Ballonkyphoplastie im Vergleich zur nichtchirurgischen Behandlung eine signifikant bessere Schmerzreduktion und eine niedrigere Sterblichkeit.

One of the most frequently underestimated symptoms in orthopedic practices is coccygodynia. The clinical picture of coccygodynia was first described in 1859. Nevertheless, discussions about the importance of coccygeal problems remain a controversial topic. All patients have in common that they have gone through a long ordeal with many therapists, examinations and therapeutic approaches without having received a real diagnosis. The main symptom of coccygodynia is pain directly on the lowest segment of the coccyx, which often only occurs when sitting and is intensified by a change in position, usually from a sitting to a standing position. Trauma can only be described as the trigger in 50% of cases. Women are four times more likely to be affected than men. The gold standard for imaging should be viewed from standing and seated dynamic lateral radiographs of the coccyx. After the diagnosis has been made, conservative treatment should first be started with oral nonsteroidal anti-inflammatory drugs (NSAID), relief with a coccyx cushion with a recess and, if necessary, physiotherapy to strengthen or loosen the pelvic floor. Local infiltration with a glucocorticoid and a local anesthetic directly in the painful area are also often promising. If the symptoms persist for more than 6 months, surgical treatment in the sense of removing the coccyx can be discussed with the patient. The literature shows a success rate of 80-90% if the indications are correct.Eines der am häufigsten unterschätzten Krankheitsbilder in orthopädischen Praxen ist die Kokzygodynie. Das Krankheitsbild der Kokzygodynie wurde erstmals 1859 beschrieben. Dennoch bleiben Diskussionen über den Stellenwert der Steißbeinbeschwerden ein kontroverses Thema. Allen Patienten ist gemeinsam, dass sie einen langen Leidensweg mit vielen Behandlern, Untersuchungen und Therapieansätzen hinter sich haben, ohne eine wirkliche Diagnose gestellt bekommen zu haben. Das Leitsymptom der Kokzygodynie ist der Schmerz direkt am untersten Segment des Steißbeins, der häufig nur beim Sitzen auftritt und durch den Lagewechsel – meist von sitzender in die stehende Position – verstärkt wird. Als Auslöser kann nur in 50 % der Fälle ein Trauma beschrieben werden. Frauen sind 4‑mal häufiger betroffen als Männer. Als Goldstandard für die Bildgebung sollten dynamische, seitliche Röntgenbilder des Steißbeins im Stehen und im Sitzen angesehen werden. Nach Diagnosestellung sollte zunächst die konservative Therapie mittels oraler NSAR(nichtsteroidales Antirheumatikum)-Einnahme, Entlastung durch ein Steißbeinkissen mit Aussparung und ggf. Krankengymnastik zur Stärkung oder auch Lockerung des Beckenbodens begonnen werden. Auch lokale Infiltrationen mit einem Glukokortikoid und Lokalanästhetikum direkt im schmerzhaften Bereich sind häufig vielversprechend. Bei Beschwerdepersistenz mehr als 6 Monate kann die operative Therapie im Sinne der Entfernung des Steißbeins mit den Betroffenen besprochen werden. Die Literatur zeigt bei richtiger Indikationsstellung eine Erfolgsquote von 80–90 %.

Unicompartmental knee arthroplasty and total knee arthroplasty are well established treatment options for end-stage osteoarthritis, UKA still remains infrequently used if you take all knee arthroplasties into account. An important factor following knee arthroplasty is pain control in the perioperative experience, as high postoperative pain level is associated with persistent postsurgical pain. There is little literature which describes pain values and the need for pain medication following UKA and/or TKA. So far, no significant difference in pain has been found between UKA and TKA. The aim of the study was to evaluate differences in the postoperative course in unicompartmental knee arthroplasty vs. total knee arthroplasty regarding the need for pain medication and patient-reported outcomes including pain scores and side effects. We hypothesized that unicompartmental knee arthroplasty is superior to total knee arthroplasty in terms of postoperative pain values and the need of pain medication. In this project, we evaluated 2117 patients who had unicompartmental knee arthroplasty and 3798 who had total knee arthroplasty performed, from 2015 to 2018. A total of 4144 patients could be compared after performing the matched pair analysis. A professional team was used for data collection and short patient interviews to achieve high data quality on the first postoperative day. Parameters were compared after performing a 1:1 matched pair analysis, multicenter-wide in 14 orthopedic departments. Pain scores were significantly lower for the UKA group than those of the TKA group (p p = 0.004 for non-opioids). The opiate consumption was similarly lower for the UKA group, but not statistically significant (p = 0.15). In the ward, the UKA group needed less opioids (p

