Orthopadie (Heidelberg, Germany)最新文献

Anticoagulation in most patients with familial thrombophilia-hypofibrinolysis and primary osteonecrosis (ON) before hip or knee collapse relieves pain, prevents joint collapse and usually averts the need for joint replacement but is not successful in secondary ON or if started after joint collapse. Anticoagulation in Perthes disease and in ON acutely appearing in post-COVID patients, particularly when factor V Leiden is present, may be valuable as an approach to prevent the otherwise high likelihood of subsequent joint failure. Anticoagulation in primary ON with concurrent thrombophilia-hypofibrinolysis should be considered within the treatment spectrum of ON.

Background: The demographic shift is expected to lead to a further increase in the number of hip joint replacements. Accordingly, as has already been observed in recent years, a further increase in periprosthetic femoral fractures (PPF) is to be expected. PPF is now the third most common reason for revision surgery after hip arthroplasty.

Objectives: Taking into account the known risk factors for PPF, fracture treatment strategies are evaluated based on current evidence in order to make recommendations for practice.

Methods: Narrative review.

Results: Overall, the literature is very heterogeneous and evidence is lacking for many aspects. Numerous recommendations are based on non-randomized studies with low patient count. Mortality after PPF is high regardless of the treatment chosen. Age and bone quality influence the partly heterogeneous results and play a role in the treatment strategy. The use of both cemented and uncemented stems in revision surgery due to proximal PPF is frequently described in the literature. There are no significant differences in terms of outcome. The advantage of uncemented modular stems is currently not supported by the literature.

Conclusions: An individualized approach to the treatment of PPF is recommended, considering environmental factors and comorbidities. In geriatric patients, full weight-bearing of the lower extremity should be aimed for postoperatively to avoid complications.

Introduction: The present meta-analysis compared intra-articular injections of hyaluronic acid (HA) versus plasma rich in growth factors (PRGF) in patients with knee osteoarthritis (OA). The outcome of interest was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Methods: This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses: the 2020 PRISMA statement. All the head-to-head randomised controlled trials (RCT) comparing intra-articular HA injections versus PRGF were accessed and included in the present study. Only studies that clearly stated that injections were performed in patients with knee OA, irrespective of the severity of OA, were considered. Data concerning the WOMAC index were retrieved at baseline and last follow-up. The endpoint of interest was to investigate whether intra-articular HA injections are associated with WOMAC score improvement compared to PRGF injections at 4-6 months follow-up.

Results: Data from 432 patients were collected and 76.3% (330 of 432) of the patients were women. The mean age of the patients was 58.2 ± 1.5 years and the mean body mass index (BMI) was 28.0 ± 0.5 kg/m². At baseline, comparability in mean age, BMI, male:female ratio, WOMAC and related subscales were documented. The PRGF group evidenced lower values of the function subscale of the WOMAC index (P = 0.03). No difference was found in the overall WOMAC index (P = 0.05) and its stiffness (P = 0.4) and pain (P = 0.07) subscales.

Conclusion: The current level I evidence suggests that the use of PRGF might be associated with more favorable clinical outcomes than using HA.

Background: In total knee arthroplasty (TKA), there is a trend towards personalized concepts. This includes the implementation of new technologies and the increasing popularity of individualized alignment strategies.

Targets: The purpose of personalized TKA is to restore the patient's bony anatomy and constitutional alignment, as well as the physiological soft tissue balance and joint kinematics. Modern technologies facilitate a thorough, three-dimensional analysis of the bony structures and the patient's constitutional alignment. Virtual planning enables a simulation component placement, gap balancing and postoperative alignment. After approval of the surgical plan, the technology-aided execution shows a greater accuracy, precision and reproducibility of implant alignment compared to conventional manual instrumentation.

Overview: This article focuses on novel technologies in total knee arthroplasty, including patient-specific instrumentation (PSI), custom implants, navigation and robotics. The purpose of this article is to summarize current evidence, including radiological and functional outcomes, as well as economic aspects. Furthermore, the implementation of novel technologies in the context of personalized alignment strategies will be discussed.

