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Abstract Purpose Calibration of radiographs is a critical step in digital templating for hip arthroplasty. Calibration errors of > 1.5% lead to over- or undersizing of the templated implants and may affect logistics and patient safety. Contemporary calibration methods are known to be imprecise with average errors of 6.5% and wide variance. A novel bi-planar radiograph-based calibration method is proposed, and a phantom study was conducted as proof of concept. Methods A spherical external calibration marker (ECM) is placed in front of the pubic symphysis of a pelvic bone model at twelve different positions. For each marker position, standard anteroposterior radiographs and four corresponding lateral radiographs with different degrees of rotation (0°–30°) are taken (overall, 60 radiographs). Calibration factors are calculated for an internal calibration marker (ICM) at the centre of the right hip (reference) and the ECM using a novel algorithm. Rotation and marker positions simulate foreseeable use errors and misplacements and aim to test robustness of the method against these errors. Results ECM calibration factor was 125.9% (range 124.7–127.2), and the mean ICM calibration factor was 126.6% (range 126.2–127.1) ($$p p < 0.001 ). Four images (8.3%) were beyond the 1% error threshold (all with 30° rotation). The mean difference was 0.79% (SD 0.49). Conclusion The bi-planar method precisely predicts the true calibration factor of the hip joint plane under various conditions. In lateral radiographs, rotation of up to 20° did not adversely affect the precision and all images had calibration errors below the threshold for clinical significance.

Purpose of this study was an external evaluation of the recently developed European Foot and Ankle Society (EFAS) Score.From July 2021 to January 2022, all consecutive patients with foot and ankle disorders were asked to complete three validated questionnaires prior to the medical examination. Validity was evaluated with correlations between the EFAS Score, Manchester-Oxford Foot Questionnaire (MOxFQ) and Foot and Ankle Outcome Score (FAOS). Cronbach's alpha, floor and ceiling effects and the minimal important difference (MID) were determined.In a total of 161 included patients, the EFAS Score demonstrated a very good correlation with the MOxFQ index score (r = 0.76, p 0.001). There were no floor or ceiling effects. Cronbach's alpha was 0.863, and the MID amounts 3 points and 7 points for significant changes respectively.In terms of reliability and validity, the EFAS Score demonstrated good to excellent psychometric values. A change of 7 points or more in the EFAS Score in longitudinal examinations is clinically highly relevant.

Purpose Bone cement is frequently used for implant fixation in orthopaedic surgery. The occurrence of pulmonary cement embolism (PCE) in hip and knee arthroplasty has been described previously, but the exact extent and frequency have not been adequately studied. A postmortem cohort provides a unique opportunity for a more detailed analysis of this phenomenon. Methods Through retrospective analysis of whole-body computed tomography (CT) scans and autopsy protocols, we identified 67 cases with previous cemented total hip or knee arthroplasties. A grading system originally developed for PCE after cemented spine procedures was used. Findings were compared with two control groups: 35 individuals with previous cementless total joint arthroplasty as well as 25 individuals without evidence of prostheses. Results PCE was detected in 46.3% of the cases: grade 1 (31.3%), grade 2 (10.5%), and grade 3 (4.5%). No statistically significant difference was found between hip and knee arthroplasties in terms of PCE frequency. Importantly, none of the autopsy reports listed PCE as a cause of death or a contributing factor for the patients’ death. In the two control groups, only one case per group was classified as grade 1 PCE, while the remaining cases did not show any evidence of PCE. Conclusion The presented data reveal a high frequency of PCE in hip and knee arthroplasties, which is almost identical to previous findings in patients with cement-augmented interventions in the spine. This way, our results underline the relevance of PCE after arthroplasty, suggesting an adaptation of surgical methods to minimize this complication.

Skeletal adaptation is substantially influenced by mechanical loads. Osteocytes and their lacuno-canalicular network have been identified as a key player in load sensation and bone quality regulation. In the femoral neck, one of the most common fracture sites, a complex loading pattern with lower habitual loading in the superolateral neck and higher compressive stresses in the inferomedial neck is present. Variations in the femoral neck-shaft angle (NSA), i.e., coxa vara or coxa valga, provide the opportunity to examine the influence of loading patterns on bone quality. We obtained femoral neck specimens of 28 osteoarthritic human subjects with coxa vara, coxa norma and coxa valga during total hip arthroplasty. Bone mineral density (BMD) was assessed preoperatively by dual energy X-ray absorptiometry (DXA). Cortical and trabecular microstructure and three-dimensional osteocyte lacunar characteristics were assessed in the superolateral and inferomedial neck using ex vivo high resolution micro-computed tomography. Additionally, BMD distribution and osteocyte lacunar characteristics were analyzed by quantitative backscattered electron imaging (qBEI). All groups presented thicker inferomedial than superolateral cortices. Furthermore, the superolateral site exhibited a lower osteocyte lacunar density along with lower lacunar sphericity than the inferomedial site, independent of NSA. Importantly, BMD and corresponding T-scores correlated with microstructural parameters at the inferomedial but not superolateral neck. In conclusion, we provide micromorphological evidence for fracture vulnerability of the superolateral neck, which is independent of NSA and BMD. The presented bone qualitative data provide an explanation why DXA may be insufficient to predict a substantial proportion of femoral neck fractures. STATEMENT OF SIGNIFICANCE: The femoral neck, one of the most common fracture sites, is subject to a complex loading pattern. Site-specific differences (i.e., superolateral vs. inferomedial) in bone quality influence fracture risk, but it is unclear how this relates to hip geometry and bone mineral density (BMD) measurements in vivo. Here, we examine femoral neck specimens using a variety of high-resolution imaging techniques and demonstrate impaired bone quality in the superolateral compared to the inferomedial neck. Specifically, we found impaired cortical and trabecular microarchitecture, mineralization, and osteocyte properties, regardless of neck-shaft angle. Since BMD correlated with bone quality of the inferomedial but not the superolateral neck, our results illustrate why bone densitometry may not predict a substantial proportion of femoral neck fractures.