Die Bildwandler-gestutzten Injektionstechniken sind ein wichtiges Werkzeug zur Behandlung von zervikalen und lumbalen Schmerzsyndromen. Die zur Anwendung notwendige differenzierte Betrachtung der Symptome an der Hals- und Lendenwirbelsaule fuhrt zu einer Aufschlusselung der Beschwerden in zugeordnete Schmerzgeneratoren, sodass eine zielgerichtete Therapie erfolgen kann. Je nach Schmerzgenerator wird wurzelnah oder an die Gelenke gespritzt. Dadurch wird der Teufelskreis des Schmerzes durchbrochen. Von groser Bedeutung ist das korrekte technische Vorgehen. Die pharmakologische Wirkung und spezielle Komplikationen mussen exakt beachtet werden. Ein Monitoring und Vorsichtsmasnahmen sind verpflichtend.

Study DesignProspective Study DesignObjectivesThe aim of the present study was to evaluate the efficacy of a multimodal pain therapy (MPM) regarding the objective parameter muscle strength of segment-dependent lower limb muscle groups before and after such a treatment. Methods52 patients with a history of low back pain and/or leg pain received standardized multimodal pain management. Strength of segment indicating lower limb muscles were assessed for each patient before and after ten days of treatment by handheld dynamometry. ResultsOverall strength increased significantly from 23.6kg ± 6.6 prior to treatment to 25.4 ± 7.3 after treatment, p≤0.001. All muscle groups significantly increased in strength with exception of great toe extensors. ConclusionDespite lower basic strength values at the beginning of treatment, all investigated muscle groups, with the exception of the great toe extensors, showed a significant increase of overall strength after completion of the multimodal pain management concept. Increased overall strength could help with avoiding further need of medical care by supporting patients’ autonomy in daily life activities, as well as maintaining working abilities. Thus, our study is the first to show a significant positive influence on lower limb strength in patients with low back pain after a conservative MPM program.

The number of patients with the diagnosis of lumbar spinal stenosis (LSS) is steadily increasing and simultaneously, the patients' expectations are also increasing. Nevertheless, evidence from studies for the appropriate treatment is still lacking. Treatment options mainly result from the practitioner 's experience and the clinical focus. The findings described in magnetic resonance imaging (MRI) often do not correlate with the patient's symptoms. Basically, the treatment should be started with a conservative treatment and preferably with a multimodal approach. Severe pain with extensive neurogenic claudication symptoms and unsuccessful conservative treatment should be treated surgically. Absolute indications for surgery, such as a conus-cauda syndrome are rare. The goal of all surgical procedures is to decompress the spinal canal without compromising the stability of the motion segment. Instability can also make an additional fusion necessary.

Background Computed tomography (CT) is the gold standard for the accurate measurement of cup inclination and anteversion in total hip arthroplasty (THA). However, functional cup position strongly depends on the tilt of the pelvis and thus pelvic tilt in the supine position on the CT table harbors the risk of misinterpretation. Purpose To evaluate the influence of pelvic tilt on cup measurements in postoperative CT scans. Material and Methods This is a secondary outcome analysis of a prospective study. In 123 patients undergoing THA, anatomic cup inclination and anteversion as measured on postoperative 3D-CT scans were compared between: (i) the anterior pelvic plane (APP) resembling neutral pelvic tilt; and (ii) the coronal plane representing the standard planes on CT. Furthermore, the effect of the variation on cup positions within Lewinnek’s safe zone in relation to the applied reference plane was assessed. Results Mean pelvic tilt in supine position was –3.5° ± 5.6°. This resulted in a mean difference for anteversion between APP und coronal plane of 2.1° ± 3.7° and of 2.1° ± 1.9° for cup inclination, respectively. The change varied up to 20.2° for cup inclination and up 12.2° for cup anteversion. The overall conversion rate for inclination and/or anteversion regarding Lewinnek’s safe zone was high at 23.6% (29/123). Conclusion Pelvic tilt affects cup orientation on CT scans depending on the applied reference plane. Standard CT planes should be corrected regarding pelvic tilt before measurements to avoid errors in measurement.

