Konservative Therapie der chronischen Enthesiopathien

The majority of insertional and noninsertional tendinopathy cases are associated with repetitive or overuse injuries. Certain tendons are particularly vulnerable to degenerative pathology; these include the Achilles and patella tendon, the rotator cuff, and forearm extensors/flexors. Disorders of these tendons are often chronic and can be difficult to manage successfully in the long term. Eccentric exercise has the strongest evidence of therapeutic efficacy. Extracorporeal shock wave treatment, sclerosing agents as well as nitric oxide patches show promising early results but require long-term studies. Corticosteroid and nonsteroidal antiinflammatory medications have not been shown to be effective except for temporary pain relief for rotator cuff tendinopathy. Platelet-rich plasma injections show encouraging short-term results.     

Diagnosespezifische Unterschiede der Kniegelenkgeometrie

Background

Arthrotic deformities with changes in knee geometry can produce difficulties in implanting long stem knee prosthesis systems using intramedullary alignment. They can result in incorrect lower limb axis and prosthesis positioning. The aim of the presented study was to measure knee geometry in patients with varus and valgus gonarthrosis in order to define diagnosis related differences.

Methods

A total of 75 patients with indication for total knee arthroplasty were divided in two groups using the weight bearing lower limb axis: patients with varus gonarthrosis (n=43) and with valgus gonarthrosis (n=32). Angles and extensions, important for knee prosthesis implantation, were measured, digitalized and analyzed. The results were investigated for diagnosis specific differences.

Results

After regulation of the measured extension in mean femur/tibia lengths, significant diagnosis specific differences were found: femur condyles were widened towards pathologic weight bearing (P<0.044), and the mechanical tibia axis of the varus gonarthrosis group is transferred to the lateral side (P<0.046) and in projection over the lateral internal cortical substance.

Conclusion

The significant differences in deformed arthrotic knees indicate that for an optimal postoperative result the use of standard implants is not always sufficient. Modular knee prosthesis systems can provide adequately for individual demands.     

Influence of orthopaedic-technical aid on the kinematics and kinetics of the knee joint of patients with neuro-orthopaedic diseases

In our gait laboratory, the gait pattern of 18 youths with neurogenic foot deformities as a result of spina bifida or cerebral palsy was examined. The influence of technical orthopaedic devices for the foot and ankle on kinematics and kinetics of the gait and especially of the knee joint were analyzed. Kinematic data were derived from 3D-video analysis, kinetic data from force plates and pressure distribution plates. Muscle activities were measured with eight-channel EMG. The data were examined to see if there were differences when using the technical devices. All patients had already been supported externally with the different devices like orthopaedic shoes, insoles, Nancy Hilton orthoses and orthoses for the lower leg extremity. The devices restricted to the foot and the ankle joint improved the feeling of gait stability of the patients. In this investigation, the different supports had various but little effects on the kinematics and kinetics of the knee joint, depending on the type of orthoses used and the kind of handicap of the youths. Because of the great expenditure, the data obtained in this study were taken from a small number of patients. Therefore, they are individual findings and are of restricted general significance.     

Calculation of hallux bending moments from plantar pressure distribution measurement

PURPOSE: The following study aims to demonstrate the bending stress on a hallux valgus during normal gait. The bending axis was related to the position of an open wedge osteotomy. The moments were calculated from plantar pressure measurements. METHOD: In the gait analysis laboratory plantar pressure distribution measurement was done with healthy adult volunteers during barefoot gait. From the plantar pressure distribution the vertical forces were derived just for the region hallux metatarsal I. The following calculation of the bending stress regarding to the hypothetic region of the osteotomy was done by integrating the pressure distribution multiplicated with the distance to the osteotomy. The measurements are compared with theoretical values derived from the anatomy of the foot under some plausible assumptions. RESULTS: The results of the mean values of the bending stress were 15.8 +/- 4.8 Nm for the female subjects and 21.6 +/- 5.6 Nm for the male subjects. The amount of the bending moments depended with low significance on the weight. More important is the individual type of gait. CONCLUSION: The measurements show the size of bending stress the plate stabilizing the osteosynthesis has to resist under unfavorable circumstances (for example if the plantar foot muscles are not adequately activated) and if no external stabilization (for example, cast) is used.     

Chronische Radikulopathie

Zusammenfassung Die Behandlung chronischer Rückenschmerzen mit radikulärer Symptomatik ist ein bis heute nicht gelöstes klinisches Problem. Die von Racz beschriebene Technik der perkutanen minimal-invasiven Neurolyse findet zunehmend Anwendung zur Behandlung der chronischen Radikulopathie. Es wurden 61 Patienten mit einer entsprechenden Symptomatik nach Prüfung der Ein- und Ausschlusskriterien mittels Kathetertechnik nach Racz im Bereich der lumbalen Spinalnerven behandelt. 3 und 6 Monate nach perkutaner minimal-invasiver epiduraler Neurolyse kam es zu einer deutlichen klinischen Verbesserung. Die subjektive Schmerzempfindung, quantifiziert auf dem McNab-Score, zeigte sowohl nach 3 als auch nach 6 Monaten eine deutliche Verbesserung. Mit Ausnahme einer partiellen Katheterabscherung in 2 Fällen und einer Infektion konnten keine relevanten Nebenwirkungen festgestellt werden.Die Kathetertechnik nach Racz ist zur Behandlung der chronischen Radikulopathie nach Bandscheibenoperationen oder Bandscheibenvorfällen geeignet und nebenwirkungsarm.     