Introduction Several studies have reported good to excellent outcomes of revision total hip arthroplasty (rTHA) using allografts for treating severe acetabular bone defects. However, precise information on the impact of allograft type and reconstruction method is not available. Material and methods Systematic literature search was performed in Medline and Web of Science including patients with acetabular bone loss classified according to the Paprosky classification who underwent rTHA involving the use of allografts. Studies with a minimum follow-up of 2 years published between 1990 and 2021 were included. Kendall correlation was applied to determine the relationship between Paprosky grade and allograft type use. Proportion meta-analyses with 95% confidence interval (CI) were performed to summarize the success of various reconstruction options, including allograft type, fixation method, and reconstruction system. Results Twenty-seven studies met the inclusion criteria encompassing 1561 cases from 1491 patients with an average age of 64 years (range 22–95). The average follow-up period was 7.9 years (range 2–22). Structural bulk and morselized grafts were used in equal proportions for all Paprosky acetabular defect types. Their use increased significantly with the type of acetabular defect (r = 0.69, p = 0.049). The overall success rate ranged from 61.3 to 98.3% with a random effect pooled estimate of 90% [95% CI 87–93]. Trabecular metal augments (93% [76–98]) and shells (97% [84–99]) provided the highest success rates. However, no significant differences between reconstruction systems, allograft types and fixation methods were observed (p > 0.05 for all comparisons). Conclusion Our findings highlight the use of bulk or morselized allograft for massive bone loss independent of Paprosky classification type and indicate similar good mid- to long-term outcomes of the different acetabular reconstruction options using allografts. Clinical trial registration PROSPERO: CRD42020223093.

Purpose Ultrasound has been used to diagnose hip dysplasia in neonates and to screen until the end of their first year. For older children, femoral head containment disorders such as developmental dysplasia of the hip, Legg-Calvé-Perthes disease or cerebral palsy are usually diagnosed with plain radiographs. The aim of the present study was to evaluate ultrasound in comparison with radiographic imaging in children up to age 12 years and to determine reference values for sonographic containment parameters. Methods Hip ultrasound and radiographic imaging were acquired on the same day and then compared. As a reference, normal acetabular angle and acetabulum head index were determined on radiographs. Lateral cartilage distance (LCD), lateral head distance (LHD) and femoral head extrusion angle (HA) were measured on ultrasound images. Results We included 96 patients with 167 healthy hips in the study. A total of 55 patients were female and 41 male. The mean age was 5.2 years (sd 3.3; 1.0 to 11.9). LCDultrasound, LHDultrasound and HAultrasound correlated significantly with radiographic parameters. The following ultrasound values were calculated as limits for impending loss of containment: LCDultrasound ≥ 6.5 mm, LHDultrasound ≥ 3.3 mm and HAultrasound ≥ 27.6°. Conclusion Ultrasound is a simple, radiation-free diagnostic tool to detect femoral head containment disorders, even in children older than one year. This study provides reference values for hip ultrasound in children up to 12 years. Level of evidence III

Background Impacted bone-grafting with morselized allograft chips is commonly used to reconstruct acetabular bone defects in revision total hip arthroplasty (THA). While the overall clinical outcome of this procedure is described to be excellent, the microstructural basis and histological determinants of allograft incorporation remained to be further elucidated. Methods The acetabula of 23 individuals with documented previous use of allograft chips during revision THA were explanted post mortem. The time that the allografts were in situ averaged 10.3 ± 4.5 years (range, 1.2 to 19.8 years). The host bone (HB)-allograft bone (AB) interface was characterized using a suite of high-resolution (HR) imaging techniques including HR-peripheral quantitative computed tomography (HR-pQCT), histological analysis, cellular histomorphometry, and scanning electron microscopy. Results AB could be identified in 16 of the 23 cases. The HB and AB showed overlap (i.e., ingrowth) in 91.3% of the total interface. The mean ingrowth was 2.2 ± 1.0 mm with a maximum of 4.7 ± 2.1 mm. The periphery of the AB showed a tight interconnection with the HB associated with increased bone remodeling indices and increased trabecular thickness. While no association between the time in situ and the ingrowth was observed, the bone defect area was positively associated with the thickness of a fibrosis layer separating the ingrowth zone from the AB. Conclusions Allograft chips in revision THA form an adequate osseous foundation with successful incorporation through ingrowth of the HB (i.e., osteoconduction). While complete remodeling was not observed, larger defects were associated with fibrosis formation, which may compromise stability. Clinical relevance Our study provides the first systematic, multiscale long-term evaluation of chip allograft incorporation in revision THA to underscore its successful clinical use. As larger defects were associated with fibrous ingrowth, structural allografts may be superior for larger defects in terms of long-term outcomes.

