Management after acute rupture of the anterior cruciate ligament (ACL). Part 1: ACL reconstruction has a protective effect on secondary meniscus and cartilage lesions

PURPOSE

The aim of this consensus project was to validate which endogenous and exogenous factors contribute to the development of post-traumatic osteoarthritis and to what extent ACL (anterior cruciate ligament) reconstruction can prevent secondary damage to the knee joint. Based on these findings, an algorithm for the management after ACL rupture should be established.

METHODS

The consensus project was initiated by the Ligament Injuries Committee of the German Knee Society (Deutsche Kniegesellschaft, DKG). A modified Delphi process was used to answer scientific questions. This process was based on key topic complexes previously formed during an initial face-to-face meeting of the steering group with the expert group. For each key topic, a comprehensive review of available literature was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Consensus was defined a-priori as eighty percent agreement.

RESULTS

Of the 17 final statements, 15 achieved consensus, and 2 have not reached consensus. Results of the consensus were summarized in an algorithm for the management after ACL rupture (infographic/Fig. 2).

CONCLUSION

This consensus process has shown that the development of post-traumatic osteoarthritis is a complex multifactorial process. Exogenous (primary and secondary meniscus lesions) and endogenous factors (varus deformity) play a decisive role. Due to the complex interplay of these factors, an ACL reconstruction cannot always halt post-traumatic osteoarthritis of the knee. However, there is evidence that ACL reconstruction can prevent secondary joint damage such as meniscus lesions and that the success of meniscus repair is higher with simultaneous ACL reconstruction. Therefore, we recommend ACL reconstruction in case of a combined injury of the ACL and a meniscus lesion which is suitable for repair.

LEVEL OF EVIDENCE

Level V.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Histomorphological Alterations of Human Anterior Cruciate Ligament Grafts During Mid-Term and Long-Term Remodeling

Objective

The aim of the present paper is to analyze mid‐term and long‐term alterations of human anterior cruciate ligament (ACL) grafts during the remodeling process with special regards to cellularity, α‐smooth muscle protein (αSMP) expression, and crimp length in comparison to the native ACL.

Methods

A total of 34 patients were included (23 male and 11 female). Biopsies of 13 semitendinosus tendon and 14 patellar tendon autografts were obtained during surgical revision secondary to an ACL reconstruction. According to the interval between the index procedure and sample collection, the patients were divided into four groups: 4–12 months, 13–60 months, 61–108 months, and >108 months. Seven samples of native ruptured ACL tissue obtained during surgical intervention served as control. All biopsies were taken from the intraligamentous part of the ACL or the graft. Histomorphological and immunohistochemical analyses were conducted after samples were stained using hematoxylin–eosin, Giemsa, and αSMP enzyme‐labeled antibodies. The total cell density, the numbers of fibroblasts and fibrocytes, the fibroblast/fibrocyte ratio, the number of αSMP+ cell nuclei, and the percentage of αSMP+ cells per fibroblast as well as the crimp lengths were determined using light microscopy.

Results

In the early phase of remodeling, the grafts featured extensively high total cell counts (1021.2 ± 327.8, P = 0.001), with high numbers of fibroblasts (841.4 ± 245.2, P = 0.002), fibrocytes (174.5 ± 113.0, P = 0.04), and αSMP+ cells (78.3 ± 95.0, P = 0.02) compared to controls (390.1 ± 141.7, 304.5 ± 160.8, 65.6 ± 31.4 and 2.3 ± 2.6, respectively). Thereafter, the numbers of all cell entities decreased. After more than 108 months, the percentage of αSMP+ cells per fibroblast reached physiological values (ratio 1.3 ± 1.0, P = 0.41; control 0.8 ± 0.8), while the total cell count (834.3 ± 183.7, P = 0.001) as well as the numbers of fibroblasts (663.5 ± 192.6, P = 0.006) and fibrocytes (134.1 ± 73.0, P = 0.049) remained significantly high. The fibroblast/fibrocyte ratio showed no significant alterations over the course of time compared to the controls. The collagen crimp lengths were elongated by tendency in the early phase (28.8 ± 12.9 mm, P = 0.15; control 20.7 ± 2.2 mm) and significantly shortened over time, with the lowest values in the long term (14.8 ± 2.0 mm, P = 0.001). The comparison of biopsies from semitendinosus tendon and patellar tendon autografts revealed no significant differences for any of the histomorphological parameters investigated.

Conclusion

This study reveals distinctive mid‐term and long‐term immunomorphological alterations during human ACL graft remodeling. These data clearly indicate that the remodeling is a process that continues for 9 years or more. Furthermore, it seems to be a process of adaptation rather than full restoration. Even in the long run, several biological properties of the native ACL are not completely reestablished.

High prevalence of recreational and illicit drug use in German people living with HIV with a potential for drug-drug interactions with antiretroviral therapy

Recreational drug use is higher in people living with HIV (PLHIV) than in the general population in Europe. This use increases the risk for drug-drug interactions (DDIs) and adverse events. We assessed the prevalence and clinical consequences of substance abuse among PLHIV. BESIDE was a cross-sectional, multi-center study in 2016/18, evaluating comorbidities, polypharmacy and recreational/illicit drug use in PLHIV on antiretroviral therapy (ART) in Germany. Legal and illicit drug use was recorded using two anonymous patient questionnaires one year apart (Q1 and Q2). The BESIDE study population consisted of 453 PLHIV (22% female, median age 46 years). Recreational drug use was reported by the majority (Q1: ever used 73%, within previous 6 months 56%): nitrite inhalants ("poppers"), cannabis and PDE-5 inhibitors were common across all age groups; ecstasy, (meth-)amphetamine and gamma-hydroxybutyrate/gamma-butyrolactone were predominantly reported by younger PLHIV. Based on Q2, two-thirds of PLHIV (67%) had been informed about potential risks of drug abuse by their doctors, whereas one-third (33%) had talked to their doctors on their own initiative with only 7% considering drug use in combination with ART a problem. Strikingly, 44% and 42% had undergone medical treatment or had been hospitalized due to drug use. These data emphasize the high clinical relevance of recreational drug use in PLHIV and the need for treating physicians to pro-actively communicate the potential risks.