The aim of this study is to show the concordance of an app-based decision support system and the diagnosis given by spinal surgeons in cases of back pain. 86 patients took part within 2 months. They were seen by spine surgeons in the daily routine and then completed an app-based questionnaire that also led to a diagnosis independently. The results showed a Cramer’s V = .711 (p

Introduction Because of the ongoing discussion of imageless navigation in total knee arthroplasty (TKA), its advantages and disadvantages were evaluated in a large patient cohort. Methods This retrospective analysis included 2464 patients who had undergone TKA at a high-volume university arthroplasty center between 2012 and 2017. Navigated and conventional TKA were compared regarding postoperative mechanical axis, surgery duration, complication rates, one-year postoperative patient-reported outcome measures (PROMs) (WOMAC and EQ-5D indices), and responder rates as defined by the criteria of the Outcome Measures in Rheumatology and Osteoarthritis Research Society International consensus (OMERACT-OARSI). Results Both navigated (1.8 ± 1.6°) and conventional TKA (2.1 ± 1.6°, p = 0.002) enabled the exact reconstruction of mechanical axis. Surgery duration was six minutes longer for navigated TKA than for conventional TKA (p p = 0.39), joint infection (p = 0.42 and thromboembolic events (p = 0.03). Periprosthetic fractures occurred more frequently during conventional TKA (p = 0.001). One-year PROMs showed excellent improvement in both groups. The WOMAC index was statistically higher for navigated TKA than for conventional TKA (74.7 ± 19.0 vs. 71.7 ± 20.7, p = 0.014), but the increase was not clinically relevant. Both groups had a similarly high EQ-5D index (0.23 ± 0.24 vs. 0.26 ± 0.25, p = 0.11) and responder rate (86.5% [256/296] vs. 85.9% [981/1142], p = 0.92). Conclusion Both methods enable accurate postoperative leg alignment with low complication rates and equally successful PROMs and responder rates one year postoperatively. Level of evidence III. Retrospective cohort study.

Study Design Retrospective observational study. Objective The objective of this study is to identify possible sex-dependent differences in symptom-related disability in patients with lumbar spinal stenosis. Methods 103 consecutive outpatients (42 men and 61 women) with lumbar spinal stenosis were assessed on the basis of their medical history, the physical examination, and a series of questionnaires including the Oswestry Disability Index (ODI), the Roland Morris Disability Questionnaire (RMDQ), the Patient Health Questionnaire module 9 (PHQ-9), and the Depression Anxiety Stress Scales (DASS). Narrowing of the spinal canal was graded according to the method established by Schizas. Parameters were statistically analyzed according to the biological sex of the patients. The influence of the variables on the disability scores was analyzed by means of a multivariate regression model. Results Symptom severity was equally distributed between men and women. Female patients showed higher RMDQ and ODI scores as well as significantly higher intermediate depression scores. The confounding variables age, pain chronicity, and psychological affection as well as the symptoms level of pain and paresis were dependent on patient sex. Conclusion The study shows sex-depended differences in the perception of symptoms of lumbar spinal stenosis and disability of life. The findings suggest that the main mediators are pain perception and psychological influences on the quality of life.

Purpose Valgus deformity presents a particular challenge in total knee arthroplasty. This condition regularly leads to contractures of the lateral capsular ligament complex and to overstretching of the medial ligamentous complex. Reconstruction of the knee joint kinematics and anatomy often requires lateral release. However, data on how such release weakens the stability of the knee are missing in the literature. This study investigated the effects of sequential lateral release on the collateral stability of the ligament complex of the knee in vitro. Methods Ten knee prostheses were implanted in 10 healthy cadaveric knee joints using a navigation device. Soft tissue lateral release consisted of five release steps, and stiffness and stability were determined at 0, 30, 60 and 90° flexion after each step. Results Soft tissue lateral release increasingly weakened the ligament complex of the lateral compartment. Because of the large muscular parts, the release of the iliotibial band and the M. popliteus had little effect on the stability of the lateral and medial compartment, but release of the lateral ligament significantly decreased the stability in the lateral compartment over the entire range of motion. Stability in the medial compartment was hardly affected. Conversely, further release of the posterolateral capsule and the posterior cruciate ligament led to the loss of stability in the lateral compartment only in deep flexion, whereas stability decreased significantly in the medial compartment. Conclusion Our study shows for the first time the association between sequential lateral release and stability of the ligamentous complex of the knee. To maintain the stability, knee surgeons should avoid releasing the entire lateral collateral ligament, which would significantly decrease stability in the lateral compartment.