Ersatz des Huftgelenkes durch die Implantation einer bipolaren Hemiendoprothese (HEP) – anterolateraler Zugang. Geriatrietypische Multimorbiditat und hoheres Alter >70 Jahre, Alter >80 Jahre, geringer funktioneller Anspruch. Floride Infektion. Relative Kontraindikationen: dysplastisches Huftgelenk. Ruckenlagerung. Anterolateraler Zugang. Eroffnung des Tractus, Eingehen in das Intervall zwischen M. tensor fasciae latae/M. gluteus medius. Kapselresektion. Schenkelhalsosteotomie. Inspektion des Acetabulums. Grosenbestimmung des bipolaren Prothesenkopfes. Uberfuhrung des Beines bis maximal in die 4er-Position. Darstellen der Schenkelhalsebene und Femurpraparation mit den Schaftraspeln (Antetorsion: 10–15°) bis zur geplanten Grose/Position. Probereposition. Luxationsprufung. Bildwandlergestutzte Kontrolle. Zementstopper, Jet-Lavage, Trocknung des Markraumes und Zementierung des Originalschaftes unter Beachtung der Hohe/Anteversion. Montage/Implantation des bipolaren Originalkopfes mit der gewahlten Kopflange auf den Schaftkonus. Reposition des Gelenkes. Wundverschluss. Schmerzadaptierte Vollbelastung. Beugelimitation: 90° fur 6 Wochen, keine forcierte Rotation/Adduktion. Thromboseprophylaxe. Osteoporosediagnostik/-therapie. Klinisch-radiologische Kontrolle (nach 6 Wochen, 1/3/5 Jahren). Die Implantation einer zementierten bipolaren HEP uber den anterolateralen Zugang ist ein muskelschonendes und luxationssicheres Operationsverfahren mit geringem Revisionsrisiko, das eine zugige Mobilisation der Patienten bei guter Funktion des Huftgelenkes ermoglicht.

Zusammenfassung Hintergrund Osteoidosteome zählen zu den benignen ossären Neoplasien und können am gesamten Skelett auftreten. Die verlängerte Diagnosestellung eines Osteoidosteoms der Großzehe veranlasste uns, einen Fallbericht mit Review der Literatur zu verfassen, um mögliche Fehlerquellen zu identifizieren und einen Beitrag zur zügigeren Diagnosefindung und Therapie zu leisten. Literatur In der deutschen Literatur sind aktuell nur zwei Fallberichte zu Osteoidosteomen der Zehen bekannt. International wurde allerdings eine Vielzahl an Fällen beschrieben, die in der Zusammenschau ein homogenes Bild ergeben. Eine sehr deutliche Häufung von Osteoidosteomen am Endglied der Großzehe lassen eine posttraumatische Ätiologie möglich erscheinen. Der typische NSAR-sensible Nachtschmerz ist klinisch eindeutig und sollte an jeder Lokalität des Körpers an ein Osteoidosteom denken lassen. Auffällig ist das an den Zehen einzigartige Symptom der Makrodaktylie, was ein dankbarer Hinweis zur Diagnosefindung sein kann. Die mittlere Zeit vom Symptombeginn bis zur korrekten Diagnosestellung betrug 12 Monate. Häufig wurden Fehldiagnosen und Fehltherapien unter einer anderen Verdachtsdiagnose beschrieben. Eine mögliche Ursache ist die häufig atypische und uneindeutige Bildgebung. Die operative Therapie stellt bei Osteoidosteomen der Zehen die Methode der Wahl dar und sollte stets durch eine histopathologische Untersuchung ergänzt werden.

Hajdu-Cheney syndrome (HCS) is a rare genetic connective tissue disorder caused by gain-of-function mutations in the NOTCH2 gene. We report a 38-year-old male HCS patient with a history of multiple pathologic fractures, poor bone stock under intermittent antiresorptive therapy, and secondary osteoarthritis (OA) of the knee, in which we successfully performed total knee arthroplasty (TKA). Next to a detailed skeletal assessment including laboratory bone metabolism markers, dual energy X-ray absorptiometry (DXA), and high-resolution peripheral quantitative computed tomography (HR-pQCT), undecalcified histologic and histomorphometric analysis was performed on intraoperatively obtained tibial cut sections. This multiscale assessment revealed a severe, combined trabecular-cortical microarchitectural deterioration, increased bone turnover indices, and advanced cartilage degeneration, thus demonstrating the crucial role of Notch2 in skeletal and cartilage homeostasis, which is in line with the findings of previous mouse models. Supplementary Information The online version contains supplementary material available at 10.1007/s00198-021-05914-6.

Summary We detected a high prevalence of low bone mineral density assessed by DXA in 268 elderly patients with end-stage osteoarthritis scheduled for total hip arthroplasty (18% osteoporosis, 41% osteopenia). Therefore, and due to the identified concomitant undertreatment, routine DXA measurements should be considered in elderly patients prior to surgery. Introduction Bone quality represents a decisive factor for osseointegration, durability, and complications of an implanted prosthesis. Although the risk of osteoporosis increases with age and the assessment of bone mineral density (BMD) prior to total hip arthroplasty (THA) is recommended in elderly patients, a systematic, unbiased analysis of such patients is not available in the literature. Methods In this retrospective study, we examined 268 elderly patients (age ≥70 years) who underwent dual-energy X-ray absorptiometry (DXA) within 3 months prior to primary THA. Demographics, medical history, radiographic OA grade, and stem fixation method (i.e., cemented or cementless) were obtained. Results In total, 153 (57%) cemented and 115 (43%) cementless stem fixations during THA were performed. Forty-nine patients (18%) were diagnosed with osteoporosis (T-score ≤−2.5), 110 patients (41%) with osteopenia (T-score ≤−1.0), and 109 patients (41%) with normal BMD (T-score >−1.0). Importantly, 36/49 patients (73%) with osteoporosis were not diagnosed before, resulting in a relevant undertreatment. Female sex and low body mass index (BMI) were the main factors negatively influencing the bone mineral density (BMD). Conclusions Due to a high incidence of undiagnosed and untreated osteoporosis in elderly patients with potential effects on the success of osseointegration as well as other clinical outcomes, DXA measurements should be included in the clinical routine for these patients prior to THA.