Week 48 Resistance Analyses of the Once-Daily, Single-Tablet Regimen Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Adults Living with HIV-1 from the Phase III Randomized AMBER and EMERALD Trials

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is being investigated in two Phase III trials, AMBER (NCT02431247; treatment-naive adults) and EMERALD (NCT02269917; treatment-experienced, virologically suppressed adults). Week 48 AMBER and EMERALD resistance analyses are presented. Postbaseline samples for genotyping/phenotyping were analyzed from protocol-defined virologic failures (PDVFs) with viral load (VL) ≥400 copies/mL at failure/later time points. Post hoc analyses were deep sequencing in AMBER, and HIV-1 proviral DNA from baseline samples (VL <50 copies/mL) in EMERALD. Through week 48 across both studies, no darunavir, primary PI, or tenofovir resistance-associated mutations (RAMs) were observed in HIV-1 viruses of 1,125 participants receiving D/C/F/TAF or 629 receiving boosted darunavir plus emtricitabine/tenofovir-disoproxil-fumarate. In AMBER, the nucleos(t)ide analog reverse transcriptase inhibitor (N(t)RTI) RAM M184I/V was identified in HIV-1 of one participant during D/C/F/TAF treatment. M184V was detected pretreatment as a minority variant (9%). In EMERALD, in participants with prior VF and genoarchive data (N = 140; 98 D/C/F/TAF and 42 control), 4% had viruses with darunavir RAMs, 38% with emtricitabine RAMs, mainly at position 184 (41% not fully susceptible to emtricitabine), 4% with tenofovir RAMs, and 21% ≥ 3 thymidine analog-associated mutations (24% not fully susceptible to tenofovir) detected at screening. All achieved VL <50 copies/mL at week 48 or prior discontinuation. D/C/F/TAF has a high genetic barrier to resistance; no darunavir, primary PI, or tenofovir RAMs were observed through 48 weeks in AMBER and EMERALD. Only one postbaseline M184I/V RAM was observed in HIV-1 of an AMBER participant. In EMERALD, baseline archived RAMs to darunavir, emtricitabine, and tenofovir in participants with prior VF did not preclude virologic response.

Editorial Commentary: No Difference in Knee Osteoarthritis After Single-Bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction

Systematic reviews now play a key role in evidence-based medicine, summarizing empirical findings from evaluated studies on a specific problem and examining the variability of those. These reviews help scientists integrate and evaluate relevant information in their research and support practitioners in decision-making processes. Since the early years of the current century, there has been a debate as to whether double-bundle or single-bundle reconstruction of the anterior cruciate ligament will better protect the knee. An essential aspect in the general indication of ligament reconstruction of the knee joint is the aim to prevent or at least to slow down the development process of osteoarthritis. At present, most clinical measures show no difference in outcome between single-bundle and double-bundle anterior cruciate ligament reconstruction. Systematic review of the literature investigating development of knee osteoarthritis after single-bundle and double-bundle anterior cruciate ligament reconstruction also shows no difference in outcome for this very important measure.

Single-Bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction-5-Year Results

PURPOSE

To compare anatomic single-bundle (SB) with double-bundle (DB) anterior cruciate ligament reconstruction (ACL-R) and to evaluate the respective clinical outcome results.

METHODS

In a prospective randomized study, 64 patients were included and separated into 2 groups. Anatomic SB and DB ACL-Rs were performed with hamstring tendons. Five years after surgery, the follow-up (FU) examination comprised International Knee Documentation Committee (IKDC) 2000, Laxitester (ORTEMA Sport Protection, Markgroeningen, Germany) measurement, and radiograph evaluation. Power calculation was performed to achieve a 95% confidence interval and 80% power on the base of 7-point IKDC subjective difference between the groups.

RESULTS

A total of 53 patients (83% FU) were examined at 63.2 ± 4.7 months after surgery: 28 patients in the DB group and 25 patients in the SB group. IKDC subjective (SB: 92.8 ± 6.2, DB: 91.6 ± 7.1; P = .55) and objective scores (grade A SB/DB 20%/25%, B SB/DB 72%/57%, C SB/DB 8%/18%, D SB/DB 4%/0%; P = .45) showed no differences comparing both groups. The Laxitester measurements showed no significant difference in regard to anterior-posterior translation in neutral, internal, and external rotation or to rotation angles (P = .79). No difference was seen between the groups regarding osteoarthritic changes and tunnel widening.

CONCLUSIONS

At the 5-year FU, no advantage for either the DB or SB technique in ACL-R can be seen with regard to patient-related and objective outcome measures.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled clinical trial.

Long-term Results of Arthroscopic Arthrolysis for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction

PURPOSE

The current study was conducted to evaluate the long-term clinical and radiological outcomes after arthroscopic arthrolysis for arthrofibrosis after anterior cruciate ligament reconstruction (ACLR).

METHODS

All patients treated with arthrolysis between 1990 and 1998 were included. Indication was arthrofibrosis in at least one knee compartment or a cyclops syndrome limiting range of motion (ROM) by > 5° of extension deficit and 15° of flexion deficit. International Knee Documentation Committee (IKDC) 2000 subjective and objective, Lysholm score, and x-ray evaluation were documented. Statistical analysis and power calculation were performed (P < .05).

RESULTS

One hundred forty-one patients (follow-up, 71%) were examined at a mean of 18.7 ± 2.6 years after arthroscopic arthrolysis. Mean IKDC 2000 score was 79.49 ± 14.32. IKDC objective was normal in 0%, nearly normal in 6%, abnormal in 56%, and severely abnormal in 38%. One hundred percent of patients showed more than grade II osteoarthritis. ROM improvement after arthrolysis did not change significantly compared with midterm results (t = 4.5 years). Patients with persisting motion deficits (P = .02) and after medial meniscus resection (P < .001) at time of ACLR showed significantly greater progression of osteoarthritis in comparison with patients without these additional disorders. In case of arthrolysis later than 1 year after ACLR, a more severe osteoarthritis grade (4% vs 20% grade III; P = .038) and a lower jump distance (IKDC: 61% A, 25% B vs 39% A, 41% B; P = .028) were obvious compared with patients who underwent arthrolysis within the first year after ACLR.

