Sekundäre Steife der Schulter

Background

In addition to idiopathic shoulder stiffness, secondary shoulder stiffness in particular is often associated with extra-articular subacromial adhesions between the rotator cuff and the surrounding anatomical structures.

Objective

The aim of this article is to present clinical results and complications as well as the surgical technique of extra-articular release in the context of secondary shoulder stiffness.

Material and Methods

Selective review of the literature and presentation of own clinical experience.

Results

Intra-articular and extra-articular release are related to a high patient satisfaction and an improved range of motion. Exact knowledge of the extra-articular anatomy is necessary to prevent iatrogenic lesions of vessels, nerves and the rotator cuff. Compared to patients with a primary stiff shoulder, patients suffering from posttraumatic stiff shoulder benefit more from arthroscopic interventions with intracapsular and extracapsular release.

Conclusion

Restrictions in range of motion of the shoulder can be related to extra-articular adhesions. These adhesions need to be specifically addressed during arthroscopic treatment of stiff shoulders.

     

Arthroskopische Therapie der Kniesteife

Background

Knees with a limited range of motion caused by intraarticular scars benefit from arthroscopic arthrolysis. Usually these scars result from previous surgery, severe trauma with damage of intraarticular structures.

Objectives

The aim of this procedure is to improve the patients’ range of motion which is necessary for activities of work and daily life. Scar tissue is debrided and resected arthroscopically with a radiofrequency device, a shaver or a punch.

Indications

Indications are a flexion deficit of max. 40°, an extension deficit of max. 20°, reduced mobility of patella, intraarticular reason for limited range of motion, cyclops after anterior cruciate liagment reconstruction, fibrotic Hoffa fat pad.

Contraindications

Contraindications are an extraarticular origin of limited range of motion (e.?g. fibrotic quadriceps muscle), local and general infection, major osteoarthritis, noncompliance, complex regional pain syndrome type I.

Postoperative management

A continuous physical therapy to maintain range of motion is essential. If necessary, continuous passive motion is implemented. Pain adapted weight-bearing should be used for mobilization. A sufficient oral and (when indicated) regional pain management is important to guarantee the benefit of the surgery.

Results

Patients with a lack of mobility of the knee gain a significantly increased range of motion by this arthroscopic procedure. Because of the minimal invasiveness, trauma of surgery and risk of infection are reduced. In many cases the function of the knee joint can be completely restored or at least improved considerably. Complications such as early osteoarthritis can be avoided.

     

Primäre kapsuläre Steife der Schulter

Background

Primary capsular stiffness (PCS) is a common shoulder disease without identifiable etiology or associated pathology. The stage-adapted multimodal treatment of PCS is challenging and still requires optimization.

Objectives

The newest, evidence-based perceptions related to PCS with recommendation of clinically relevant diagnostic and therapeutic guidelines are summarized.

Materials and methods

Relevant, new findings regarding the etiology and diagnosis of PCS from the last 10 years were summarized. A 2012 treatment algorithm for PCS was updated and expanded with the most current knowledge.

Results

The subacromial space is involved in inflammatory processes in the initial phase of PCS. Identification of advanced glycation end products help with understanding the fibrotic changes. Elevated serum lipid levels are associated with PCS but their exact role remains unclear. Distension of the bursa in the superior subscapularis recess is a “new” suggestive MRI sign of the pathology. Combined intraarticular and subacromial corticosteroid injections seem favorable over intraarticular-only injections. Hospital-based exercise class is more effective regarding the functional outcomes of PCS than individual physiotherapy or home exercise. Additional passive stretching of the capsule in the pain-free frozen and thawing states is beneficial. After failure of nonoperative treatment of at least 6 months, arthroscopic arthrolysis is recommended.

Conclusions

Several publications in the literature over the past few years have contributed to an improved understanding and better treatment of PCS.

     

Entropy-based particle correspondence for shape populations

Purpose

Statistical shape analysis of anatomical structures plays an important role in many medical image analysis applications such as understanding the structural changes in anatomy in various stages of growth or disease. Establishing accurate correspondence across object populations is essential for such statistical shape analysis studies.

Methods

In this paper, we present an entropy-based correspondence framework for computing point-based correspondence among populations of surfaces in a groupwise manner. This robust framework is parameterization-free and computationally efficient. We review the core principles of this method as well as various extensions to deal effectively with surfaces of complex geometry and application-driven correspondence metrics.

Results

We apply our method to synthetic and biological datasets to illustrate the concepts proposed and compare the performance of our framework to existing techniques.