Methotrexate (MTX) is one of the most commonly prescribed drugs for autoimmune rheumatic diseases. As there is no consensus on its negative effects on bone, the purpose of this investigation was to determine the clinical spectrum of patients with stress fractures due to long-term MTX treatment (i.e., MTX osteopathy). We have retrospectively analyzed data from 34 patients with MTX treatment, severe lower extremity pain and immobilization. MRI scans, bone turnover markers, bone mineral density (DXA) and bone microarchitecture (HR-pQCT) were evaluated. Stress fractures were also imaged with cone beam CT. While the time between clinical onset and diagnosis was prolonged (17.4 ± 8.6 months), the stress fractures had a pathognomonic appearance (i.e., band-/meander-shaped, along the growth plate) and were diagnosed in the distal tibia (53%), the calcaneus (53%), around the knee (62%) and at multiple sites (68%). Skeletal deterioration was expressed by osteoporosis (62%) along with dissociation of low bone formation and increased bone resorption. MTX treatment was discontinued in 27/34 patients, and a combined denosumab–teriparatide treatment initiated. Ten patients re-evaluated at follow-up (2.6 ± 1.5 years) had improved clinically in terms of successful remobilization. Taken together, our findings provide the first in-depth skeletal characterization of patients with pathognomonic stress fractures after long-term MTX treatment. Electronic supplementary material The online version of this article (10.1007/s00223-020-00765-5) contains supplementary material, which is available to authorized users.

Study Design Retrospective Cohort Study Objectives To investigate and compare the prevalence of low bone mineral density (BMD) and abnormal laboratory bone metabolism parameters in patients undergoing elective primary discectomy, decompression, and fusion and to outline possible differences in these parameters between patients undergoing revision for skeletal vs non-skeletal complications. Methods We retrospectively evaluated BMD measurements by dual-energy x-ray absorptiometry (DXA) in 389 consecutive patients scheduled for elective lumbar spine surgery. Next to demographic characteristics, laboratory bone metabolism parameters were assessed. Group comparisons were performed between primary discectomy, decompression, and fusion. In patients scheduled for revision surgery after fusion, potential differences in the skeletal status between those with skeletal vs non-skeletal complications were analyzed. Results Osteoporosis by T-score was detected in 6.7%, 11.0% and 14.7% of the patients undergoing discectomy, decompression and fusion, respectively. While vitamin D deficiency (67.6%) and hyperparathyroidism (16.4%) were frequently detected, no differences in laboratory bone metabolism markers could be found between the groups. Female sex (PConclusions Osteoporosis represents a relevant comorbidity in patients scheduled for elective spine surgery, which is why DXA should be routinely performed in these patients. However, DXA may provide limited information in identifying patients at increased risk for skeletal complications after fusion.

Tumor-induced osteomalacia (TIO) or oncogenic osteomalacia (OOM) is a rare paraneoplastic renal phosphate wasting syndrome. The disease is mostly triggered by small, benign mesenchymal tumors that express somatostatin receptors (SSTR) and produce excessive levels of fibroblast growth factor 23 (FGF 23) or other phosphatonins. These reduce the phosphate back resorption in the proximal tubules of the kidneys, thereby causing hypophosphatemia and lead to an absolute or relatively low calcitriol serum concentration. The main symptoms include muscle weakness, bone pain and recurrent insufficiency fractures secondary to sometimes pronounced osteomalacia. The suspected diagnosis can only be confirmed by determination of the phosphate level. It can often take years before the tumor is successfully localized. The necessary tumor localization is often the most difficult step in the treatment before the OOM can be curatively treated by open surgical resection of the tumor. In recent years new approaches for faster tumor localization and treatment of the tumor have been developed. Positron emission tomography (PET) in co-registration with computed tomography (Die onkogene Osteomalazie (OOM) oder tumorinduzierte Osteomalazie (TIO) ist ein seltenes paraneoplastisches Phosphatverlustsyndrom. Ausgelöst wird die OOM meist durch kleine gutartige Somatostatinrezeptor-positive Tumoren, die meist über eine ektope Überproduktion von FGF23 („fibroblast growth-factor 23“) oder anderen Phosphatoninen zu einer verminderten renalen Phosphatrückresorption im proximalen Nierentubulus und folglich einer Hypophosphatämie sowie einer absolut bzw. relativ erniedrigten Calcitriolserumkonzentration führen. Zu den Hauptsymptomen gehören Muskelschwäche, Knochenschmerzen und rezidivierende Insuffizienzfrakturen infolge einer zum Teil ausgeprägten Osteomalazie. Die Verdachtsdiagnose kann nur durch die Bestimmung des Phosphatspiegels gestellt werden. Bis zur erfolgreichen Tumorlokalisation und Therapieeinleitung vergehen oft Jahre. Hierbei stellt häufig die dazu notwendige Tumorlokalisation den schwierigsten Schritt in der Behandlung dar, bevor die OOM durch eine offen-chirurgische Tumorresektion kurativ behandelt werden kann. Neue Ansätze zur schnelleren Tumorlokalisation und zur Therapie der OOM wurden in den letzten Jahren entwickelt. So ist die Positronenemissionstomographie (PET) in Koregistrierung mit einer Computertomographie (