CONCLUSIONS

Long-term motion improvement can be achieved by arthrolysis. Persistent loss of motion resulted in a higher degree of osteoarthritis in the study population. Early intervention seems advisable as patients with arthrolysis later than 1 year after index surgery reached worse IKDC objective grading.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures

PURPOSE

To prospectively evaluate the prevalence and characteristics of meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures and to test for possible relationships between associated meniscal lesions and patient demographics or injury characteristics.

METHODS

A prospective multicenter study was conducted to arthroscopically assess the prevalence and characteristics of meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures between 04/2014 and 10/2015. Patient demographics and injury characteristics were assessed preoperatively. The presence of a meniscal injury was evaluated arthroscopically and characterized according to tear type and location (Cooper classification). Patients with and without meniscal injuries were compared with regard to sex, age, height, weight, BMI, type of injury, mechanism of injury, time to surgery, Tanner stage, sexual maturity (prepubescent vs. pubescent), and modified Meyers and McKeever classification.

RESULTS

A total of 54 consecutive patients (65 % males, mean age: 12.5 ± 3.2 years) were enrolled. Meniscal injury were found in 20 patients (37 %). The lateral meniscus was involved in 18 patients (90 % of all meniscus injuries) and the medial meniscus in 2 patients (10 % of all meniscus injuries). The most common tear pattern was a longitudinal tear of the posterior horn of the lateral meniscus (30 % of all meniscus injuries) and the second most common tear was a root detachment of the anterior horn of the lateral meniscus (20 % of all meniscus injuries). Higher age, advanced Tanner stage, and pubescence were significantly associated with an accompanying meniscal injury.

CONCLUSION

Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures must be expected in almost 40 %, with a higher prevalence with increasing age and sexual maturity. With regard to the clinical relevance, the results of the present study argue in favor for magnetic resonance imaging prior to surgery in every patient with a suspected tibial eminence fracture and for an arthroscopic approach to adequately diagnose and treat meniscal injuries.

LEVEL OF EVIDENCE

II.

PEPDar: A randomized prospective noninferiority study of ritonavir-boosted darunavir for HIV post-exposure prophylaxis

OBJECTIVES

PEPDar compared the tolerability and safety of ritonavir-boosted darunavir (DRV/r)-based post-exposure prophylaxis (PEP) with the tolerability and safety of standard of care (SOC). The primary endpoint was the early discontinuation rate among the per-protocol population.

METHODS

PEPDar was an open-label, randomized, multicentre, prospective, noninferiority safety study. Subjects were stratified by type of event (occupational vs. nonoccupational, i.e. sexual) and were randomized to receive DRV/r plus two nucleoside reverse transcriptase inhibitors (NRTIs) or SOC PEP. Twenty-two private or university HIV clinics in Germany participated. Subjects were ≥ 18 years old and had documented or potential HIV exposure and indication for HIV PEP. They initiated PEP not later than 72 h after the event and were HIV negative.

RESULTS

A total of 324 subjects were screened, the per-protocol population was 305, and 273 subjects completed the study. One hundred and fifty-five subjects received DRV/r-based PEP and 150 subjects received ritonavir-boosted lopinavir (LPV/r)-based PEP for 28-30 days; 298 subjects also received tenofovir/emtricitabine. The early discontinuation rate in the DRV/r arm was 6.5% compared with 10.0% in the SOC arm (P = 0.243). Adverse drug reactions (ADRs) were reported in 68% of DRV/r subjects and 75% of SOC subjects (P = 0.169). Fewer DRV/r subjects (16.1%) had at least one grade 2 or 3 ADR compared with SOC subjects (29.3%) (P = 0.006). All grades of diarrhoea, nausea, and sleep disorders were significantly less frequent with DRV/r, while headache was significantly more frequent. No HIV seroconversion was reported during follow-up.

CONCLUSIONS

Noninferiority of DRV/r to SOC was demonstrated. DRV/r should be included as a standard component of recommended regimens in PEP guidelines.

Single-Bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction: A Comparative 2-Year Follow-up

PURPOSE

To compare anatomic single-bundle (SB) versus double-bundle (DB) anterior cruciate ligament (ACL) reconstruction and to determine possible differences in clinical outcomes.

METHODS

In this prospective randomized study, 64 patients were divided into 2 equal groups. Anatomic SB and DB ACL reconstructions were performed using hamstring tendons. A follow-up examination 2 years after surgery comprised International Knee Documentation Committee (IKDC) 2000 assessment, Laxitester (ORTEMA Sport Protection, Markgröningen, Germany) measurement of anteroposterior translation regarding rotational stability, and radiographic evaluation. Statistical analysis and power calculation were performed (P < .05).

RESULTS

We examined 62 patients at a mean of 26 months (range, 23.3 to 32.7 months) after surgery. IKDC subjective and objective scores showed no significant differences when both groups were compared. The Laxitester measurements showed no significant differences regarding anteroposterior translation in the neutral position, internal rotation, and external rotation. However, there was a significant improvement in rotational laxity in external rotation in the DB group (P = .02). No differences were seen between the groups regarding osteoarthritic changes and tunnel widening.

CONCLUSIONS

There were no differences in IKDC subjective and objective scores between patients who underwent anatomic SB ACL reconstruction and those who underwent anatomic DB ACL reconstruction.

LEVEL OF EVIDENCE

Level I, prospective, randomized controlled clinical trial.