The influence of different implantation techniques in TKA on tibiofemoral kinematics was analysed in few investigations so far. However, the influence on patellar kinematics remain unclear. The aim of the present investigation was to compare patellar kinematics of the natural knee with those of knees after both kinematically and mechanically aligned TKAs. Patellar kinematics of ten cadaveric knees before and after TKAs implanted using both a kinematic and mechanic alignment technique were investigated and compared using a commercial optical computer navigation system. There was a statistically significant difference between natural patellar kinematics and both implantation techniques analysing mediolateral shift. Patellar lateral tilt showed significant better results in the kinematically compared to the mechanically aligned TKAs. In terms of patella rotation, the patella of both mechanically and kinematically aligned TKAs showed significant higher values for external rotation compared to the natural knee. Regarding epicondylar distance again a significant better restoration of natural kinematics could be found in the kinematically aligned TKAs. Kinematically aligned TKAs showed a better overall restoration of patellar kinematics compared to a conventional mechanical alignment technique. In terms of clinical usefulness, the present study highlights the potential benefit for clinical outcome using a kinematically aligned implantation technique in TKA to achieve a better restoration of natural patellofemoral kinematics.

In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to − 15°. No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

Low back pain is one of the most common diseases of modern civilization. Multimodal pain management (MPM) represents a central approach to avoiding surgery. Short-term results are published rarely and often incomparable because of different treatment concepts. This study compared the subjective and objective parameters as well as the anamnestic and clinical parameters of 445 patients with low back pain before and after inpatient MPM to investigate the influence of this type of therapy on short-term outcome. The majority of patients were very satisfied (39%) or satisfied (58%) with the treatment outcome. The median pain reduction for back pain was 3.0 (IQR 2.88) (numeric rating scale, NRS), thus 66% and 2.75 (IQR 3.38, 62%) for leg pain. The main pain reduction occurred within the first 10 days of treatment and was clinically significant from day 5 onwards. The outcome for patients with hospitalization of more than 10 days was significantly worse. The parameters female sex, BMI of > 30, local pain, and pain duration of 3–24 months had a significantly better outcome. In contrast, age, treatment cause, depression, anxiety, and other diseases had no statistically significant influence on outcome. MPM therapy for more than 5 days seems to be an efficient short-term approach to treating low back pain. Knowledge of some of the outcome predictors helps to early identify patients who require more intensive individual care. In the case of no clear indication for surgery, MPM can be an appropriate treatment option.

The differentiated consideration of cervical and lumbar pain syndromes leads to a decoding of complaints to assignable pain generators which enables a targeted injection method. Depending on the origin of pain injections are placed at the nerve root or the joints. Thus, the vicious cycle can be stopped. A correct technical procedure is of enormous importance. Because pharmacological effects and special complications are possible, monitoring and precautions are mandatory.

The number of spinal fusion surgeries is steadily increasing and biomechanical consequences are still in debate. The aim of this study is to provide biomechanical insights into the sagittal balance of the spine and to compare spinal load before and after spinal fusion. The joint reaction forces of 52 patients were analyzed in proximo-distal and antero-posterior direction from the levels T12–L1 to L5–S1 using musculoskeletal simulations. In 104 simulations, pre-surgical forces were equal to post-surgical. The levels L4–L5 and T12–L1, however, showed increased spinal forces compression forces with higher sagittal displacement. Improved restauration of sagittal balance was accompanied by lower spinal load. AP shear stress, interestingly decreased with sagittal imbalance. Imbalanced spines have a risk of increased compression forces at Th12–L1. L4–L5 always has increased spinal loads. These slides can be retrieved under Electronic Supplementary Material.

Steadily increasing numbers of hip arthroplasties are reported in the past years. Different types of anesthetic methods for surgery itself as well as pain management programs have been established. It is one of the main goals to reduce postoperative pain levels and guarantee better and faster mobilization in the postoperative period. The present study aims to compare the use of general and regional spinal anesthesia and their combination regarding perioperative pain management and patient satisfaction.All patients included in the present study had undergone primary hip arthroplasty. Parameters were analyzed on the first postoperative day within the scope of the "Quality Improvement in Postoperative Pain Management" project, which is conducted nationwide in 49 orthopedic departments at the time of data evaluation.From 2009-2015, 18,118 patients underwent primary hip arthroplasty and have been evaluated. Demographic and general patient data were homogenous. The need for opioids was significantly higher in patients where general and combination anesthesia was applied (P.001, respectively). Pain scores and pain management satisfaction were significantly better in regional and combination anesthesia (P .001, respectively).We were able to show a highly significant advantage in the use of regional or the combination of regional and general anesthesia in comparison with general anesthesia alone in hip arthroplasty regarding patients' satisfaction and the requirement of opioid pain medication, although maybe below clinical relevance.

