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Background: Consensus-orientated Delphi studies are increasingly used in various areas of medical research using a variety of different rating scales and criteria for reaching consensus. We explored the influence of using three different rating scales and different consensus criteria on the results for reaching consensus and assessed the test-retest reliability of these scales within a study aimed at identification of global treatment goals for total knee arthroplasty (TKA)., Methods: We conducted a two-stage study consisting of two surveys and consecutively included patients scheduled for TKA from five German hospitals. Patients were asked to rate 19 potential treatment goals on different rating scales (three-point, five-point, nine-point). Surveys were conducted within a 2 week period prior to TKA, order of questions (scales and treatment goals) was randomized., Results: Eighty patients (mean age 68 ± 10 years; 70% females) completed both surveys. Different rating scales (three-point, five-point and nine-point rating scale) lead to different consensus despite moderate to high correlation between rating scales (r = 0.65 to 0.74). Final consensus was highly influenced by the choice of rating scale with 14 (three-point), 6 (five-point), 15 (nine-point) out of 19 treatment goals reaching the pre-defined 75% consensus threshold. The number of goals reaching consensus also highly varied between rating scales for other consensus thresholds. Overall, concordance differed between the three-point (percent agreement [p] = 88.5%, weighted kappa [k] = 0.63), five-point (p = 75.3%, k = 0.47) and nine-point scale (p = 67.8%, k = 0.78)., Conclusion: This study provides evidence that consensus depends on the rating scale and consensus threshold within one population. The test-retest reliability of the three rating scales investigated differs substantially between individual treatment goals. This variation in reliability can become a potential source of bias in consensus studies. In our setting aimed at capturing patients' treatment goals for TKA, the three-point scale proves to be the most reasonable choice, as its translation into the clinical context is the most straightforward among the scales. Researchers conducting Delphi studies should be aware that final consensus is substantially influenced by the choice of rating scale and consensus criteria.

Background: Due to demographic changes an increasing number of hip osteoarthritis can be expected with corresponding effects on the health care system. Hence, the objectives of our study were to obtain substantiated evidence about current medical care situation of hip osteoarthritis patients including outpatient care situation and hip replacement surgery., Patients and Methods: Overall, the medical care data of 2.4 million insurees of the AOK Baden-Württemberg for the years 2007 to 2016 were analyzed. Lower limit of age was 40 years. The data includes outpatient and inpatient healthcare claims., Results: The age standardized prevalence of hip osteoarthritis in adults aged 40 years or older is 6.18% (95% CI: ± 0.09%) among women and 6.02% (95% CI: ± 0.09%) among men. From the age of 75, sex differences become significant. The maximum number of newly diagnosed cases of hip osteoarthritis (women: 1.31%, men: 1.16%) is found in the 80 - 84-year-olds. From the age of 85, 17.4% of all women and 16.5% of all men show a hip osteoarthritis. The maximum number of hip replacement surgery among osteoarthritis patients (women: 5.2%, men: 4.3%) appears in the 75- to 79-year-olds. After the initial diagnosis of a hip osteoarthritis, every eighth (13.0%) AOK insured person receives a hip replacement surgery within the first year and one in four (24.8%) insurees within 8 years. Irrespective of the main diagnosis, numbers of hip replacement surgery did not increase between 2009 and 2016. On average, 300.9 (women) and 275.8 (men) hip replacement surgeries were performed per 100 000 insured years. From the age of 80, hip osteoarthritis drops back as the main diagnosis fur surgery. Consequently, from the age of 85 more than 70% of all hip replacement patients show a femoral fracture as main diagnosis. Only about ¾ of the hip osteoarthritis patients were in outpatient specialist care in the year before surgery, and far less than half of hip osteoarthritis patients received a referral to physiotherapy., Conclusion: Osteoarthritis of the hip occurs approximately equally often in women and men up to the age of 75 years. Nevertheless, women underwent surgery more frequently. Overall, the number of hip replacement surgery has not increased in the last eight years. Within the first eight years after initial diagnosis of hip osteoarthritis 24.8% of all patients receive a hip TEP. Hence, the majority of patients is treated conservatively in the first eight years. A direct comparison between incidence and prevalent hip osteoarthritis patients reveals that after many years of therapeutic care in the last 1 - 2 years prior to surgery, both the specialist care as well as the referral to physiotherapy are reduced. A reassessment of conservative treatment options over time seems to be necessary., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Total knee arthroplasty (TKA) is one of the most frequent surgical procedures in orthopaedic surgery. Until now there have not been any standardized indication criteria, which might contribute to the large geographical differences in the frequency of TKA. This guideline aims to consent minimal requirements (main criteria), additional important aspects (minor criteria), as well as relative and absolute contraindications for TKA. The following main criteria have been consented: knee pain, radiological confirmation of osteoarthritis or osteonecrosis, inadequate response to conservative treatment, adverse impact of knee disease on the patient's quality of life and the burden of suffering due to the knee disease. Relative contraindications have been consented as severe general disease with reduced life expectancy and a BMI ≥40; absolute contraindications are an active infection and if the patient is not able to undergo major surgery.