Sports activity following total knee arthroplasty in patients older than 60 years

In a retrospective study with a population over 65 years, sports activity was conducted 6 years after cruciate retaining (CR) total condylar knee arthroplasty (TKA) with rotating platform (RP). Eighty-one Patients (71.8±5.4years) were examined at follow-up 6.4±0.9 years postoperative. Sport was practiced 5.3 hours every week in mean. Patients were active in sports 3.5times per week. Twenty-five percent performed high impact sports, 47% medium impact sports and 52% low impact sports at follow-up. In KOOS sports 60±28 was reached, in WOMAC 12.1±15.1. It can be concluded that in this population 50% of patients were active in medium and low impact sport 6 years after surgery. However, a quarter of patients were also active in high impact sports.

Hodgkin lymphoma is as common as non-Hodgkin lymphoma in HIV-positive patients with sustained viral suppression and limited immune deficiency: a prospective cohort study

OBJECTIVES

The incidence of HIV-related non-Hodgkin lymphoma (NHL) but not that of Hodgkin lymphoma (HL) has been declining. The aim of the study was to compare HIV-infected patients with NHL and HL with respect to antiretroviral therapy (ART) exposure at the time of lymphoma diagnosis.

METHODS

HIV-infected patients with NHL and HL included in a prospective multicentre cohort study since January 2005 were compared with respect to ART exposure and viral load at the time of lymphoma diagnosis.

RESULTS

As of 31 December 2012, data for 329 patients with NHL and 86 patients with HL from 31 participating centres were available. Patients with HL were more likely to be on ART (73.5% vs. 39.1%, respectively; P < 0.001) and more frequently had a viral load below the detection limit (57.3% vs. 27.9%, respectively; P < 0.001) than patients with NHL. The proportion of patients with HL was 8.0% in ART-naïve patients, 34.8% in patients with current HIV RNA < 50 HIV-1 RNA copies/mL, and 50.0% in patients with both HIV RNA < 50 copies/mL for > 12 months and a CD4 cell count of > 200 cells/μL. Of note, 45.8% of all patients with NHL were not currently on ART and had a CD4 count of < 350 cells/μL.

CONCLUSIONS

This prospective cohort study shows that HL was as common as NHL in patients with sustained viral suppression and limited immune deficiency. In contrast to NHL, the majority of patients with HL were on effective ART, suggesting that ART provides insufficient protection from developing HL. The high proportion of untreated patients with NHL suggests missed opportunities for earlier initiation of ART.

Brace or no-brace after ACL graft? Four-year results of a prospective clinical trial

PURPOSE

A controversial discussion is held on using stabilizing knee braces after anterior cruciate ligament (ACL) surgery. The current study investigated the influence of a stabilizing knee brace on results after ACL reconstruction using patellar tendon autografts.

METHODS

A prospective randomized study was started including 64 patients divided into two equal groups and treated with or without a stabilizing knee brace for 6 weeks post-operatively. A follow-up examination 4 years after operation comprised IKDC 2000, KT1000 measurement, a visual analogue pain scale (VAS; scores 0-10) and radiographic evaluation. The t test for independent and paired samples and the Pearson's Chi-square test were used for statistical analysis (p < 0.05). The primary endpoint was the difference in IKDC classification.

RESULTS

Eighty-one per cent of the patients were examined 4 years post-operatively. IKDC 2000 subjective (brace group 90.5 ± 8.9, braceless group 93.2 ± 6.1) and objective results (brace A 30%, B 56%, C 16%; braceless A 32%, B 48%, C 20%) and instrumental measurement of anteroposterior laxity with KT1000 (brace 0.6 ± 2.4 mm, braceless 1.8 ± 3.4 mm) showed no significant differences. VAS pain results were significantly better in the braceless group at 1.0 ± 1.2 versus 1.9 ± 1.4 under sports activity or heavy physical work (p = 0.015). There were no radiographic differences concerning osteoarthritic findings and tunnel widening between the groups.

CONCLUSION

Post-operative treatment with a stabilizing knee brace after ACL replacement showed no advantage over treatment without a brace at 4-year follow-up. The use of a knee-stabilizing brace after isolated ACL reconstruction with autologous patellar tendon graft is not recommended.

LEVEL OF EVIDENCE

II.

Rotational laxity and collateral ligament laxity following total knee arthroplasty with rotating platform

PURPOSE

The aim of this study was to evaluate laxity in knees with pre-operative (preop) valgus alignment compared to knees with pre-operative varus alignment after total knee arthroplasty (TKA).

METHODS

This was a retrospective study including 81 patients, with six years follow-up, for pre-operative valgus- or varus alignment of the leg. All patients had been supplied with the same cruciate retaining (CR) TKA with rotating platform. Clinical findings were assessed by KSS, OKS and IKDC 2000 score. Rotational knee laxity was evaluated by a validated instrument (Laxitester®) with 2 Nm torque in 30° flexion. Collateral ligament laxity was tested manually in 30° flexion with a bending moment of approximately 5 Nm. Biomechanical results were compared to the contralateral side.

RESULTS

Thirty-one patients had a preop valgus alignment of 8.96° and 50 patients a varus leg axis of 4.99° in the mean. In the preop valgus knees rotational analysis showed an increased laxity of 10.7° compared to preop varus knees (p = 0.001). There was no significant difference in medial (valgus 2.6 mm, varus 2.5 mm) and lateral (valgus 2.8 mm, varus 2.7 mm) laxity. KSS and OKS showed no significant differences in the follow-up results. In the IKDC 2000 objective score 50 % of the preop varus knees and 25.8 % of the preop valgus knees were classified as nearly normal. The difference in the IKDC objective was highly significant (p < 0.001).

CONCLUSION

Preop valgus knees show a significantly increased rotational laxity but no increased collateral ligament laxity compared to pre-operative varus knees six years after TKA with rotating platform. There is a significant difference in IKDC objective.

Therapy and prophylaxis of opportunistic infections in HIV-infected patients: a guideline by the German and Austrian AIDS societies (DAIG/ÖAG) (AWMF 055/066)

INTRODUCTION

There was a growing need for practical guidelines for the most common OIs in Germany and Austria under consideration of the local epidemiological conditions.