Der Ansturm auf das Medizinstudium ist ungebrochen. Allein im Wintersemester 2016 gab es fur 9150 Studienplatze in Deutschland uber 43.800 Bewerber. Einer der Kernpunkte im „Masterplan 2020“ ist die Reform der Lehre an den medizinischen Fakultaten. Studierende der Humanmedizin werden demnach zukunftig primar auf Grundlage kompetenzorientierter, integrierter Curricula ausgebildet werden. Der vorliegende Beitrag soll Sie mit modernen Lehrkonzepten/-methoden und mit aktuellen Prufungsformaten vertraut machen, die in der studentischen Ausbildung in Orthopadie und Unfallchirurgie eine besondere Rolle spielen. Die Vermittlung von arztlichen und evidenzbasierten Handlungskompetenzen, klinischen Untersuchungstechniken, diagnostischen/therapeutischen Verfahren und hygienisches Arbeiten sind dabei besonders wichtig. Krankheitsbezogene, kompetenzorientiert formulierte Lernziele und Prufungsformate sollen den Studierenden helfen, die Tiefe des Fachs zu erfassen.

Aim of this study is to show the outcome of postoperatively measured lumbar lordosis in upright position in comparison to the intraoperatively estimated lumbar lordosis in prone position, as the lumbar lordosis is one of the most important factors for the clinical outcome after spinal fusion. Eighty-two patients, receiving lumbar fusion were included in this retrospective study. Intraoperative radiographs were scanned. Then radiographs of the whole spine pre- and postoperatively, as well as 1 year after surgery were measured by a spine surgeon and a radiologist. The visible segment lordosis angles were measured and compared (L2–S1, L3–S1, L4–S1, L5–S1). In addition, the pelvic parameters pelvic incidence, pelvic tilt and sacral slope were measured pre- and postoperatively. The intraobserver reliability was almost perfect. The mean lordosis angle L4–S1 was 32.6° ± 7.8° intraoperatively and 29° ± 10.8° postoperatively. A linear correlation of these two measurements can be seen. In mean, the postoperative lordosis is 4° smaller than intraoperatively. This trend can also be seen in the level L3–S1. In levels L2–S1 and L5–S1 the postoperative values were slightly higher than intraoperatively, but without any significance. Also, 1 year after surgery there were no significant changes in global lumbar lordosis. Measuring lordosis angles intraoperatively resulted in almost the same values as measurements in standing plane radiographs postoperatively, despite prone position. These findings could especially be shown for the level L4–S1. The intraobserver reliability was almost perfect for both, intra- and postoperative measurements. In conclusion, the intraoperative measurement of a lumbar lordosis angle can perfectly predict the postoperative result.

Handgelenk und Hand bilden ein hochkomplexes Organ, das fur den Menschen bei fast allen Alltagstatigkeiten von groser Bedeutung ist – zum einen als Werkzeug, zum anderen als Tastorgan. Beschwerden und Verletzungen der Hand und des Handgelenkes sind haufig. Die detaillierte Anamneseerhebung fuhrt in vielen Fallen bereits zur Verdachtsdiagnose. Fast alle Strukturen sind der anschliesenden klinischen Untersuchung zuganglich und konnen anhand von Inspektion, Palpation und klinischen Tests und im Rahmen der dynamischen Untersuchung gut beurteilt werden. Die Ursachen fur Handbeschwerden sind vielfaltig. Neben traumatischen konnen auch degenerative, mechanische, neurologische oder systemisch entzundliche Veranderungen fur Beschwerden verantwortlich sein. Eine gezielte erganzende Bildgebung rundet die Diagnosestellung ab.