Background: This study aimed to determine the clinical and radiological course in children who had Legg–Calvé–Perthes disease (LCPD) associated with juvenile idiopathic arthritis (JIA). Methods: In a retrospective chart review between 2007 and 2019, eight consecutive JIA patients diagnosed with concomitant LCPD were identified and compared with a case-control group of 10 children with LCPD only. Results: LCPD was diagnosed at a mean age of 8.1 years (3.0–14.7) in children with JIA as compared to 6.1 years (2.9–10.0) in controls. According to the modified Harris Hip Score (mHHS), four children with JIA and all controls had an excellent result. Regarding the fragmentation severity and the duration of each stage, we found no differences using the lateral pillar and modified Elizabethtown classification. Five hips were classified as Stulberg I/II, two hips as Stulberg III, and one hip as Stulberg V with no evidence of hip dysplasia or severe overcoverage in either group. Conclusions: The radiological outcome of LCPD did not differ between both groups, while the clinical outcome was slightly better in controls. Physicians should be aware that children with LCPD may have JIA too. In suspicious cases, further investigations are recommended, and patients should be referred to pediatric rheumatologists.

Importance: Costal cartilage calcification (CCC) of the cartilage graft, commonly used in reconstruction of nasal/auricular deformities, can cause poor surgical outcome, but structural and quantita...

Introduction Osteoporosis is a common comorbidity in elderly patients with osteoarthritis (OA) and may increase perioperative complications in orthopedic surgery (e.g., component migration, periprosthetic fractures). As there is no investigation of bone mineral density (BMD) in elderly patients prior to total knee arthroplasty (TKA) in Europe, we investigated this issue with a particular focus on a potential treatment gap. Materials and methods We assessed the BMD by dual-energy X-ray absorptiometry (DXA) in 109 consecutive elderly patients (age ≥ 70 years) scheduled for TKA. In addition to a detailed assessment of osteoporosis and osteopenia, the influence of clinical risk factors and radiological OA severity on BMD was evaluated using group comparisons and linear regression models. In addition, we analyzed differences in BMD between patients scheduled for TKA vs. total hip arthroplasty (THA). Results Of the included 109 patients, 19 patients (17.4%) were diagnosed with osteoporosis and 50 (45.9%) with osteopenia. In the osteoporotic patients, a clinically relevant underdiagnosis concomitant with a serious treatment gap was observed in 95.0% of the patients. Body mass index, OA grade, and glucocorticoid use were identified as independent factors associated with BMD. No differences in BMD were found between the patients scheduled for TKA vs. THA. Conclusions Considering the high prevalence of osteoporosis and osteopenia in elderly patients, DXA screening should be recommended for patients ≥ 70 years indicated for TKA.

In accordance with the rheumatological concept of "hit hard and early", the timing of synovectomy should also be selected to be as early as possible and should be adjusted to the onset of the effect of biologicals in order to prevent joint destruction. This means that after an early diagnosis of rheumatoid arthritis and start of drug therapy, a low disease activity has been achieved and a rebellious joint is evident, a very prompt synovectomy is indicated.Entsprechend dem internistisch-rheumatologischen Konzept „hit hard and early“ sollte auch der Zeitpunkt der Synovialektomie so früh wie möglich gewählt werden und an den Wirkeintritt der Biologika angepasst werden, um Gelenkdestruktionen zu verhindern. Das heißt, wenn nach früher Diagnosestellung einer rheumatoiden Arthritis und medikamentösem Therapiebeginn eine niedrige Krankheitsaktivität erzielt wurde und sich ein rebellisches Gelenk zeigt, besteht hier die Indikation zu einer sehr zeitnahen Synovialektomie.

BACKGROUND Ankle arthropathy is a frequent complication of haemophilia, reducing the patients' quality of life. Despite intensive conservative therapy, end-stage arthropathy requires surgical treatment, either by ankle fusion (AF) or total ankle replacement (TAR). METHODS Eleven consecutive AFs were performed in nine patients and 11 TARs were implemented in 10 patients. Outcomes were assessed clinically by AOFAS score and radiologically by the Pettersson and Gilbert scores. RESULTS The mean age of the patients in these groups were 35.7 years and 49.4 years, respectively. Of the 11 ankles that underwent fusion, 10 showed bony consolidation not later than 12 weeks after surgery, whereas one still showed non-union after 6 months. VAS pain scores decreased significantly in both groups. Mean AOFAS scores also improved significantly, from 28.1 before to 80.3 after AF and from 21.5 before to 68.0 after ankle replacement. No perioperative complications were observed in either group. Late deep infection was observed in two patients that underwent TAR, which required removal of the implant. CONCLUSION Our data indicate that both AF and TAR result in significantly reduced pain in patients with haemophilia with end-stage haemophilic arthropathy. While TAR is associated with a higher risk of deep infection and minimal persistent pain, it preserves the pre-operative range of motion. AF on the other hand is associated with the risk of non-union and a longer post-operative recovery period but results in greater pain reduction.

The distal fibula represents one of the most common fracture sites, and its epidemiology is characterized by a high incidence in both adolescence and the elderly. While fracture occurrence is influenced by trauma mechanism, a possible underlying skeletal microarchitectural deterioration in certain patient groups remains elusive. The purpose of this study was to determine the influence of age, sex, and overall skeletal status on fibular microarchitecture. We analyzed the microarchitecture of the distal fibula in 300 people by high-resolution peripheral quantitative computed tomography (HR-pQCT). Three areal bone mineral density (aBMD) groups (normal, osteopenia, osteoporosis; n = 100 per group) based on the concurrent assessment of aBMD by dual-energy X-ray absorptiometry (DXA) at the lumbar spine and total hip were established. Next to group comparisons, linear and non-linear regression analyses were carried out to assess the association between age, sex, BMI, tibial and fibular microarchitecture. While women had lower values for both trabecular bone volume fraction (BV/TVd, p

