[Treatment of symptomatic end-stage osteoarthritis of the ankle with anterolateral approach and an anatomical plate]

OBJECTIVE

The aim of this paper is to describe the anterolateral approach using an anatomical plate for ankle arthrodesis and to present the first mid-term results with this technique in a high-risk population.

INDICATIONS

The indication for arthrodesis of the ankle joint with this described technique is moderate to severe osteoarthritis of the ankle.

CONTRAINDICATIONS

In addition to the general contraindications typical of any operation, there is a specific contraindication in cases of active infection of the soft tissues and accompanying osteomyelitis at the ankle.

SURGICAL TECHNIQUE

The incision is made along the course of the peroneus tertius muscle. After that, the mobilization of the peroneus superficialis nerve is carried out, followed by the mobilization of the long extensor tendons, especially the extensor digitorum muscle in a medial direction opening the capsule and removal of the residual cartilage on the distal tibia and talus. Subsequently, the subchondral sclerosis is opened, and the implantation of a suitable osteosynthesis material, e.g., an anatomical angle-stable plate, is carried out. Finally, wound closure is performed involving the muscle belly of the extensor digitorum muscle covering the plate.

POSTOPERATIVE MANAGEMENT

Immobilization of the ankle for 5-7 days in a dorsal knee-high splint. Retention in a walker after decongestion for another 5 weeks. Increased loading can be done after X‑ray/computed tomography (CT) control from the 6th week.

RESULTS

In all, 11 patients were observed retrospectively for an average of 14 months. There were no complications. The European Foot and Ankle Society (EFAS) score improved significantly from 3.3 to 17.8 points. All patients were subjectively satisfied with the result and would have the operation again.

Modern Radiological Postoperative Diagnostics of the Hip Joint in Children and Adults

The assessment of bone healing and loosening of endoprosthesis material was long the primary indication for postoperative projection radiography and CT imaging of the hip joint following trauma and endoprosthesis implantation. With the increasing number of joint-preserving surgery, e. g. of surgical hip luxation and hip arthroscopy for the treatment of femoroacetabular impingement (FAI), high-resolution imaging of intra-articular pathologies before and after surgery has become increasingly important. In this review article, diagnostic imaging of the hip joint is presented following common trauma surgery and orthopedic surgery interventions. The imaging modalities of projection radiography, CT and MRI including direct MR-arthrography are discussed with regard to their diagnostic capability in the postoperative assessment of the hip joint. Among others topics, imaging is discussed following hip arthroplasty, following surgical hip luxation and arthroscopic interventions for the treatment of FAI, as well as following core decompression for avascular necrosis of the femoral head. Moreover, orthopedic interventions of the hip joint in children and adolescents are presented and the dedicated reporting of postoperative imaging is outlined.

KEY POINTS

• Consolidation of osteotomies and position of implants should be assessed in postoperative imaging. • MRI is useful for confirming correct articulation after treatment of congenital hip dislocation. • Radiologically assessable complications after total hip replacement are inlay wear, loosening, dislocation, periarticular ossifications and infection. • MRI can detect and classify pseudotumours in cases of metal-metal pairing after total hip replacement.

Prediction of in vivo bone forming potency of bone marrow-derived human mesenchymal stem cells

Human mesenchymal stem cells (MSC) have attracted much attention for tissue regeneration including repair of non-healing bone defects. Heterogeneity of MSC cultures and considerable donor variability however, still preclude standardised production of MSC and point on functional deficits for some human MSC populations. We aimed to identify functional correlates of donor-dependency of bone formation in order to develop a potency assay predicting the therapeutic capacity of human MSC before clinical transplantation. MSC from 29 donors were characterised in vitro and results were correlated to bone formation potency in a beta-tricalcium-phosphate (β-TCP)-scaffold after subcutaneous implantation into immunocompromised mice. In contrast to osteogenic in vitro differentiation parameters, a doubling time below 43.23 hours allowed to predict ectopic bone formation at high sensitivity (81.8%) and specificity (100%). Enriched conditions adapted from embryonic stem cell expansion rescued bone formation of inferior MSC populations while growth arrest of potent MSC by mitomycin C abolished bone formation, establishing a causal relationship between neo-bone formation and growth. Gene expression profiling confirmed a key role for proliferation status for the bone forming ability suggesting that a rate limiting anabolism and open chromatin determined and predicted the therapeutic potency of culture-expanded MSC. Proliferation-based potency testing and switch to enriched expansion conditions may pave the way for standardised production of MSC for bone repair.