MATERIALS AND METHODS

The German and Austrian AIDS societies developed these guidelines between March 2010 and November 2011. A structured Medline research was performed for 12 diseases, namely Immune reconstitution inflammatory syndrome, Pneumocystis jiroveci pneumonia, cerebral toxoplasmosis, cytomegalovirus manifestations, candidiasis, herpes simplex virus infections, varizella zoster virus infections, progressive multifocal leucencephalopathy, cryptosporidiosis, cryptococcosis, nontuberculosis mycobacteria infections and tuberculosis. Due to the lack of evidence by randomized controlled trials, part of the guidelines reflects expert opinions. The German version was accepted by the German and Austrian AIDS Societies and was previously published by the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF; German Association of the Scientific Medical Societies).

CONCLUSION

The review presented here is a translation of a short version of the German-Austrian Guidelines of opportunistic infections in HIV patients. These guidelines are well-accepted in a clinical setting in both Germany and Austria. They lead to a similar treatment of a heterogeneous group of patients in these countries.

Indications for and results of arthroscopy in the arthritic knee: a European survey

PURPOSE

The place of arthroscopic treatment in osteoarthritis of the knee has generated much controversy. A survey was initiated to collect the opinion of experienced surgeons.

METHODS

Of the 211 surgeons interviewed, 170 (80.6%) replied to the electronic questionnaire. Respondents had at least ten years of experience in arthroscopy and currently perform more than 100 arthroscopies per year. Various indications and treatment modalities for arthroscopy in osteoarthritis of the knee had to be evaluated on a scale from "excellent" to "no indication".

RESULTS

The respondents generally believe that an improvement is more likely in low-grade osteoarthritis (p < 0.001) and in neutral leg axis (p < 0.001). The outcome was rated better if symptoms had persisted for less than six months (p < 0.001) and for patients that were younger than 60 years (p < 0.001). Partial meniscectomy and notchplasty in cases of extension deficit were considered as successful treatment options. Debridement was an accepted indication, with an outcome mainly rated as fair. A majority saw no indication for joint lavage, arthroscopic treatment of arthrofibrosis and removal of osteophytes. The outcome appears to be poor if a bone edema is diagnosed on magnetic resonance imaging prior to arthroscopy. Only 55.9% of respondents were comfortable with the current definition of osteoarthritis.

CONCLUSIONS

Experienced arthroscopic surgeons all over Europe believe arthroscopy in osteoarthritis is appropriate, under certain conditions. The major task for surgeons is to select the right patients who are likely to benefit from this intervention.

Validation of a measurement device for instrumented quantification of anterior translation and rotational assessment of the knee

PURPOSE

A test setup for clinical use in the awake and non-anesthetized patient measuring anteroposterior translation and rotation of the knee joint is the subject of validation.

METHODS

A measuring device featuring fixation of the foot at 30° of knee flexion with varus/valgus stress posts for the knee was developed. Tibial rotation (external/internal) was imposed with a torque of 2 Nm on the footrest with the ankle locked in dorsiflexion. Anterior translation of the tibia in relation to the femur was measured with a commercially available arthrometer. Measurements were performed in a neutral position, internal rotation, and external rotation. Intrarater and inter-rater reliability was validated in 10 healthy volunteers (Cronbach α). We examined 10 patients with isolated anterior cruciate ligament (ACL) rupture, as well as 10 patients with ACL rupture plus medial instability and 10 patients with additional lateral instability. Side-to-side differences were used for calculation.

RESULTS

Comparison of healthy volunteers and subjects with isolated ACL rupture showed significant differences: internal rotation, 0.79 mm and 2.46 mm, respectively (P = .001); neutral position, 0.4 mm and 3.35 mm, respectively (P < .0001); and external rotation, 0.29 mm and 2.5 mm, respectively (P = .003). Significant differences (P = .008) were found between isolated ACL rupture and ACL rupture plus medial instability by use of the ratio of anterior translation in external rotation versus the neutral position. Inter-rater reliability was 0.948 in 10 healthy volunteers and 0.981 in 10 subjects with unilateral ACL rupture. Intrarater reliability in the volunteers was 0.829.

CONCLUSIONS

By use of the developed measurement device, the "Laxitester" (ORTEMA Sport Protection, Markgroeningen, Germany), objective differentiation between isolated ACL rupture and ACL rupture plus additional medial instability is possible. Values for anterior translation are reliable and reproducible by different examiners and by the same examiner at different times.

CLINICAL RELEVANCE

The Laxitester allows objectification of medial instability in combination with ACL injuries and provides a reference regarding the need for additional medial stabilization. Compared with the isolated measurement of anteroposterior translation, knee instability can be assessed in a more differentiated manner.

Instrumented examination of anterior cruciate ligament injuries: minimizing flaws of the manual clinical examination

The clinical examination is a basic language of orthopaedics; it is how orthopaedic surgeons communicate with one another. However, each surgeon speaks a different dialect that has been influenced by where and with whom that surgeon trained, as well as that person's own experiences. Because of the inherent variability in the magnitude, direction, and rate of force application during the clinical examination, manual arthrometers were developed in an attempt to more consistently quantify the clinical examination. Instrumented manual devices, such as the KT-1000 (MEDmetric, San Diego, CA), were the first to provide objective numbers to surgeons and researchers evaluating anteroposterior (AP) knee joint laxity. Although these devices provide surgeons with feedback related to the amount of force applied, the rate at which the force is applied is uncontrolled, resulting in a lack of reliability similar to that of the clinical examination itself. In addition to potential errors in measuring AP laxity, rotational laxity has proven to be very difficult to quantify. Robotic systems that make use of computer-driven motors to perform laxity testing have recently been developed to control the magnitude, direction, and rate of force application and thus improve the accuracy and reliability of both AP and rotational laxity evaluation. This review discusses the evolution of instrumented clinical knee examination over the past 3 decades and highlights the advantages and disadvantages of the various testing systems, as well as how current and future developments in this area may improve the field of orthopaedics by minimizing the flaws of the manual clinical examination.