Rotation of the lower limb in weight bearing long leg radiographs has a great impact on measured component and lower limb alignment parameters. We asked which rotational errors of long leg radiographs are present in a high volume centre and which radiological and clinical consequences arise regarding measured coronal component and lower limb alignment after total knee arthroplasty. In 100 long leg radiographs coronal femoral and tibial component alignment and hip knee ankle angle (HKA) were measured. Present rotational errors in long leg radiographs were determined by fibular overlap and its impact on alignment parameters calculated. A mean internal rotation of 8.1° (9.3 SD) with a range between 36° of internal and 16° of external rotation was found in long leg radiographs. This resulted in mean differences between measurements before and after rotational correction regarding femoral and tibial component alignment and HKA of 0.6–0.8° (range 3.5° valgus and 1.6° varus error). Clinically, 11 out of 100 patients were wrongly assigned to either mal- or well-alignment (neutral mechanical alignment within ±3° varus or valgus). Surgeons should be aware of potential rotational errors in long leg radiographs after total knee arthroplasty resulting in wrong measurements. In case of rotational errors, radiographs should be repeated or rotational corrections calculated. For study purposes only radiographs after rotational correction should be accepted.

Bei Syndromen der Halswirbelsaule (HWS) und Lendenwirbelsaule (LWS) sind gezielte Injektionen der Schlussel fur eine effektive Schmerztherapie. Je nach Schmerzgenerator wird wurzelnah oder zu den Gelenken gespritzt. Dadurch wird der Teufelskreis des Schmerzes durchbrochen. Von groser Bedeutung ist das korrekte technische Vorgehen. Die pharmakologische Wirkung und spezielle Komplikationen mussen exakt beachtet werden. Ein Monitoring und Vorsichtsmasnahmen sind verpflichtend.

Purpose To investigate the influence of sacral slope on the correlation between measurements of lumbar lordosis obtained by standing radiographs and magnetic resonance images in supine position (MRI). Little information is available on the correlation between measurements of lumbar lordosis obtained by radiographic and MR images. Most relevant studies have shown correlations for the thoracic spine, but detailed analyses on the lumbar spine are lacking. Methods MR images and standing lateral radiographs of 63 patients without actual low back pain or radiographic pathologies of the lumbar spine were analyzed. Standing radiographic measurements included the sagittal parameters pelvic incidence (PI) pelvic tilt (PT), and sacral slope (SS); MR images were used to additionally measure lumbar L1-S1 lordosis and single level lordosis. Differences between radiographic and MRI measurements were analyzed and divided into 4 subgroups of different sacral slope according to Roussouly’s classification. Results Global lumbar lordosis (L1-S1) was 44.99° (± 10 754) on radiographs and 47.91° (± 9.170) on MRI, yielding a clinically relevant correlation (r = 0.61, p Conclusions Although measurements of global lumbar lordosis significantly differed between the two scanning technologies, the mean difference was just 2.9°. MRI in supine position may be used for estimating global lumbar lordosis, but single level lordosis should be determined by means of standing radiographs. Key Points Citation Format

Gemas der demografischen Entwicklung nimmt der Anteil der endoprothetischen Versorgungen am Kniegelenk bei alteren Menschen zu. Es erfolgte eine Analyse zu der speziellen Situation beim alteren Menschen, alternativen Therapieoptionen, perioperativen Risiken, praoperativer Vorbereitung, intraoperativen Besonderheiten und Outcome. Die gegenwartige wissenschaftliche Datenlage wurde ausgewertet und die eigenen wissenschaftlichen Studienergebnisse werden prasentiert. Altere Menschen haben ein erhohtes perioperatives Risiko beim kunstlichen Kniegelenkersatz. Eine grundliche interdisziplinare Vorbereitung ist erforderlich, um Risiken zu reduzieren. Die Stabilitat des Kapselbandapparates nimmt mit zunehmenden Alter nicht ab. Das postoperative Ergebnis nach kunstlichen Kniegelenkersatz wird bei alteren Menschen von der praoperativen Funktion und psychosozialen Faktoren entscheidend beeinflusst. Der kunstliche Kniegelenkersatz beim alteren Menschen ist eine besondere Herausforderung fur den orthopadischen Chirurgen und bedarf einer engen interdisziplinaren Zusammenarbeit.