Conclusions

Through the numerous extensions and variations presented here, we create a very flexible framework that can effectively handle objects of various topologies, multi-object complexes, open surfaces, and objects of complex geometry such as high-curvature regions or extremely thin features.

     

Management of Pediatric Ankle Fractures

Purpose of Review

Summarize classic and recent information regarding the unique subset of ankle fractures in children with open growth plates and share the authors’ decision-making and surgical techniques.

Recent Findings

Recent research on pediatric ankle fractures has centered on the accurate prediction and prevention of growth arrest following fractures of the distal tibia. Another source of discussion is the necessity and benefit of CT scanning in classification and treatment approach.

Summary

Pediatric ankle fractures continue to pose clinical challenges for orthopedic surgeons. While open anatomic reduction and internal fixation continue to produce good outcomes for intra-articular fractures, outcomes of physeal injuries are more difficult to predict. More studies are needed to determine which patients may benefit more from surgical treatment of physeal injuries.

     

Posterior Cruciate Ligament: Anatomy and Biomechanics

Purpose of Review

The purpose of this review is to present an in-depth look at the most recent literature regarding pertinent posterior cruciate ligament (PCL) anatomy and biomechanics.

Recent Findings

The PCL is an important restraint of posterior tibial translation relative to the femur. In addition, the PCL acts as a secondary restraint to resist varus, valgus, and external rotation moments about the knee. While less common than ACL injuries, injuries to the PCL can occur from a posterior force directed on the tibia, most common with the knee in a flexed position.

Summary

The PCL is composed of two functional bundles and has important implications for knee stability. The anterolateral and posteromedial bundles have different patterns of tensioning throughout knee range of motion. The two bundles therefore contribute to resisting posterior tibial translation and rotation at different angles of knee flexion.

     

Indications and Guidelines for Debridement and Implant Retention for Periprosthetic Hip and Knee Infection

Purpose of Review

Prosthetic joint infection is one the most common causes of revision surgery after hip or knee replacement. Debridement and implant retention (DAIR) is one method of treating these infections; however, significant controversy exists. The purpose of our review was to describe current knowledge about indications, intraoperative/postoperative patient management, and outcomes of DAIR.

Recent Findings

Patient selection affects the success of DAIR. Medical comorbidities, duration of symptoms, and nature of infectious organism all influence outcomes. Intraoperative techniques such as open arthrotomy, extensive debridement, copious irrigation, and exchange of modular parts remain current standards for DAIR. Postoperative administration of antibiotics tailored to operative cultures remains critical. Antibiotic suppression may increase the success of DAIR.

Summary

DAIR provides reasonable infection eradication between 50 and 80% with improved outcomes in appropriately selected patients. More research is needed on the use of adjuvant therapies intraoperatively and the role of postoperative antibiotic suppression.

     

Stellenwert der Knochenmarkstimulation

Introduction

Bone marrow stimulation is a well-established technique for cartilage reconstruction. Over the last decades abrasion arthroplasty has been widely replaced by microfracturing. Furthermore, drilling techniques and subchondral needling are used to access deeper blood channels and have been investigated during the last years.

Results

Studies with the highest evidence levels have identified several factors which affect the clinical outcome after bone marrow stimulation for the treatment of cartilage defects of the knee; however, these influencing factors may be specific for the knee as other joints differ in biomechanics, loading and cartilage structure. In contrast, bone marrow stimulation promotes a low tissue quality in all joints which is predominantly fibrous in nature and with a variable content of hyaline-like cartilage.

Conclusion

Treatment using cartilage repair requires a careful patient selection by a specialized surgeon that considers the indication criteria, joint-specific biomechanical aspects and the reduced loading capacity of the newly formed tissue.

     

Olanzapine vs haloperidol: treating delirium in a critical care setting

Objective

To compare the safety and estimate the response profile of olanzapine, a second-generation antipsychotic, to haloperidol in the treatment of delirium in the critical care setting.

Design

Prospective randomized trial

Setting

Tertiary care university affiliated critical care unit.

Patients

All admissions to a medical and surgical intensive care unit with a diagnosis of delirium.

Interventions

Patients were randomized to receive either enteral olanzapine or haloperidol.

Measurements

Patient’s delirium severity and benzodiazepine use were monitored over 5 days after the diagnosis of delirium.

Main results

Delirium Index decreased over time in both groups, as did the administered dose of benzodiazepines. Clinical improvement was similar in both treatment arms. No side effects were noted in the olanzapine group, whereas the use of haloperidol was associated with extrapyramidal side effects.