[Symptomatic bilateral soft tissue tumor of the breast wall]

A 54-year-old woman presented with progressive swelling of the right scapula as well as motion-dependent pain. The medical history revealed a polyglandular autoimmune syndrome and lumbar disc degeneration. The magnetic resonance imaging (MRI) scan showed a bilateral well-defined muscle isointense space-occupying lesion situated between the scapula, rib cage and thoracic muscles with homogeneous contrast enhancement. The constellation is indicative of a elastofibroma dorsi, a rare mesenchymal tumor often appearing bilaterally.

Autologous capping during resection arthroplasty of the hip in patients with cerebral palsy

In patients with severe quadriplegic cerebral palsy and painful hip dislocation proximal femoral resection arthroplasty can reduce pain, but the risk of heterotopic ossification is significant. We present a surgical technique of autologous capping of the femoral stump in order to reduce this risk, using the resected femoral head as the graft.

A retrospective study of 31 patients (43 hips) who had undergone proximal femoral resection arthroplasty with (29 hips) and without autologous capping (14 hips) was undertaken. Heterotopic ossification was less frequent in patients with autologous capping, and a more predictable pattern of bony overgrowth was found.

For a selected group of non-ambulatory patients with long-standing painful dislocation of the hip, we recommend femoral resection arthroplasty over more complicated reconstructive operations. The risk of heterotopic ossification, which is a major disadvantage of this operation, is reduced by autologous capping.

Instant stem cell therapy: characterization and concentration of human mesenchymal stem cells in vitro

In regenerative medicine, there is an approach to avoid expansion of the mesenchymal stem cell (MSC) before implantation. The aim of this study was to compare methods for instant MSC therapy by use of a portable, automatic and closed system centrifuge that allows for the concentration of MSCs. The main outcome measures were the amount of MSCs per millilitre of bone marrow (BM), clusters of differentiation (CD), proliferation and differentiation capacities of the MSC. A volume reduction protocol was compared to the traditional laboratory methods of isolation using a Ficoll gradient and native BM. Fifty millilitres of BM were obtained from haematologically healthy male Caucasians (n=10, age 8 to 49 years). The number of colony forming units-fibroblast (CFU-F)/ml BM was highest in the centrifuge volume reduction protocol, followed by the native BM (not significant), the centrifuge Ficoll (p=0.042) and the manual Ficoll procedure (p=0.001). The MSC of all groups could differentiate into the mesenchymal lineages without significant differences between the groups. The CD pattern was identical for all groups: CD13+; CD 44+; CD73 +; CD90+; CD105+; HLA-A,B,C+; CD14-; CD34-; CD45-; CD271-; HLA-DR-. In a further clinical pilot study (n=5) with 297 ml BM (SD 18.6), the volume reduction protocol concentrated the MSC by a factor of 14: there were 1.08 x 10(2) MSC/ml BM (standard deviation (SD) 1.02 x 10(2)) before concentration, 14.8 x 10(2) MSC/ ml BM (SD 12.4 x 10(2)) after concentration, and on average 296 x 10(2) MSC (SD 248.9 x 10(2), range 86.4-691.5 x 10(2)) were available for MSC therapy. The volume reduction protocol of the closed centrifuge allows for the highest concentration of the MSC, and therefore, is a promising candidate for instant stem cell therapy.