Nociceptive sensory nerve fibers have never been investigated in the ligamentum flavum (LF) of patients with LSS. The aim was to analyze nociceptive sensory nerve fibers in the ligamentum flavum (LF) of patients with LSS. A prospective study in patients with lumbar spinal stenosis (LSS) undergoing invasive surgical treatment for lumbar spinal stenosis (LSS) with flavectomy was performed. Patients with LSS were subjected to flavectomy and density of sensory and sympathetic nerve fibers, macrophages, vessels, activated fibroblasts, and cells were investigated by immunostaining techniques. A group of patients with acute disc herniation served as control group. We found a higher density of sensory nerve fibers in LSS patients versus controls. These findings support the role of LF in associated low back pain. Density of sensory nerve fibers in LSS, was positively correlated with typical markers of clinical pain and functional disability, but not with LF density of activated fibroblasts. Inflammation as estimated by macrophage infiltration and higher vascularity does not play a marked role in LF in our LSS patients. In the present study, compared to men with LSS, women with LSS demonstrate more pain and depression, and show a higher density of sensory nerve fibers in LF. This study shed new light on nociceptive nerve fibers, which are increased in LSS compared to controls. The findings speak against a strong inflammatory component in LSS. A higher pain levels in women compared to men can be explained by a higher density of nociceptive nerve fibers. (c) 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-7, 2019.

Correct rotational implant alignment is associated with increased postoperative function and implant survival in total knee arthroplasty (TKA). Due to conformity between tibial and femoral implants, particularly in full extension, we assumed a mutual interference of femoral and tibial component rotations. We, therefore, hypothesized that different rotational alignments of the tibial or femoral components change the rotational postures between the tibia and femur after TKA. In 10 healthy knees of whole body cadavers, TKA was performed. Both femoral and tibial components were implanted in different internal (6 degrees) and external (3 and 6 degrees) rotational alignments. Consequential osseous rotational changes between the tibia and the femur were measured in full extension using a commercial computer navigation device. External rotation of the femoral component resulted in significant external rotation of the tibia, while external rotation of the tibial component caused a significant internal rotation of the tibia. The opposite applied to femoral and tibial component internal rotations. Therefore, largest changes of the osseous tibiofemoral rotational postures were found by the combination of 6 degrees femoral component internal and 6 degrees tibial component external rotations (mean 11.2 degrees, standard deviation 5.0, p < 0.001), as both cause tibial internal rotation. In conclusion, the present results suggest that axial component alignment significantly affects lower limb rotational alignment. However, its clinical impact on forefoot progression, Q-angle, the patella, collateral, and cruciate ligaments, and surrounding soft tissues has to be clarified in further clinical and biomechanical studies.

Hintergrund: Der Zusammenhang von Bandscheibenvorfallen und degenerativen Veranderungen der Wirbelsaule ist fur den klinischen Alltag und gutachterliche Fragestellungen interessant. In der vorliegenden klinisch-radiologischen Studie wurde untersucht, ob ein Zusammenhang zwischen degenerativen Bandscheibenveranderungen (Chondrose) und dem Auftreten von lumbalen Bandscheibenvorfallen besteht. Patienten und Methode: Bei der vorliegenden Arbeit handelt es sich um eine klinisch-radiologische retrospektive Studie, welche im Rahmen einer konservativen oder operativen Behandlung von Ruckenpatienten im Zeitraum von 2011 bis 2013 durchgefuhrt wurde. Dazu konnten 100 Patienten mit Bandscheibenvorfallen und Chondrose in aktuellen MRT-Bildern akquiriert werden. Hierbei wurde der Anteil der Falle mit Vorfall und Chondrose, mit alleinigem Vorfall sowie mit alleiniger Chondrose ermittelt. Die statistische Auswertung des Zusammenhangs von Chondrose und Vorfall erfolgte mit dem Chi-Quadrat-Test. Zusatzlich wurden die Odds Ratios fur Vorfall und Chondrose sowie die Interobserver-Reliabilitat (Kappa-Wert) zwischen Primar- und Sekundarbefundung des radiologischen Bildmaterials berechnet. Ergebnisse: Insgesamt wurden bei unseren 100 Patienten in allen lumbalen Segmenten 119 radiologische Befunde (entspricht 100 %) erhoben, davon wurden 54-mal (45 %) Bandscheibenvorfalle mit Chondrosen, 43-mal (36 %) nur Bandscheibenvorfalle und 22-mal (19 %) nur Chondrosen festgestellt. Hauptsachlich betroffen sind dabei die Segmente LWK IV/V und LWK V/SWK I. Ein Zusammenhang von Bandscheibenvorfall und Chondrose konnte statistisch mit dem Chi-Quadrat-Test nachgewiesen werden. Bei den Odds Ratios zeigte sich ein Bandscheibenvorfall mit Chondrose 1,25-mal haufiger als ein Bandscheibenvorfall ohne Chondrose und eine Chondrose mit Bandscheibenvorfall ergab sich 2,37-mal haufiger als die Chondrose ohne Bandscheibenvorfall. Die Interobserver-Reliabilitat ergab einen Kappa-Wert von 0,79 bei den Bandscheibenvorfallen und einen Kappa-Wert von 0,85 bei den Chondrosen. Schlussfolgerung: Anhand unserer Arbeit lies sich erkennen, dass in der uberwiegenden Anzahl der Falle ein Bandscheibenvorfall in Kombination mit einer Chondrose auftritt. Ein Zusammenhang von Bandscheibenvorfall und Chondrose im selben Segment konnte statistisch nachgewiesen werden. Bei der Interobserver-Reliabilitat wurde eine gute Ubereinstimmung der radiologischen Befunde bei Bandscheibenvorfallen und eine sehr gute Ubereinstimmung bei Chondrosen festgestellt.