Background and Objectives Knee osteoarthritis (OA) is a significant public health burden. Rates of total knee arthroplasty (TKA) in OA vary substantially between geographical regions, most likely due to the lack of standardised indication criteria. We set out to define indication criteria for the German healthcare system for TKA in patients with knee OA, on the basis of best evidence and transparent multi-stakeholder consensus. Methods We undertook a complex mixed methods study, including an iterative process of systematic appraisal of existing evidence, Delphi consensus methods and stakeholder conferences. We established a consensus panel representing key German national societies of healthcare providers (orthopaedic surgeons, rheumatologists, pain physicians, psychologists, physiotherapists), payers, and patient representatives. A priori defined consensus criteria were at least 70% agreement and less than 20% disagreement among the consensus panel. Agreement was sought for (1) core indication criteria defined as criteria that must be met to consider TKA in a normal patient with knee OA, (2) additional (not obligatory) indication criteria, (3) absolute contraindication criteria that generally prohibit TKA, and (4) risk factors that do not prohibit TKA, but usually do not lead to a recommendation for TKA. Results The following 5 core indication criteria were agreed within the panel: 1. intermittent (several times per week) or constant knee pain for at least 3 - 6 months; 2. radiological confirmation of structural knee damage (osteoarthritis, osteonecrosis); 3. inadequate response to conservative treatment, including pharmacological and non-pharmacological treatment for at least 3 - 6 months; 4. adverse impact of knee disease on patient's quality of life for at least 3 - 6 months; 5. patient-reported suffering/impairment due to knee disease. Additional indication criteria, contraindication criteria, and risk factors for adverse outcome were also agreed by a large majority within the multi-perspective stakeholder panel. Conclusion The defined indication criteria constitute a prerequisite for appropriate provision of TKA in patients with knee OA in Germany. In eligible patients, shared-decision making should eventually determine if TKA is performed or not. The next important steps are the implementation of the defined indication criteria, and the prospective investigation of predictors of success or failure of TKA in the context of routine care provision in Germany., Competing Interests: Conflict of Interest/Interessenkonflikt: The authors declare that they have no competing interests./Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To evaluate the clinical outcome in 108 total knee arthroplasty (TKA) patients with a medial-lateral balanced versus unbalanced gap after a mean follow-up of 34 months., Methods: 64 women and 44 men (mean age, 69.5 years) underwent computer-assisted TKA for osteoarthritis using a cemented fixed-bearing cruciate-retaining prosthesis. The medial-lateral gap difference (measured with the prosthesis in situ and the patella reduced) was balanced (≤2 mm) in 81 patients and unbalanced (>2 mm) in 27 patients. After a mean follow-up of 34 months, patients were assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire for pain, stiffness, and physical function. Scores were normalised to 0% (worst) to 100% (best)., Results: The balanced and unbalanced gap groups were comparable in terms of age, severity of osteoarthritis, and proportion of pre- and post-operative mechanical alignment. Compared with the balanced gap group, the unbalanced gap group had a larger medial-lateral extension gap difference (0.75±0.57 vs. 2.02±1.15 mm, p=0.001) and medial-lateral flexion gap difference (0.79±0.63 vs. 2.98±2.13 mm, p=0.001) and lower normalised total WOMAC score (84.9±18 vs. 74.8±20.8, p=0.017)., Conclusion: WOMAC score is better in TKAs with a medial-lateral balanced (<2 mm) gap.