Safety and efficacy of a saquinavir-containing antiretroviral regimen in previously ART-naïve or pretreated but protease inhibitor-naïve HIV-positive patients

BACKGROUND

The RAINBOW survey is a multinational observational study assessing the tolerability and efficacy of ritonavir-boosted saquinavir (SQV/r), using the 500-mg film-coated SQV formulation, in routine clinical practice. This analysis presents data from the German subgroup of antiretroviral therapy (ART)-naïve and pretreated but protease inhibitor (PI)-naïve patients.

METHODS

This was a multicenter, prospective, open-label, 48-week observational cohort study. Tolerability assessments included changes in liver enzymes and lipid levels from baseline to week 48. Efficacy assessments included changes in the proportion of patients with HIV-1 RNA <50 and <400 copies/ml, and changes in CD4 cell count from baseline to week 48.

RESULTS

The analysis included 275 ART-naïve and 179 pretreated but PI-naïve patients. The proportion of ART-naïve patients achieving <50 copies/ml by 48 weeks was 53.1% by intent-to-treat (ITT) analysis and 67.3% using last observation carried forward (LOCF) analysis. In pretreated but PI-naïve patients, the proportions achieving <50 copies/ml by 48 weeks were 53.1% (ITT) and 70.4% (LOCF). The median increase in CD4 count at week 48 was +174 cells/mm3 (interquartile range [IQR] 86, 265) in the ART-naïve group and +100 cells/mm3 (IQR 0, 209) in the pretreated but PI-naïve group (p < 0.01 for both; LOCF). Drug-related adverse events were reported in 7.6% of ART-naïve and 2.8% of pretreated but PI-naïve patients. Treatment with SQV/r was stopped in 21.5% of ART-naïve and 17.9% of pretreated but PI-naïve patients (due to side effects in 3.3% and 2.8%, respectively). There were no clinically relevant changes in liver enzyme levels. Overall, the total cholesterol, triglyceride, low-density lipoprotein, and high-density lipoprotein levels increased to week 48, although the levels remained within normal ranges in the majority of patients.

CONCLUSIONS

The results of this observational cohort study of treatment with the 500-mg tablet formulation of SQV are consistent with high efficacy and tolerability results seen in controlled studies of SQV/r. This analysis confirms that SQV/r is effective and well tolerated in ART-naïve and pretreated but PI-naïve patients in 'real-world' clinical settings.

Effective treatment of patients in a deep salvage situation with "non-active HAART": experiences with the expert advice system RADATA

BACKGROUND

Clinical studies suggest expert recommendations as a possibility to optimize highly active antiretroviral therapy (HAART) in patients with multi-drug resistant virus strains. An online system (RADATA) has been developed to provide expert advice for the drug therapy of HIV-infected patients.

OBJECTIVE

To evaluate the efficacy of expert-advice-guided HAART switches in patients with triple-class failure.

METHODS

Virological and immunological outcome of patients having undergone at least three prior ART regimens, including nucleoside inhibitor (NRTI), nonnucleoside reverse transcriptase inhibitor (NNRTI), and protease inhibitor (PI) use, were analyzed. Changes in HIV-RNA and CD4-cell count were evaluated every 3 months.

RESULTS

183 patients with a median baseline viral load of 3.90 log copies/ml (1.88-6.54 log) and a CD4-cell count of 298 c/ll (5-910 c/ll) were eligible for analysis. The patients had a median of seven prior ART regimens and a treatment duration of 83 months. A median of three (range 0-8) NRTI-, two (0-7) thymidine-associated (TA), one (0-4) NNRTI-, and three (0-13) PI-associated resistance mutations were present at baseline. Despite available resistance analyses and expert recommendations, 66% (n = 119) of the patients started a new ART regimen without any active drugs according to the resistance analysis. The HIV-RNA declined by a median of 0.61 log and 0.92 log after 12 and 24 months, respectively, while the CD4-cell count rose by a median of +9 c/microl and +25 c/microl during this period. No significant differences related to number of prior regimens or number of active substances used could be found.

CONCLUSION

Despite extensive pre-treatment and multiple resistances against prescribed HAART, our patients demonstrated a decline in viral load and a stable CD4-cell count over the observation period. We conclude that the activity of antiretroviral regimens is not exclusively explained by the current algorithms used for estimating antiretroviral drug activity.

Evolving characteristics of toxoplasmosis in patients infected with human immunodeficiency virus-1: clinical course and Toxoplasma gondii-specific immune responses

Toxoplasmic encephalitis (TE) is the most important opportunistic infection of the central nervous system in patients infected with human immunodeficiency virus (HIV)-1. This study evaluated the effect of highly active anti-retroviral therapy (HAART) and Toxoplasma gondii-specific immune responses on the occurrence of TE. The clinical characteristics of all patients diagnosed with TE in two centres since 1990 (n = 140) were analysed. Patients were grouped according to the date of diagnosis (period 1, 1990-1993; period 2, 1994-1996; period 3, 1997 onwards). Immune responses to T. gondii were evaluated in a subgroup (n = 12) by interferon (IFN)-gamma-specific ELISPOT tests. There were marked differences in the estimated Kaplan-Meier overall survival (OS), with a 1-year OS (5-year OS) of 41% (7%) in period 1, 56% (29%) in period 2, and 90% (78%) in period 3 (p <0.0001). In period 3, TE was found to be the first AIDS-defining illness more frequently than in earlier periods (74% vs. 38%, p 0.0002). Persistent neurological deficits caused by TE were present in 37% of the patients. Patients with an acute episode of TE or a TE relapse had significantly lower responses in the T. gondii-specific ELISPOT than patients who discontinued maintenance therapy and were relapse-free (p 0.0044). Survival of HIV patients with TE has improved markedly since the introduction of HAART, but persistent neurological deficits are often present in surviving patients. While preventive therapy remains essential, evaluation of T. gondii-specific immune responses may be an important step in improving estimates of the individual risk of TE and TE relapses.

Remission of a cutaneous Mycosis fungoides after topical 5-ALA sensitisation and photodynamic therapy in a patient with advanced HIV-infection

BACKGROUND

Treatment of Mycosis fungoides (MF) in HIV-infected patients is controversially discoursed. Photodynamic therapy (PDT) after topical sensitization with 5-aminolevulinic acid (5-ALA) is a new and effective modality for treatment of skin malignancies.