A sheep model for fracture treatment in osteoporosis: benefits of the model versus animal welfare

Animal models are necessary to evaluate new options for the treatment of fractures in osteoporotic bone. They permit both the biological response of a living system and the influence of the pathological processes to be taken into account. A sheep model for osteoporosis was established by combining oestrogen deficiency, calcium and vitamin D-deficient diet with steroid medication. Bone mineral density (BMD) was reduced by >30% after 12 weeks of combined treatment. Osteoporosis similar to the human situation with corresponding changes in the micro-architecture and mechanical properties of bone was observed. This publication focuses on the impressive results obtained with the model and contrasts them with considerations of animal welfare. Considerable side-effects associated with steroid medication became manifest. Animals in the treatment groups showed signs of infection of various degrees due to the immunosuppressive effect of the medication. The infections were mostly caused by Corynebacterium pseudotuberculosis. Antibody testing revealed a 100% prevalence of infection in this breed of sheep. A modification of the steroid treatment, i.e. less-frequent injections, reduced the incidence of side-effects. This sheep model shows a significant and reproducible reduction in cancellous BMD of >30%, including relevant changes in biomechanical properties and increased fracture risk. However, the severity of the side-effects cannot be overlooked. The model must be improved if it is to be used in the future. Options to reduce the side-effects are discussed.

Delayed administration of adenoviral BMP-2 vector improves the formation of bone in osseous defects

The direct, local, administration of adenovirus carrying human BMP-2 cDNA (Ad.BMP-2) heals critical-sized femoral bone defects in rabbit and rat models. However, the outcome is suboptimal and the technology needs to provide a more reliable and uniform outcome. To this end, we investigated whether the timing of Ad.BMP-2 administration influenced the formation of mineralized tissue within the defect. Critical-sized defects were created in the femora of 28 Sprague-Dawley rats. Animals were injected intralesionally with a single, percutaneous injection of Ad.BMP-2 (4 x 10(8) plaque-forming units) either intraoperatively (day 0) or 24 h (day 1), 5 days or 10 days after surgery. The femora were evaluated 8 weeks after surgery by X-ray, microcomputed tomography, dual-energy X-ray absorptiometry and biomechanical testing. The incidence of radiological union was markedly increased when administration of Ad.BMP-2 was delayed until days 5 and 10, at which point 86% of the defects healed. These time points also provided greater bone mineral content within the defect site and improved the average mechanical strength of the healed bone. Thus, delaying the injection of Ad.BMP-2 until 5 or 10 days after surgery enables a greater percentage of critical-sized, segmental defects to achieve radiological union, producing a repair tissue with enhanced mineralization and greater mechanical strength.

Direct adenoviral transfer of bone morphogenetic protein-2 cDNA enhances fracture healing in osteoporotic sheep

Osteoporosis, a major public health burden, is associated with increased fracture risk. Fracture healing in osteoporosis is delayed, with reduced callus formation and impaired biomechanical properties of newly formed bone leading to high risk of fixation failure. Adenoviral gene transfer of bone morphogenetic protein-2 (BMP-2) has been shown to enhance fracture healing. This study evaluated the ability of gene transfer to enhance bone healing in osteoporosis. An established sheep model of osteoporosis with well-characterized alterations in fracture healing was used. Osteotomies were created surgically in the tibias of adult female sheep and monitored for 8 weeks, using radiographic, biomechanical, and histological methods. For pilot experiments, primary ovine osteoblasts and mesenchymal stem cells were transduced with a recombinant adenovirus carrying BMP-2 cDNA (Ad.BMP-2). Large increases in alkaline phosphatase production and mineralization confirmed the ability of human BMP-2 to stimulate osteoblastic differentiation in sheep. In vivo bending stiffness measurements during fracture healing as well as ex vivo torsional stiffness measurements demonstrated stiffer callus tissue after treatment with Ad.BMP-2. The differences were found mainly in the early fracture-healing period. Computed tomography demonstrated that animals receiving the BMP-2 cDNA had larger cross-sectional callus area and higher callus density. Histological examination of the tibias confirmed enhanced callus formation. Direct, local adenoviral delivery of an osteogenic gene thus led to enhanced healing of fractures in an ovine model of osteoporosis. These promising data encourage the further development of genetic approaches to enhance bone healing in patients suffering osteoporosis-associated fractures.