Background: Musculoskeletal illnesses and injuries are among the most common ailments in the Federal Republic of Germany. In 2008 they generated costs of nearly 29 billion euros. Figures about their incidence and prevalence are necessary for a demand-oriented planning of future patient-centred care., Method: Pseudonymised data of 3.8 million people insured by AOK Baden-Württemberg between 2008 and 2013 were evaluated. The diagnoses were assigned to nine injury groups. For outpatient care confirmed diagnoses were considered, and for inpatient care both primary and secondary diagnoses were considered. For all patients with structural knee injuries, it was evaluated whether they made use of one of five eligible treatment paradigms either in the quarter in which they were injured or in the following quarter., Results: 418,257 patients were treated in 2013 for at least one new-onset injury (10.9 % of all insurees); 86,783 insurees (2.3 % of all insurees) had a newly occurring knee injury. The vast majority of the patients were treated by specialist doctors. While magnetic resonance imaging clearly increased during the observation period, the incidence of surgical therapy did not change. Striking are the different age distributions regarding the types of injuries, with a high injury incidence amongst young men and a significant increase in injuries between 2008 and 2013, especially amongst women., Conclusion: For the first time, the data quantify the knee injury incidences of a large cohort in Germany. They show which inpatient and outpatient health care services have been claimed and that an age- and gender-adapted prevention and an increased awareness are needed.

Purpose: Reconstruction of the joint line is crucial in total knee arthroplasty (TKA). A routine height of tibial cut to maintain the natural joint line may compromise the preservation of the PCL. Since the PCL footprint is not accessible prior to tibial osteotomy, it seems beneficial to identify a reliable extraarticular anatomic landmark for predicting the PCL footprint and being visible within standard TKA approach. The fibula head predicts reliably the location of PCL footprint; however, it is not accessible during TKA. The aim of this study now was to analyze whether the tibial tuberosity can serve as a reliable referencing landmark to estimate the PCL footprint height prior to tibial cut., Methods: The first consecutive case series included 216 CR TKA. Standing postoperative lateral view radiographs were utilized to measure the vertical distance between tibial tuberosity and tibial osteotomy plane. In the second case series, 223 knee MRIs were consecutively analyzed to measure the vertical distance between tibial tuberosity and PCL footprint. The probability of partial or total PCL removal was calculated for different vertical distances between tibial tuberosity and tibial cutting surface., Results: The vertical distance between the tibial tuberosity and tibial cut averaged 24.7 ± 4 mm. The average vertical distance from tibial tuberosity to proximal and to distal PCL footprint was found to be 22 ± 4.4 and 16 ± 4.4 mm, respectively. Five knees were considered at 50% risk of an entire PCL removal after CR TKA., Conclusions: Current surgical techniques of tibial preparation may result in partial or total PCL damage. Tibial tuberosity is a useful anatomical landmark to locate the PCL footprint and to predict the probability of its detachment pre-, intra-, and postoperatively. This knowledge might be useful to predict and avoid instability, consecutive pain, and dissatisfaction after TKA related to PCL insufficiency., Level of Evidence: III.

Background: Anterior knee pain is a known complication after implantation of a prosthesis and a possible reason is a posterior knee joint instability; however, the influence on postoperative stability is just as unknown as the possible influence of the type of prosthesis on postoperative stability., Aim: This study investigated two possible preoperative and intraoperative influencing factors by determination of the preoperative joint stability and type of prosthesis.