OBJECTIVE

In this report we describe, what is, to our knowledge, the first case of a patient with MF through advanced HIV-infection, successfully experiencing topical 5-ALA sensitization and PDT.

METHODS

5-ALA ointment was applied to plaques and held in occlusion for 4 hours. PDT was applied using the PDT 1200 irradiation source (Waldmann Medizintechnik System) with 180 J/cm superset 2.

RESULTS

Complete remission of MF was achieved, after two completed cycles of photodynamic therapy.

CONCLUSION

MF lesions in the presended case showed a high response to 5-ALA sensitization and PDT. This modality appeared to be very effective in treatment of MF in a HIV-infected patient and could be a valuable treatment option for cutaneous T-cell lymphoma in HIV-infected patients.

Radata - implementation of resistance analysis and expert advice for optimized HAART switches in general practice of HIV-infected individuals via a compiling internet presence

BACKGROUND

HIV-infected patients fail viral load suppression, because resistance against antiretroviral drugs arises or for other reasons. HIV-resistance analyses can aid to achieve effective HAART regimen. Furthermore, clinical benefits from genotyping in study settings are significantly higher for treating physicians, who can include external advice from HIV-experts into HAART switch.

OBJECTIVE

To develop a compiling internet presence to provide expert advice for HAART switch in general practice of HIV-infected individuals after therapy failure. -

DESIGN

A multifactorial (genotyping, drug monitoring, adherence, expert advice) interdisciplinary internet service (www.radata.de) with an associated server hosted database.

PATIENTS AND METHODS

HIV-infected patients after failure to HAART are eligible for registration to the Radata project. Genotyping is performed according to protocols specific for each participating institution. Therapeutic drug monitoring (NNRTIs, PIs) follows setting for drug level detection by mass spectrometry. An adherence self-report is completed by every patient. Clinical documentation is provided by the treating Primary Care Physician. Clinical expert advice for implementation into HAART switch in daily clinical practice for treating physicians is provided by HIV-experts according to data obtained. Clinical and laboratory follow-up visits are scheduled firstly 4 weeks after HAART switch and three monthly afterwards, over a period of one year.

RESULTS

Technical resources and a compiling internet presence for generation of resistance analysis based expert advice were developed. Initially, 7 HIV-treatment centres, 7 laboratories and 17 HIV advisors contribute to Radata database project. 15 patients were enrolled during test period. 30 expert advices were generated during the test phase. Expert advice was provided in 6 weeks median for implementation into HAART switch. 13 out of 15 expert advices were implemented into HAART switch by treating Primary Care Physicians.

CONCLUSIONS

Radata is a novel database concept with features to generate expert advice for implementation into HAART switch of HIV-infected subjects. A test period has shown, that the concept is technically approved to fit all requirements with regard to data collection, evaluation and to generate expert advice for therapy switch in daily clinical practice.

HHV-8 DNA in blood and the development of HIV-associated Kaposi's sarcoma in the era of HAART--a prospective evaluation

OBJECTIVE

To explore the significance of HHV-8 viremia in HIV-positive individuals for the risk of developing Kaposi's sarcoma (KS) in the era of highly active antiretroviral therapy.

METHODS

237 HIV-positive patients were included in this prospective evaluation and followed over an average duration of 34 months. HHV-8 DNA in peripheral blood mononuclear cells (PBMCs) and CD4-lymphocytes were determined. In addition AIDS-defining conditions and antiretroviral therapy were documented of all participating subjects.

RESULTS

HHV-8 DNA was detectable in PBMCs of 12.6% out of all individuals. 53.3% of these patients initially complained about KS, although 9.2% of patients without HHV-8 DNA in PBMCs were found on KS as well. Furthermore, four patients in total were observed with newly developed KS during follow up visits. None of these patients were noted with detectable HHV-8 DNA at their initial evaluation.

CONCLUSIONS

Prevalence of HHV-8 DNA in PBMCs of subjects in this investigation was quite similar to former investigations. However, new diagnosed KS occurred less frequently than demonstrated in previous studies. All of those observed patients with new KS manifestations were negative for HHV-8 DNA in PBMCs at study entry. This observation differs from earlier studies which have postulated the detection of HHV-8 DNA in PBMCs as a predictive value for development of KS. Due to results as presented, a single HHV-8 DNA test in blood has no predictive value in support of predictability of KS development. With respect toto costs and to a less complicated performance antibody assays should be preferred.

Remission of cutaneous Mycobacterium haemophilum infection as a result of antiretroviral therapy in a Human Immunodeficiency Virus--infected patient

We describe the first Mycobacterium haemophilum infection that occurred in a patient with human immunodeficiency virus in Germany and report 7 newly diagnosed cases of M. haemophilum infection. In the former case, a local M. haemophilum skin infection resolved as a result of successful antiretroviral therapy only; however, that clinical outcome may not be possible for more invasive forms of the disease.

Monitoring of endogenous interferon-alpha and human herpesvirus 8 in HIV-infected patients with Kaposi's sarcoma

The incidence of AIDS-associated Kaposi's sarcoma has declined since the mid-nineties due to the availability of potent antiretroviral therapy including protease inhibitors. However, Kaposi's sarcoma is still the most common neoplasia in HIV-infected patients. In the pathogenesis of the HIV-associated as well as other forms of this disease an infectious agent seems to play a role, namely the human herpesvirus 8. Even before the discovery of the HIV virus, high levels of an unusual acid-labile form of endogenous interferon alpha were found in patients with AIDS-associated KS. The administration of recombinant interferon alpha evolved as standard therapy for Kaposi's sarcoma in HIV-infected patients with a moderate immunodeficiency in addition to antiretroviral therapy. This investigation monitored the levels of HHV 8 and endogenous interferon in 4 patients with and without Kaposi's sarcoma during the course of HIV-disease. The results of our experiments lead us to two hypotheses: First of all, the pre-therapeutic level of endogenous interferon may be a predictor of the response to an interferon-alpha therapy for HIV-associated Kaposi's sarcoma. Secondly, the determination of HHV 8 DNA in blood of HIV-positive patients may allow conclusions about the risk for the development of Kaposi's sarcoma. However these hypotheses should be tested by monitoring the levels of endogenous interferon and HHV 8 DNA in clinical studies of a greater number of HIV-infected patients.