Conclusions

Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom haloperidol is contraindicated.

     

Preoperative Education for Hip and Knee Replacement: Never Stop Learning

Purpose of review

Participation in alternative payment models has focused efforts to improve outcomes and patient satisfaction while also lowering cost for elective hip and knee replacement. The purpose of this review is to determine if preoperative education classes for elective hip and knee replacement achieve these goals.

Recent findings

Recent literature demonstrates that patients who attend education classes prior to surgery have decreased anxiety, better post-operative pain control, more realistic expectations of surgery, and a better understanding of their surgery. As a result, comprehensive clinical pathways incorporating a preoperative education program for elective hip and knee replacement lead to lower hospital length of stay, higher home discharge, lower readmission, and improved cost.

Summary

In summary, we report convincing evidence that preoperative education classes are an essential element to successful participation in alternative payment models such as the Bundle Payment Care Initiative.

     

Prevention and Management of Post-operative Complications Following ACL Reconstruction

Purpose of Review

The goal of this paper is to review the current management and prevention of post-operative complications after anterior cruciate ligament (ACL) reconstruction. Trends in rehabilitation techniques will be presented, in addition to suggestions for interventions and expected milestones in ACL reconstruction recovery.

Recent Findings

ACL reconstruction protocols have evolved to more of a criterion-based progression rather than a tissue-healing time frame. Given the evolution of ACL surgical reconstruction techniques and rehabilitation protocols, the risk of post-operative complications can arise both early and late in the recovery process. This paper will discuss the role of preventative measures as it applies to the post-operative patient with ACL reconstruction.

Summary

Short-term complications following ACL reconstruction include infection and deficits to knee motion and strength, whereas long-term complications include secondary ACL injury to either the involved or contralateral knee and lack of ability to return to high-level sports following this procedure. Future research should continue to address the multifactorial causes of secondary ACL injury and limited ability of patients to return to high level activities.

     

Predictive factors for polypharmacy among child and adolescent psychiatry inpatients

Background

Aim was to determine the predictive factors for polypharmacy among inpatient children and adolescents with psychiatric disorders.

Methods

Blinded, case-note review of children and adolescents with ICD 10 diagnosis of psychiatric disorders on psychotropic medication was conducted. Data on demography, illness, and treatment was analyzed with univariate and multivariate techniques.

Results

Proscribing non-pharmacological interventions (OR = 4.7) and pro re nata medication (OR = 3.3), increased the risk of polypharmacy. Prescribing physical restraint reduced the risk of receiving multiple medications (OR = 0.3).

Conclusion

Proscribing non-pharmacological interventions, pro re nata medication and physical restraints increased polypharmacy.

     

Low dose quetiapine induced galactorrhoea: a case report

Background

Quetiapine causes less prolactin elevation and/or galactorrhoea than other atypical antipsychotics.

Case Presentation

Ms AB had galactorrhoea and raised prolactin levels at only 100 mg of quetiapine daily.

Conclusion

Low dose quetiapine can also cause galactorrhoea.

     

Minimally invasive techniques for lumbar decompressions and fusions

Purpose of review

The purpose of this study is to summarize the recent literature investigating the use of minimally invasive (MIS) techniques in the treatment of lumbar degenerative stenosis, spondylolisthesis, and scoliosis.

Recent findings

MIS lumbar decompression and fusion techniques for degenerative pathology are associated with reduced operative morbidity, shortened length of hospital stay, and reduced postoperative pain and narcotics utilization. Recent studies with long-term clinical follow-up have demonstrated equivalence in clinical outcomes between open and MIS surgical procedures. Radiographically, MIS procedures provide adequate postoperative correction of coronal alignment. Correction of sagittal alignment, however, is more variable based on current reports.

Summary

MIS techniques are both safe and effective in the treatment of lumbar degenerative pathologies. While some studies have reported on long-term outcomes and costs associated with MIS procedures, more investigation into these topics is still necessary. Additionally, further work is required to analyze the training requirements and learning curves of MIS procedures to better promote adoption amongst surgeons.

     

Investigating physical fitness and race performance as determinants for the ACL injury risk in Alpine ski racing

Background

ACL ruptures in Alpine ski racers are frequently observed. This study analysed the association between physical fitness, race performance and the knee injury history.

Methods

A retrospective study was conducted to investigate the influence of physical fitness and performance on the knee injury outcome. As part of this study an injury data base (covering 2004–2013) was established that recorded information about the athletes, their fitness status as determined by a standardised fitness test (Swiss Ski Power Test, SSPT) as well as medical information related to injuries. The performance of athletes who sustained knee injury was compared to athletes who suffered no injury or a different injury.