Effect of BMP-2 gene transfer on bone healing in sheep

Critical size defects of bone and delayed fracture healing due to metabolic disorders are still problems in orthopaedic surgery. Adenoviral vectors encoding bone morphogenetic protein-2 (Ad.BMP-2) have been used to stimulate bone formation in small animals. The present study evaluated the use of direct adenoviral gene transfer for inducing bone formation in a large animal. Standardized iliac crest defects were created surgically on both sides of the pelvic bone of white mountain sheep. The efficiency of gene transfer was evaluated using recombinant adenoviruses carrying the cDNA for luciferase. High levels of transgene expression, restricted to the site of injection, were found for the 1st week. Transgene expression then fell considerably, but could still be detected for up to 5 weeks. To investigate the effect on bone healing, Ad.BMP-2 (10(11) particles in 200 mul saline) was unilaterally injected into iliac crest defects and into tibial osteotomies. The contralateral defects remained untreated to evaluate possible systemic effects. The controls were treated with saline solution. Bone formation within the defect, assessed by micro-computed tomography (CT) measurement at 8 weeks, and callus formation after osteotomy were significantly reduced following direct application of Ad.BMP-2. The retardation compared to untreated control animals was additionally found at the contralateral iliac crest indicating a systemic inhibitory effect. Histological analysis confirmed the CT measurement and showed an increased number of inflammatory cells within both defects. Antibodies against the adenovirus and the transgene product were detected in all treated animals. These data show a systemic retardation of bone formation following a single local injection of Ad.BMP-2 in sheep. This finding stands in contrast to the data obtained from small animal models. Further studies are needed to determine the contribution of the immune response to these results, and whether a lower dose of Ad.BMP-2 would be advantageous.

The potential of gene therapy for fracture healing in osteoporosis

Osteoporosis-associated fractures impair a patient's function and quality of life and represent one of the major public health burdens. Demographic changes predict a dramatic increase in osteoporotic fractures. Experimental data have shown that osteoporosis impairs fracture healing. Clinical observations demonstrate high failure rates of implant fixation in osteoporosis. The reduced healing capacity, including impaired bone formation, in osteoporotic humans might be due to defects in mesenchymal stem cells that lead to reduced proliferation and osteoblastic differentiation. Growth factors show remarkable promise as agents that can improve the healing of bone or increase the proliferation and differentiation capacities of mesenchymal stem cells. Their clinical utility is limited by delivery problems. The attraction of gene-transfer approaches is the unique ability to deliver authentically processed gene products to precise anatomical locations at therapeutic levels for sustained periods of time. Unlike the treatment of chronic diseases, it is neither necessary nor desirable for transgene expression to persist beyond the few weeks or months needed to achieve healing. This review presents different approaches of gene therapy to enhance fracture healing and summarizes the promising results of preclinical studies. It focuses on applications of this new technique to fracture healing in osteoporosis. In our opinion, these applications represent some of the few examples in which gene therapy has a good chance of early clinical success.

Exercise-induced activation of coagulation in subjects with activated protein C resistance