Two-stage exchange with intermediate resection arthroplasty (RA) is a well-established surgical procedure in the treatment of chronic periprosthetic joint infection (PJI), whereby a higher failure rate of final hip geometry restoration due to tissue contraction is controversially discussed. The aim was to evaluate radiographic changes of hip geometry parameters during PJI treatment and to determine the impact of the intermediate RA on the final joint restoration after reimplantation of a total hip arthroplasty (reTHA). Radiographic parameters (leg length (LL), femoral offset (FO), horizontal/vertical acetabular center of rotation distance (h/vCORD)) of 47 patients (mean age: 64.1 years) were measured on standard radiographs of the pelvis and compared between four different stages during PJI treatment (pre-replacement status (preTHA), primary total hip arthroplasty (pTHA), RA and reTHA). The RA duration (mean: 10.9 months) and the number of reoperations during this period (mean: n = 2.0) as well as their impact on hip geometry restoration were evaluated. Between preTHA and pTHA/reTHA an equivalent restoration was measured regarding the FO (p p p = 0.016/p p = 0.003), FO (p p = 0.039/p = 0.035) at reTHA compared to pTHA. Furthermore, RA duration (p = 0.053) and the number of reoperations after RA (p = 0.134) had no impact on radiographic hip geometry restoration. The two-stage exchange with intermediate RA does not alter the preexisting hip joint parameters, whereby a good restoration of the final hip geometry, independent of the duration or the number of reoperations, can be achieved.

Objective Preoperative digital templating is a standard procedure in total hip arthroplasty. Deviations between template size and final implant size may result from inaccurate calibration, templating as well as intraoperative decisions. So far, the explicit effect of calibration errors on templating has not been addressed adequately. Materials and Methods A mathematical simulation of calibration errors up to ± 24% was applied to the templating of acetabular cups (38 to 72 mm diameter). The effect of calibration errors on template component size as deviation from optimal size was calculated. Results The relationship between calibration error and component size deviation is inverse and linear. Calibration errors have a more pronounced effect on larger component sizes. Calibration errors of 2–6% result in templating errors of up to two component sizes. Common errors of up to 12% may result in templating errors of 3–4 sizes for common implant sizes. A tabular matrix visualizes the effect. Conclusion Calibration errors play a significant role in component size selection during digital templating. Orthopedic surgeons should be aware of this effect and try to identify and address this source of error.

Osteoid osteomas belong to the benign osseous neoplasia and can occur on the entire skeleton. The prolonged diagnosis of an osteoid osteoma of the great toe prompted us to prepare a case report with a literature review to identify possible sources of error and to contribute to a more expeditious diagnosis and therapy.Currently, only two case reports on osteoid osteomas of the toes are known in the German literature. Internationally, however, a large number of cases have been described, which, when viewed as a whole, present a homogeneous picture. A very clear accumulation of osteoid osteomas at the distal phalanx of the great toe suggests a possible post-traumatic aetiology. The typical NSAID-sensitive night pain is clinically unambiguous and should make one think of an osteoid osteoma at any site on the body. The symptom of macrodactyly, which is unique to the toes, is striking and may provide a helpful clue to establishing the diagnosis. The median time from symptom onset to correct diagnosis was 12 months. One possible reason for this prolonged diagnosis is the often atypical and ambiguous imaging. Surgical therapy is the method of choice for osteoid osteomas of the toes and should always be supplemented by histopathologic examination.HINTERGRUND: Osteoidosteome zählen zu den benignen ossären Neoplasien und können am gesamten Skelett auftreten. Die verlängerte Diagnosestellung eines Osteoidosteoms der Großzehe veranlasste uns, einen Fallbericht mit Review der Literatur zu verfassen, um mögliche Fehlerquellen zu identifizieren und einen Beitrag zur zügigeren Diagnosefindung und Therapie zu leisten.In der deutschen Literatur sind aktuell nur zwei Fallberichte zu Osteoidosteomen der Zehen bekannt. International wurde allerdings eine Vielzahl an Fällen beschrieben, die in der Zusammenschau ein homogenes Bild ergeben. Eine sehr deutliche Häufung von Osteoidosteomen am Endglied der Großzehe lassen eine posttraumatische Ätiologie möglich erscheinen. Der typische NSAR-sensible Nachtschmerz ist klinisch eindeutig und sollte an jeder Lokalität des Körpers an ein Osteoidosteom denken lassen. Auffällig ist das an den Zehen einzigartige Symptom der Makrodaktylie, was ein dankbarer Hinweis zur Diagnosefindung sein kann. Die mittlere Zeit vom Symptombeginn bis zur korrekten Diagnosestellung betrug 12 Monate. Häufig wurden Fehldiagnosen und Fehltherapien unter einer anderen Verdachtsdiagnose beschrieben. Eine mögliche Ursache ist die häufig atypische und uneindeutige Bildgebung. Die operative Therapie stellt bei Osteoidosteomen der Zehen die Methode der Wahl dar und sollte stets durch eine histopathologische Untersuchung ergänzt werden.