Background: Navigation systems have been successful in reducing the outlier of leg alignment after total knee arthroplasty (TKA). Less is known about the restoration of the anatomical joint line with computer-assisted knee replacement. The aim of this study was to determine whether joint line changes <3 or ≥3 mm are predictable with several pre- and intraoperative parameters., Methods: The study included a total of 180 cases of primary computer-assisted TKA performed using the gap-balancing/tibia-first technique. The final shift of the joint line was calculated using computer verification of proximal tibial and distal femoral cuts. In consideration of the clinical relevance of a 3-mm joint line shift, patients were stratified into two groups: Group I, with joint line change <3 mm, and Group II, with joint line change ≥3 mm. Between groups, variables such as demographics, Kellgren & Lawrence degree of osteoarthritis, preoperative flexion contracture, pre-/intraoperative mechanical leg alignment, flexion/extension gaps, and implant design/sizes were compared statistically., Results: The absolute joint line shift averaged 1.6 ± 1.3 mm (range 0-6 mm). A joint line shift ≥3 mm was observed in 28 cases (15 %). A statistically significant difference between groups was not identified for any of the parameters. Shift of the joint line did not correlate with the analyzed variables., Conclusions: Joint line was adequately restored when computer navigation was carefully applied as a measuring tool for primary TKA. Knee joint deformity, leg alignment, gap balance, and implant type did not aid in predicting the joint line shift.

Introduction: Only 84 % of patients are satisfied with the operative result after total knee arthroplasty. A relevant reason is non-fulfilled preoperative expectations. Non-fulfilled preoperative expectations cannot be influenced postoperatively. So a knowledge of preoperative expectations and their influential factors is essential. The following study analyses the expectations and influential factors in patients before total knee arthroplasty in Germany., Material and Methods: On the day before total knee replacement in 104 patients the following data were collected: school leaving level, comorbidities, articular knee function, psychological mood, health-related quality of life, and preoperative expectations. Statistical evaluation was done by factor analyses of expectations and independent variables, and correlation and regression analyses., Results: The following 4 factors of expectations resulted from the factor analyses: (i) relief of pain, (ii) increase of range of motion of the knee, (iii) better mobility, and (iv) better integration in social activities. In general patient expectations on the effects of a total knee replacement are high. Age and better integration in social activities correlate negatively, as also do age and better mobility. Body mass index and better integration in social activities correlate positively. The following formula analyses the expectations of better integration in social life: social expectations = 116-0.991 × age., Discussion: For the first time this study determines expectations and influential factors of patients who undergo a total knee replacement in Germany. By knowing the interaction of satisfaction and preoperative expectations, this knowledge is an essential condition to increase satisfaction after total knee replacement in the German population. Collecting the preoperative expectations of patients has to be an indispensable feature of the clinical practice in orthopaedic surgery., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The hypothesis of our study is that a routine tibial cut during cruciate retaining TKA may result in a partial or a total removal of the PCL footprint. Therefore providing a reliable landmark is essential to estimate the probability of PCL damage with a tibial cut and to enable the surgeon to decide pre-operatively whether a cruciate retaining implant design is suitable., Methods: In a case series of 175 cruciate retaining TKA, the routinely made standing postoperative AP-view radiographs were evaluated to determine the distance between fibula head and tibial cutting plane. In a second case series knee MRI of 223 subjects were consecutively used to measure the vertical distance between tibial attachment of PCL and fibula head. The probability of partial or total PCL damage was calculated for different vertical distances between tibial cut and fibula head., Results: The vertical distance between the tibial cut and the most proximal point of the fibula head averaged 6.1 mm ±4.8 mm. The mean vertical distance from fibula head to proximal and to distal PCL footprint revealed to be 11.4 mm ±3.7 mm and 5.4 mm ±2.9 mm, respectively. The location of the insertion was not significantly different between subgroups such as age (<50 or >50 years), gender and side. Based on our results 11 (7%) knees were considered at high risk of an entire PCL removal after implantation of a cruciate retaining TKA design., Conclusions: Currently available routine tibial preparation techniques result in partial or total posterior cruciate ligament detachment. Fibula head as a landmark aids to predict the PCL location and to estimate its disruption pre- and postoperatively on AP-view radiographs.