In the recent past, numerous studies evaluating local infiltration analgesia (LIA) with controversial results have been reported. Efforts have been made to improve patients' outcome regarding operation techniques and material, as well as pain management and anesthetic methods. In this study, postoperative pain management and patient satisfaction were evaluated in patients undergoing total knee replacement surgery with or without intraoperative LIA. Within the context of the “Quality Improvement in Postoperative Pain Management” (QUIPS) project, parameters were collected on the first postoperative day. All patients included in this study underwent primary knee replacement surgery with general anesthesia. Parameters were compared after performing a 1:1 matched-pair analysis within 14 orthopaedic departments. Pain levels and pain management satisfaction were measured using the numerous rating scales, and pain medication use was compared. From 2010 to 2015, 2,789 patients who underwent primary knee arthroplasty with general anesthesia were evaluated within the project, of whom a total of 846 patients could be compared after performing a matched-pair analysis. Pain scores were significantly better in the LIA group (p = 0.019 for activity pain, p = 0.043 for maximum pain, p

The purpose of this study was to investigate the effects of sequential medial release on the stiffness and collateral stability of the ligament complex of the knee. Irrespective of the implantation technique used, varus deformity frequently requires release of the capsular ligament complex. Yet, no data are available on how stiffness and stability of the knee ligament complex are weakened by such release. After total knee arthroplasty, ten healthy Thiel-fixed knee joints were subjected to sequential medial release consisting of six release steps. After each step, stiffness and stability were determined at 0°, 30°, 60°, and 90°. Sequential medial release increasingly weakened the ligament complex. In extension, release of the anteromedial tibial sleeve 4 cm below the joint line already weakened the ligament complex by approximately 13%. Release 6 cm below the joint line reduced stiffness and stability by 15–20% over the entire range of motion. After detachment of the medial collateral ligament, stability was only about 60% of its initial value. Our study showed for the first time the association between medial release and stiffness and stability of the knee ligament complex. To maintain stability, vigorous detachment of the knee ligament complex should be avoided. Release of the anteromedial tibial sleeve already initiates loss of stability. The main stabiliser is the medial ligament, which should never be completely detached. IV.

Postoperative pain management options are of great importance for patients undergoing total hip arthroplasty, as joint replacement surgery is reported to be one of the most painful surgical procedures. This study demonstrates pain outcome until 4 weeks postoperatively and evaluates factors influencing pain in the postoperative course after total hip arthroplasty. A total of 103 patients were included in this prospective cohort trial and underwent total hip arthroplasty. Postoperative pain was described using a numerical rating scale (NRS); demographic data and perioperative parameters were correlated with postoperative pain. Evaluation of pain scores in the postoperative course showed a constant decrease in the first postoperative week (mean NRS 3.1 on day 1 to mean NRS 2.3 on day 8) and, then, a perpetual increase for 3 days (mean NRS 2.6 on day 9 to mean NRS 2.3 on day 12). Afterwards, a continuous pain-level decrease was stated (continuous to a mean NRS 0.9 on day 29). No correlation was found between the potential influencing factors sex, age, body mass index, duration of surgery, ASA score, and postoperative pain levels, but a high significant correlation could be stated for preoperative pain levels and postoperative pain intensity (pain while moving p