Backgrounds: Dega pelvic osteotomy is commonly used to correct acetabular dysplasia in children with open triradiate cartilage. The use of bovine xenogeneic bone graft (Tutobone&reg, ) for Dega osteotomy has not been reported so far. This study aimed to determine the clinical and radiological outcome in a large series of children with hip dysplasia who were treated by Dega osteotomy using a bovine xenogeneic block for stabilisation. Methods: A retrospective, single-centre study was conducted including 101 patients (147 hips) with different underlying diseases. The acetabular angle of Hilgenreiner (AA) and the lateral center-edge angle (LCA) were analysed to quantify the correction of acetabular indices. Graft incorporation was assessed using the Goldberg scoring system. Results: the mean preoperative AA improved from 28.1 (SD: 6.7) to 14.7 (SD: 5.1) after surgery (p &lt, 0.001). The mean preoperative LCA improved from 9.9 (SD: 6.7) to 21.8 (SD: 6.8) postoperatively (p &lt, 0.001). Both indices remained stable at the one-year follow-up examination. Graft incorporation was excellent with a mean Goldberg score of 6.6. Heterotopic ossification occurred in one hip without clinical relevance. Graft-related complications were not noted. Conclusions: Dega osteotomy using Tutobone&reg, is safe and effective in the treatment of acetabular dysplasia in children independent of the underlying disease.

Summary Objective Alterations in the subchondral bone (SCB) are likely to play a decisive role in the development of osteoarthritis (OA). Since aging represents a major risk factor for OA, the aim of the current study was to assess the microstructural changes of the subchondral bone in the femoral head during aging. Design Femoral heads and matched iliac crest biopsies of 80 individuals (age 21-99 years) were collected post-mortem. The bone microstructure of the subchondral trabecular bone as well as the cartilage thickness (Cg.Th) and subchondral bone plate thickness (SCB.Th) were quantified using histomorphometry. The different subregions of the SCB were also imaged by quantitative backscattered electron imaging (qBEI) in 31 aged cases to assess the bone mineral density distribution (BMDD). Results The detected linear decline of bone volume per tissue volume (BV/TV) in the femoral head with aging (Slope, 95% CI: -0.208 to -0.109 %/yr.) was primarily due to a decrease in trabecular thickness (Tb.Th, Slope, 95% CI: -0.774 to -0.343 μm/yr.). While SCB.Th declined with aging (Slope, 95% CI: -1.941 to -0.034 μm/yr.), no changes in Cg.Th were detected (Slope, 95% CI: -0.001 to 0.005 mm/yr.). The matrix mineralization of the subchondral bone was lower compared to the trabecular bone and also decreased with aging. Conclusions Regular changes of the SCB during aging primarily involve a reduction of Tb.Th, SCB.Th and matrix mineralization. Our findings facilitate future interpretations of early and late OA specimens to decipher the role of the SCB in OA pathogenesis.

Reduktion der Keimzahl im Kniegelenk durch Entfernung von infiziertem periprothetischem Weichgewebe, Spulung des Kniegelenks sowie Wechsel aller beweglichen Prothesenanteile zur Infektberuhigung und zum langfristigen Erhalt der Knietotalendoprothese (Knie-TEP). Knie-TEP-Fruhinfekt ( 4 Wochen postoperativ) oder chronische Knie-TEP-Infektion; gelockerte Knie-TEP; Problemerreger (Difficult-to-treat-Keime); kritische Weichteile mit moglicher Fistel. Ausschneiden von Wunde bzw. alter Operationsnarbe (= primarer Zugang zum Kniegelenk). Praparation des subkutanen Fettgewebes. Eroffnung der Gelenkkapsel. Schichtweises Entfernen aller alten Faden. Entnahme von Gewebeproben mit unbenutztem Instrument zur mikrobiologischen (5-mal) und histopathologischen Untersuchung (1-mal). Komplette Synovialektomie des oberen Rezessus. Teilresektion des Hoffa-Fettkorpers. Radikales Debridement peripatellar sowie im Bereich der medialen und lateralen Gelenkkapsel. Entfernung des Polyethyleninlays. Debridement der posterioren Gelenkkapsel unter Schonung von Gefasen und Nerv. Uberprufung der festen knochernen Integration der Prothesenkomponente. Antiseptische Spulung der Gelenkhohle mit mechanischer Reinigung der Prothesenkomponenten. Ausgiebige Jet-Lavage der Gelenkhohle (Spullosung 3–5 l). Handschuhwechsel und neue Operationsabdeckung. Einbringen eines neuen Polyethyleninlays. Intraartikulare Redondrainage und Wundverschluss. Redonzug am 2. postoperativen Tag. Physiotherapie und CPM-Schiene. Fadenzug um den 14. postoperativen Tag. Postoperative Antibiose fur 12 Wochen (2 Wochen i. v., 10 Wochen p. o.). Kontrolle der laborchemischen Entzundungsparameter. Bei richtiger Indikationsstellung und Therapie in bis zu 90 % der Falle positives Behandlungsergebnis mit Infektberuhigung und Erhalt der Knieprothese bei akuter Knie-TEP-Infektion.

Die chronisch-entzundliche Synovialitis sowie Tenosynovialitis fuhrt bei Patienten mit rheumatoider Arthritis zu Deformierungen des Ruck- und Vorfuses. Diese rheumatischen Fusdeformitaten schranken die Lebensqualitat der Betroffenen erheblich ein. Vor der Einfuhrung der Biologika in das Behandlungsregime der rheumatoiden Arthritis im Jahr 2000 wurde die Pravalenz rheumatischer Fusdeformitaten bei Rheumakranken, unabhangig von der Lokalisation, mit 77–94 % angegeben. Zwar scheint die Haufigkeit unter der Biologika-Therapie gemas einer skandinavischen Studie aus dem Jahr 2008 mit 45 % geringer zu sein, dennoch sind rheumatischen Fusdeformitaten weiterhin ein haufiges Problem.