Zugangswege zum Oberflächenersatz am Hüftgelenk

A large variety of approaches are described for standard total hip arthroplasty. All of them are technically based on three different approaches: anterior, anterolateral, or posterior. In recent hip resurfacing, the posterior approach is common, due to large instruments used to ream the femur. Better exposure of the acetabulum is achieved by the posterior approach, but this technique puts the important extraosseous blood supply to the femoral head at risk. The anterior approach preserves blood supply and gives better options to treat the femoroacetabular impingement. If specific surgical modifications and instruments designed for minimally invasive surgery are used, hip resurfacing can be performed with an anterolateral technique. Excellent functional and clinical outcomes have been reported after all three approaches.     

Evidence-Based Medicine and Clinical Trials in Pain Practice and Orthopedics

Abstract:   Medical practices should be based on scientific findings pursuant to the rules of evidence-based medicine. Quality standards for interventional pain therapy and orthopedic clinical studies have been lacking. As a result, the efficacy of many forms of therapy is insufficiently documented, making the level of evidence low.
This article identifies common deficiencies in the conduct of clinical trials, as well as limitations in conducting randomized controlled studies. Recommendations for improvement are provided. The discussion provides the clinically active physician with interpretation aids for the evaluation of meta-analyses, supports personal evidence-based decisions, and reviews the most important principles for planning and conducting of experimental clinical studies. Current examples in the literature verify the implementation of these principles and present current findings in accordance with evidence-based medicine (EBM) criteria.
In spite of an increasing emergence of EBM-based studies, we conclude that the number of well-designed, high quality, controlled studies conducted in accordance with the guidelines of Good Clinical Practice examining interventional pain therapy and orthopedic clinical studies remains unacceptably low.     

Biomechanische Aspekte von Wechselkomponenten für den Kniegelenkersatz

Total knee arthroplasty (TKA) is one of the most frequent orthopaedic surgical procedures. Despite continuous improvements in the endoprostheses, instruments, and operative techniques, revision TKA has a rate of about 10% of overall TKA.In addition to the restoration of the periprosthetic bone stock and a precise alignment, the choice of an adequate implant, which meets the patient's specific requirements, has high impact on the outcome. The most significant differences between implants involve the degree of reconstructed joint area (uni-, bi-, tri-compartimental) and the order of the constraining forces between the femoral and tibial component.Implants for revision TKA commonly range from un- or semiconstrained resurfacing implants to fully constrained hinged endoprostheses. In case of severe osseous, ligamentous, and/or muscular defects, special tumor endoprostheses or implants for arthrodesis might be an alternative option.     

Treatment of Plantar Fasciitis With Radial Soundwave “Early” Is Better Than After 6 Months: A Pilot Study

Extracorporeal shock wave therapy/radial soundwave therapy has been predominantly used for chronic or recalcitrant plantar fasciitis with strong scientific evidence of reliable outcomes. Most of the studies included patients with plantar fasciitis with symptoms >6 months in duration. Only 2 known studies have investigated acute plantar fasciitis, which is <6 weeks in duration. They both found suboptimal results for the use of extracorporeal shock wave therapy. To the best of our knowledge, no studies have investigated radial soundwave therapy for the subacute stage or early stage of plantar fasciitis. Data were prospectively collected from 28 eligible patients who underwent radial soundwave therapy (RSWT) during a 9-month period in 2014. Of the 28 subjects, 14 were enrolled in the “early group” with a symptom duration of <3 months and 14 in the “standard/control” group with a symptom duration of >6 months. The pretreatment and posttreatment visual analog scale scores, Roles-Maudlsey scores, and activity level were recorded and compared. The early implementation of RSWT yielded comparable outcomes when compared with the standard group. RSWT is a valid treatment modality that can be implemented soon after the initial treatment options or first-phase treatment options have failed. Early treatment is more likely to allow for maintenance of patients' activity level. Also, waiting 6 months to treat plantar fasciitis with RSWT results in delays and inferior results. Early treatment is better for active and athletic patients.     

Biomechanische Aspekte zur Implantatverankerung und Kinematik von Oberflächenersatzhüftendoprothesen

Hip resurfacing is undergoing a resurgence in orthopaedic surgery with an increasing number of implantations. The objective of this article is to present the biomechanical basics of implant anchorage as well as the kinematics of hip resurfacing implants.Today, fixation of the femoral component onto the prepared femoral head is mainly done using bone cement. Depending on the implant design, the bone structures beneath the femoral component can be exposed to stress shielding, followed by degradation of the bone density and subsequent initiation of implant loosening. However, the trabecular bone has the ability to adapt itself to the fixation peg, to additional cement pegs, and to the elastic properties of the femoral component as well.The acetabular component is mainly inserted into the bone stock without using cement. Provided that large prosthetic heads will be applied, thin-walled acetabular cups are crucial for bone-saving preparation of the acetabular bone stock. Nearly all hip resurfacing systems are currently based on metal-on-metal wear-bearing couples. The acetabular components are mainly designed as monoblock implants, which can make subsequent revision difficult.Kinematic analyses show a significantly lower range of motion of hip resurfacing implants compared with modern standard (stemmed) total hip replacement systems. This difference originates from the small ratio of the resurfaced femoral head diameter and the relatively thick neck of the femur. Impingement of the femur neck onto the rim of the acetabular component can result in subluxation, deformation of the bearing surfaces, femoral neck fracture, and impairment of the bony anchorage of the hip resurfacing implants.