Resistance analyses in HIV infected patients with a history of multiple antiretroviral treatment regimens

OBJECTIVE

To assess HIV-1 isolate based resistance profiles from extensively pretreated patients and effects of a resistance guided switch of antiretroviral therapy.

METHODS

In a prospective study phenotypic and genotypic resistance analyses were performed on HIV infected individuals with failure of the current therapy and history of at least three antiretroviral regimens. Antiretroviral therapy was changed according to the results. Viral load and CD4 lymphocyte counts were measured at baseline, after 10 (SD 2), and 24 (2) weeks.

RESULTS

All patients (n=52) failed their actual regimen. Currently versus ever previously taking the specific drug, resistance associated mutations and phenotypic resistance to AZT and 3TC were found in over 80% of individuals; resistance to DDI and D4T was detected in less than 10% of cases. A resistance guided switch of therapy was followed by a median decrease of viral load of 0.5 log10 units after 24 weeks. Individuals resistant to two or more drugs compared with patients with resistance to less than two drugs of ongoing treatment, were switched to a regimen containing DDI, D4T, and a PI or NNRTI. After 10 (SD 2) weeks viral load decrease was pronounced in patients with resistance to at least two drugs in the previous regimen.

CONCLUSIONS

Among different RTI, the profile of clinically relevant resistance indicates pronounced differences when looking at separate drugs. Regarding virological response, in the context of available drugs, resistance tested with currently used methods is of limited value in extensively pretreated patients and seems to have its value primarily in first or second switch of therapy.

Survival of AIDS patients with primary central nervous system lymphoma is dramatically improved by HAART-induced immune recovery

OBJECTIVE

To evaluate the impact of immune recovery induced by highly active antiretroviral therapy (HAART) on the survival of AIDS patients with primary central nervous system lymphoma (PCNSL).

METHODS

In a multicentric retrospective analysis, 29 HIV-infected patients with histologically confirmed PCNSL were identified. To evaluate median survival, Kaplan-Meier statistics were used. To explore the effects of different variables on survival, a Weibull accelerated failure time regression analysis was performed.

RESULTS

Median age at manifestation of PCNSL was 39.1 years and median CD4 cell count was 11 x 10(6) cells/l. Seventy per cent of the patients had had a prior AIDS-defining illness. Cranial radiation (CR) was given to 12 out of 29 patients. Six patients were treated with HAART. Survival time of these patients and of the patients treated with CR alone differed significantly from those receiving neither CR nor HAART (median Kaplan-Meier survival estimate: 1093, 132, and 33 days, respectively). In the multivariate regression model, HAART and CR were identified as the only variables independently associated with prolonged survival. HAART versus no HAART and CR versus no CR increased the time to event by a factor of 6.1 (95% confidence interval, 2.4-16.0; P = 0.0002) and 3.1 (95% confidence interval, 1.5-6.3; P = 0.002), respectively. Four out of six patients on HAART showed a marked immune recovery and survived for more than 1.5 years, with two patients still alive.

CONCLUSION

Data from this cohort indicate that immune recovery induced by HAART leads to dramatic improvement in survival of patients with AIDS-associated PCNSL. These findings may have important implications for future treatment strategies.

Bacillary angiomatosis in HIV-infected patients--an epidemiological and clinical study

BACKGROUND

No data were available on the epidemiological and clinical characteristics of bacillary angiomatosis (BA) in Germany.

OBJECTIVE

To determine epidemiological and clinical data on HIV-associated BA.

METHODS

A chart review of all BA cases between 1990 and 1998 was performed in 23 German AIDS treatment units.

RESULTS

A total of 21 cases of BA was diagnosed. During this period, the participating HIV centers treated about 17,000 HIV-infected patients. As a result, a BA prevalence of 1.2 cases/1,000 patients can be assumed. 19 BA were localized in the skin; in 5 cases bones and in 4 cases the liver were involved. Out of 20 patients who received antibiotic therapy, 13 had complete remission. The median time of duration up to complete remission was 32 days (9-82). During the follow-up of the 20 patients, 7 relapses were observed.

CONCLUSION

BA is a rare HIV-associated disease with a prevalence of 1,2 cases/1,000 patients in the presented study.

In vivo dynamics and pathogenicity of wild-type and resistant Hepatitis B virus during long-term lamivudine monotherapy - a clinical note

BACKGROUND

Genotypic resistance of Hepatitis B virus (HBV) against lamivudine evolves within months after onset of therapy.

OBJECTIVES

To determine the longitudinal order in which resistance mutations appear and to compare the kinetics and pathogenicity of wild-type and resistant HBV.

STUDY DESIGN

In a longitudinal study, consecutive samples were drawn over a period of 28 months from a patient with chronic hepatitis B, and resistance mutations were followed by sequencing a part of the polymerase region of HBV. These data were compared with HBV copy numbers, HBsAg and ALT levels, and results of consecutive liver biopsies.

RESULTS

After 21 weeks of treatment, a silent mutation at codon 528 (CTG to TTG) occurred. Significant genotypic resistance was detectable after 68 weeks, indicated by a substitution of isoleucine for methionine at residue 552 (M552I). Nineteen weeks later, the virus exhibited additional resistance-associated mutations (L528M and I552V). The resulting high-level resistance was reflected by an increase of serum HBV copies of 4.7 log(10). The turnover of wild-type and resistant HBV was 2.6x10(6) and 1.8x10(6) virions/day, respectively. HBsAg and ALT levels were lower within the period when resistant HBV was detectable. During treatment the progress of liver fibrosis was arrested.

CONCLUSIONS

The in vivo replicative capacities and dynamics of wild-type and resistant HBV were similar. However, resistant HBV seemed to exhibit reduced pathogenicity.