Results

Twenty-seven (19f, 8 m) of 70 athletes sustained a knee injury. ACL ruptures accounted for 71 % of these knee injuries. While more females sustained a knee injury, the difference between males and females was not statistically significant. It was shown that athletes with a better FIS (Fédération Internationale de Ski) rank were more prone to knee injury. However, none of the parameters related to physical fitness was linked to a history of knee injury.

Conclusions

A general fitness test as SSPT is not associated with a history of knee injury in Alpine skiing. More specific physical fitness test procedures should be investigated to determine relevant fitness factors.

     

Factors That Affect Outcome Following Total Joint Arthroplasty: a Review of the Recent Literature

Purpose of Review

It is well established that certain patient-specific risk factors affect outcomes following total joint arthroplasty. The goal of this paper is to summarize the latest data on several variables that have been investigated in the last 3 years and to characterize the effects these factors have on the success of hip and knee replacement.

Recent Findings

Preoperative diagnoses of depression and anxiety, liver disease, hypoalbuminemia, vitamin D deficiency, and diabetes mellitus are associated with increased risk of postoperative complications and can lead to worse outcomes after joint replacement surgery.

Summary

Recent investigations have clearly established a link between these patient-specific factors and poor outcomes after hip and knee arthroplasty, but future research is needed to determine best practices for stratifying and mitigating these risks for patients.

     

Return to Sports After Shoulder Stabilization Surgery for Anterior Shoulder Instability

Purpose of Review

Young athletes continue to experience traumatic shoulder instability and are often plagued by recurrent instability, limiting their return to sport. The purpose of this paper was to review return to sport in athletes after shoulder stabilization surgery for anterior shoulder instability.

Recent Findings

Athletes managed nonoperatively demonstrate unacceptably high rates of recurrent instability and are less likely to successfully return to sport. Operative management includes capsuloligamentous repair (arthroscopic versus open) and bone augmentation techniques. While modern arthroscopic techniques have provided favorable outcomes, open techniques have demonstrated lower recurrence rates among young collision athletes. A subset of athletes continue to experience recurrent instability, leading to further investigation of concomitant pathologies, which may put patients at risk of failure following Bankart repair. Bony augmentation procedures remain favorable for patients with glenoid bone loss; however, what constitutes critical bone loss in the decision between anterior labral repair versus bone augmentation has recently been questioned.

Summary

Operative management of anterior shoulder instability provides superior results, including lower recurrent instability and return to sport. Future research on patient-specific risk factors may aid surgical decision-making and optimization of outcomes.

     

Platelet-Rich Plasma and the Knee—Applications in Orthopedic Surgery

Purpose of Review

To consolidate and synthesize the most recent evidence on the effects of platelet-rich plasma (PRP) in the knee with respect to osteoarthritis, meniscal injuries, ACL reconstruction, total knee arthroplasty (TKA), and high tibial osteotomy.

Recent Findings

PRP has been shown to be more beneficial in the context of knee osteoarthritis compared to both placebo and hyaluronic acid. Direct comparison with corticosteroid injections has been sparsely studied. It has also been shown to improve the clinical postoperative course in meniscal injuries and to a lesser extent TKA. Radiographic improvements without clinically significant benefits have been observed with ACL reconstructions treated with PRP.

Summary

PRP injections may be more beneficial than other current non-surgical management options for specific knee pathologies. Further research should broaden the knowledge of PRP effects on the knee, and identify the type of PRP, growth factor distribution, and route of administration associated with the most benefit.

     

Fluoroscopy-based tracking of femoral kinematics with statistical shape models

Purpose

Precise knee kinematics assessment helps to diagnose knee pathologies and to improve the design of customized prosthetic components. The first step in identifying knee kinematics is to assess the femoral motion in the anatomical frame. However, no work has been done on pathological femurs, whose shape can be highly different from healthy ones.

Methods

We propose a new femoral tracking technique based on statistical shape models and two calibrated fluoroscopic images, taken at different flexion–extension angles. The cost function optimization is based on genetic algorithms, to avoid local minima. The proposed approach was evaluated on 3 sets of digitally reconstructed radiographic images of osteoarthritic patients.

Results

It is found that using the estimated shape, rather than that calculated from CT, significantly reduces the pose accuracy, but still has reasonably good results (angle errors around 2\(^\circ \), translation around 1.5 mm).