Introduction: Patellofemoral related complications after total knee arthroplasty (TKA) remain clinically relevant. The hypothesis of the present study was that the patellar height changes more than 10% of its preoperative height after TKA. Possible influences of age, gender, side and navigation system on patellar height were evaluated separately in subgroups., Materials and Methods: A total of 107 knees were enrolled after primary TKA. The patellar height was determined for each patient preoperatively, 1 week and 1 year postoperatively on routinely performed standing lateral view radiographs at 30° knee flexion. Insall-Salvati index (ISI), modified Insall-Salvati index (MIS) as well as Miura-Kawamura index (MKI) were determined for the whole cohort., Results: One week after TKA the ISI, MIS and MKI changed by more than 10% in 24 (22%), 33 (30%) and 54 (50%) cases, respectively. Moreover, the 1 year follow-up revealed a decrease or increase of ISI in 30 (28%), MIS in 47 (44 %) and MK in 65 (61%) knees. The frequency of patella alta, norma and baja preoperatively as well as 1 week and 1 year postoperatively were not significantly different. Significant differences of patellar height changes were not noted between the defined subgroups., Conclusions: The present study demonstrates that TKA leads, at 1 week and 1 year follow-up, to patellar height alteration more than 10% in a significant number of knee joints. However, with the use of ISI and MIS the changes of patellar height did not exceed the defined thresholds to be classified as patella alta or baja.

Total knee arthroplasty (TKA) is one of the most common operations in orthopedic surgery worldwide but despite being mainly successful only 81 % of patients are satisfied with the final result. The following systematic review compared patient satisfaction and analyzed the causal connections and influencing factors after TKA between 1990-1999 and 2000-2012. From 1990 to 1999 a total of 81.2 % of patients were satisfied after TKA and in the period 2000-2012 patient satisfaction increased to 85 %. Influencing factors on postoperative satisfaction derived from the 25 publications included in the study were consistently body-mass index, patient expectations, pain, joint function and mental factors. A lack of satisfaction scores and different designs resulted in difficulties in comparing the studies and were subsequently limitations of this study.

Purpose: Navigation has been introduced to achieve more accurate positioning of the implants after TKA. The scientific attention was mainly paid on limb alignment rather than restoration of the natural joint line. The aim of our study was to compare the accuracy of the joint line restoration in primary TKA with and without navigation. We hypothesized that joint line reconstruction in navigated TKA is more accurate., Methods: A total of 493 primary TKAs operated in a single medical centre were consecutively selected and divided into two groups. 206 cases were performed computer assisted (BrainLab CI-System), whereas 287 knees were implanted conventionally. For both groups, the joint line position of the knee was determined on standardized calibrated standing pre- and postoperative digital radiographs in ap view by a modified method of Kawamura et al. A joint line shift of more than 8 mm was defined as outlier., Results: In the conventional group, the joint line shift averaged 0.7 mm (±4.4 mm), whereas the findings in the computer-assisted cases were in average 0.6 mm (±4.5 mm). The joint line was located above 8 mm in 6 % of non-navigated versus 6.8 % of navigated primary TKAs. There were no statistically significant differences of joint line shift between the different component types. A statistically significant relation was not found between joint line shift and leg alignment changes., Conclusions: Conventional surgical technique allows a precise joint line reconstruction in primary TKA. Navigation did not improve the joint line reconstruction., Level of Evidence: Diagnostic study, Level III.

Primary involvement of skeletal muscle is a very rare event in ALK-1 positive anaplastic large cell lymphoma (ALCL). We describe a case of a 10-year old boy presenting with a three week history of pain and a palpable firm swelling at the dorsal aspect of the left thigh. Histological examination of the lesion revealed a tumoral and diffuse polymorphic infiltration of the muscle by large lymphoid cells. Tumor cells displayed eccentric, lobulated "horse shoe" or "kidney-shape" nuclei. The cells showed immunohistochemical positivity for CD30, ALK-1, CD2, CD3, CD7, CD8, and Perforin. Fluorescence in situ hybridization analysis revealed a characteristic rearrangement of the ALK-1 gene in 2p23 leading to the diagnosis of ALK-1 positive ALCL. Chemotherapy according to the ALCL-99-NHL-BFM protocol was initiated and resulted in a complete remission after two cycles. This case illustrates the unusual presentation of a pediatric ALCL in soft tissue with a good response to chemotherapy.