In the healthy individual intensive physical exercise leads to a minor activation of blood coagulation that appears to be balanced by a concomitant activation of the fibrinolytic system. This study tested the hypothesis that vigorous exercise might give rise to an exaggerated activation of coagulation in subjects with resistance to activated protein C (APC). Molecular markers of thrombin (prothrombin fragment 1 + 2, thrombin-antithrombin III complexes) and fibrin formation (fibrinopeptide A), as well as markers of the fibrinolytic activity (plasmin-antiplasmin complexes, D-dimers), were determined in nine asymptomatic male individuals with APC resistance [age, 18 +/- 3 years; maximal oxygen consumption, 56.7 +/- 2.7 ml/kg per min (mean +/- standard deviation)] and in nine male control subjects (age, 19 +/- 4 years; maximal oxygen consumption, 56.2 +/- 3.2 ml/kg per min) after 1 h of running to exhaustion. Baseline levels of prothrombin fragment 1 + 2 were higher in individuals with APC resistance than in controls [0.67 +/- 0.06 nmol/l (mean +/- standard error) versus 0.48 +/- 0.01 nmol/l; P < 0.05]. In response to exercise, hemostatic variables significantly increased in both groups to a similar small extent. Likewise, exercise-induced changes of fibrinolytic variables in subjects with APC resistance paralleled those observed in controls. In summary, exhaustive running in subjects with APC resistance does not provoke an abnormal hemostatic or fibrinolytic response, suggesting that vigorous exercise does not imply an increased risk for thrombosis in young male subjects with APC resistance.

Analysis of injuries in long-distance triathletes

Triathlon is an individual sport consisting of three disciplines - swimming, cycling and running. Triathlon has changed from a novel appearance to a very popular Olympic sport within the last fifteen years. Nevertheless, there is not sufficient data about injuries in triathlon. The aim of this retrospective survey was to investigate the incidence of injuries according to class of injuries, anatomical sites and disciplines. Relations to age, sex, performance level, training habits and medical care were analysed. Questionnaires were sent to all German speaking participants of the Ironman Europe 2000. With a response rate of 35 %, 656 questionnaires met the inclusion criteria. At least one injury was experienced by 74.8 % (95 %-CI: 71.3-78.1) of all respondents during their active time in triathlon. 51.1 % (95 %-CI: 47.2-55.0) suffered one or more contusion/skin-abrasions, 33.1 % (95 %-CI: 29.5-36.8) muscle-/tendon-injuries, 29.0 % (95 %-CI: 25.5-32.6) ligament-/capsule-injuries and 11.9 % (95 %-CI: 9.5-14.6) fractures. Most of the injuries happened during cycling (54.8 % [95 %-CI: 51.9-57.8]) within training sessions. 18.7 % (95 %-CI: 16.4-21.2) of all injuries occurred while the athletes were competing. Considering the low number of competition hours per year, the incidence of injuries during competition was higher than during training session. Significant relations were found considering the age, performance level and weekly training hours of the triathletes. Older athletes sustained more fractures (p = 0.024), high performance athletes suffered more contusions/abrasions (p = 0.003) and muscle-tendon-injuries (p = 0.001) and athletes with a large number of weekly training hours suffered more muscle-tendon-injuries (p = 0.014). To summarize, injuries in triathlon seem to be related to age, performance level and weekly training hours, but not to sex, presence of training coach and medical care.

[Myoelectric prostheses for kindergarten age children. Analysis of first reactions and experiences]

During the last few decades myoelectric prostheses were generally provided for adolescent or adult patients. Since 1991 the availability of smaller sized electric hands in conjunction with technical improvements enabled the introduction of myoelectric prostheses for preschool children.However, this progress remained widely unnoticed in Germany. This study presents the authors' experiences with prosthetic devices for preschool children with unilateral upper limb deficiency (congenital and traumatic). Twenty children received a myoelectric prosthesis between the ages of 2 and 5 years (3.9+/-1.1 years). The follow-up period was 1.7 years. The prosthesis was worn for an average of 5.6 h/day. Our hospital-based intensive training program positively influenced the acceptance rate. All children with a below-hand amputation rejected their prosthesis.However, the general dropout rate in preschool children is conspicuously lower compared to adults. In this study 2.4+/-2.9 repairs per year per patient were required. The susceptibility for repairs in this age group is much higher for myoelectric prostheses compare to body-powered devices. Since the correct indication and the intensive training program significantly influence the acceptance rate, the introduction of myoelectric prostheses to preschool children should take place at specialized centers with an interdisciplinary team composed of orthopedists,occupational therapists,and technicians.