There is growing evidence from case reports that methotrexate (MTX) therapy may impair bone metabolism in individual patients leading to low bone mass, atraumatic stress fractures and immobilizing bone pain - referred to as 'MTX osteopathy'. However, the clinical features, risk factors and treatment options of this condition are still elusive.A systematic review was conducted according to PRISMA guidelines. Two databases (MEDLINE, Embase) were searched for published cases of MTX osteopathy in patients with rheumatic musculoskeletal diseases (RMD). Data from the included publications were extracted and descriptive statistical analysis was performed.We report data from 32 studies describing 80 adult RMD patients with stress fractures in MTX osteopathy. Most cases were found in elderly women with longstanding RMD, especially rheumatoid arthritis (72.5%). MTX osteopathy commonly presented as stress fracture of the distal tibia (51.3%), calcaneus (35.0%) and proximal tibia (27.5%), mimicking arthritis in some cases. Although a majority of the patients met the densitometric criteria for osteoporosis (58.1%), typical osteoporotic fractures (e.g., vertebral fractures) were rarely seen. Patients frequently suffered from bilateral (55.0%), multiple (71.3%) and recurrent fractures (25.0%). Fractures mainly occurred at low to moderate doses of MTX therapy (45.0%). It should be noted that half (48.8%) of the patients did not receive systemic steroid therapy for at least 3 years.Low-dose MTX therapy in RMD may result in atraumatic stress fractures of the lower extremity that can mimic arthritis. MTX osteopathy is characterized by a pathognomonic type of stress fractures with band- or meander-shaped appearance along the growth plate.

The enlargement of osteocyte lacunae via osteocytic osteolysis was previously detected in situations of increased calcium demand (e.g., lactation, vitamin D deficiency). However, it is unclear whether similar processes occur also in the growing infantile skeleton and how this is linked to the mineral distribution within the bone matrix. Human iliac crest biopsies of 30 subjects (0–6 months, n = 14; 2–8 years, n = 6 and 18–25 years, n = 10) were acquired. Bone microarchitecture was assessed by micro-CT, while cellular bone histomorphometry was performed on undecalcified histological sections. Quantitative backscattered electron imaging (qBEI) was conducted to determine the bone mineral density distribution (BMDD) as well as osteocyte lacunar size and density. We additionally evaluated cathepsin K positive osteocytes using immunohistochemistry. Infantile bone was characterized by various signs of ongoing bone development such as higher bone (re)modeling, lower cortical and trabecular thickness compared to young adults. Importantly, a significantly higher osteocyte lacunar density and increased lacunar area were detected. Large osteocyte lacunae were associated with a more heterogeneous bone mineral density distribution of the trabecular bone matrix due to the presence of hypermineralized cartilage remnants, whereas the mean mineralization (i.e., CaMean) was not different in infantile bone. Absence of cathepsin K expression in osteocyte lacunae indicated nonexistent osteocytic osteolysis. Taken together, we demonstrated that the overall mineralization distribution in infantile bone is not altered compared to young adults besides high trabecular mineralization heterogeneity. Our study also provides important reference values for bone microstructure, BMDD and osteocyte characteristics in infants, children and young adults. Infantile bone displays large osteocyte lacunae indicating a developmental phenomenon rather than osteocytic osteolysis. Larger osteocytes may have superior mechanosensory abilities to enable bone adaption during growth.

Objectives To investigate if cartilage calcification (CC) is a systemic process, the purpose of this study was to determine the prevalence and the amount of meniscal/hyaline CC of the knee joint in the general population by high-resolution imaging (DCR) and to evaluate the association between CC with cartilage degeneration and age. Methods Cross-sectional DCR-study of 180 knee joints of 90 donors (42 female/48 male, mean age 62.3y). Histological hyaline (OARSI) and meniscal (Krenn) cartilage degeneration was determined of all knees. Results CC was observed in 100% of the donors (bilaterally in 98%), hyaline cartilage calcification (HCC) in 92% and meniscal calcification (MC) in 100%. CC was detected in more than three out of six distinct cartilage areas in 84.4% of all knees. The mean amount of CC correlated between both sides of donors, the different analyzed areas of the knee joint and between the various types of cartilage structures. There was more calcification in meniscal than in hyaline cartilage (factor 5.3) and in the medial than the lateral compartment (factor 1.2). HCC/MC were already detectable with only mild cartilage lesions and the amount correlated with histological cartilage degeneration, but not with age. Conclusions The present study provides evidence that meniscal and hyaline CC occurs in a pattern that is compatible with CC being a systemically driven process and that meniscal fibrocartilage is more prone to calcification than hyaline cartilage. Furthermore, the age-independent association between the amount of CC and the grade of degeneration in both hyaline and meniscal cartilage, suggests that CC is an obligatory early event in initiating cartilage degeneration.

ZusammenfassungDie Indikationsstellung zur operativen Therapie ist bei der rheumatoiden Arthritis anspruchsvoll. Mögliche Operationen müssen in den Gesamtkontext der chronischen Erkrankung eingebunden werden. Neben einer Abstimmung mit der bestehenden medikamentösen Basistherapie muss die Krankheitsaktivität und der Funktionsanspruch des Patienten mitbedacht werden. In dieser Übersichtsarbeit sollen die Indikationsgrenzen zur operativen Therapie an der unteren Extremität bei rheumatoider Arthritis dargestellt werden. Bei den operativen Verfahren in der Rheumachirurgie handelt es sich um Synovialektomien, Weichteileingriffe, Resektions interpositionsarthro - plastiken, endoprothetische Versorgungen und Arthrodesen. Für jedes Verfahren ergibt sich eine Indikation, aber auch eine Indikationsgrenze, abhängig von der anatomischen Lokalisation, dem Grad der Gelenkdestruktion und möglichen Voroperationen.