Background: Since its foundation in 2010 by the German Society for Orthopaedics and Orthopaedic Surgery (DGOOC) and its establishment together with industry representatives (Bundesverband Medizintechnologie e. V.-BVMed) and the health insurance companies (AOK-Bundesverband eGbR, Verband der Ersatzkassen e. V. (vdek)), the German Arthroplasty Registry (EPRD) has developed rapidly in terms of size and quality of results. With over 3 million data records of hip and knee prostheses, it is now the world's third largest registry for arthroplasty. The product database of the EPRD and National Joint Registry (NJR) is becoming the global standard. 2023 was a record year in terms of recorded operations and scientific publications. The results of the EPRD are increasingly analysing and influencing everyday clinical practice in hip and knee arthroplasty in Germany.

Prospects: From 2025, all EPRD clinics will be able to use the Oxford Hip and Oxford Knee Score free of charge for their patients as Patient Reported Outcome Measures (PROMs). In 2025, the recording parameters will be expanded to include surgical approaches to the hip, navigation and robotics on the knee joint, as well as an optional infection module. In 2026, voluntary registration of the surgeon with surgeon level reporting will be possible. The EPRD and the Implantateregister Deutschland (IRD) are expected to exist in parallel from 2025, and cooperation is still being sought. Data collection should be as streamlined as possible without duplicate data entries. However, the EPRD will continue to work independently of the IRD with its more than 12 years of experience and over 3 million data sets and will continue to provide clinics and specialists with its analyses and publications in the future.

Background: Today, there are several nonoperative treatment measures available for the management of osteonecrosis and bone marrow oedema of the foot and ankle.

Treatment: These include immobilisation, the use of anti-inflammatory drugs (NSAIDs), physical therapy, orthotics and extracorporeal shockwave therapy (ESWT). Furthermore, off-label use of either bisphosphonates, denosumab or prostacyclins have proven to be effective treatment options. Notably, in many cases, symptoms resolve after several months without any specific treatment. As patients often present with insufficient vitamin D levels, the measurement and correction of vitamin D status is recommended.

The adoption of 3D printing technology in hip surgery marks a substantial leap forward in orthopedic surgery. This innovative approach allows for the creation of patient-specific implants that significantly enhance fit and functionality. In our study, we demonstrate the different uses of 3D-printing techniques and their preoperative, intraoperative, and postoperative use in hip surgery for the treatment of complex acetabular defects. Moreover, the clinical outcomes of 3D-printed implants have been discussed. By overcoming many limitations of traditional manufacturing methods, 3D printing facilitates the production of complex geometries and highly porous structures that improve implant fixation and promote better bone ingrowth. We believe that in the upcoming years, with the help of new technical improvements, the use of 3D-printed implants will increase.

Background: Fast-track arthroplasty is on the rise in Germany. In comparison to established fast-track countries, such as Denmark and the USA, Germany is only at the beginning of its implementation. The biggest challenges include increasing staff shortages and cost pressure as, well as the slow progress of digitalization.

Fields of application: The use of app-based patient management systems offers the opportunity to prepare the patient extensively for the surgical procedure, to rehabilitate them according to a standardized schedule, to avoid unnecessary doctor's visits, to save staff and, thus, reduce healthcare costs. Patient apps will also play an important role in collecting patient data and abnormalities in rehabilitation. By correlating intraoperative data from robotics, predictive statements about the surgical strategy, such as implant positioning or axis alignment may be possible. In this review, the essential contents of an app-based patient management system for fast-track arthroplasty are listed and discussed, and the possibilities for using patient data are presented.

Background: In the year 2022, more than 300,000 total hip and knee primary arthroplasties were recorded in the German Arthroplasty Registry. The ever-increasing number of interventions naturally leads to an increase in the absolute number of possible complications. The abundance of internationally available data makes it possible to determine risk factors for postoperative complications.

Risk factors: Professional societies involved in the German guidelines in the field of orthopedics place great emphasis on modifiable risk factors, as their adequate management can consequently reduce the likelihood of postoperative complications. One of the most common modifiable risk factors is obesity, with its prevalence remaining consistently high in most developed countries. In the field of orthopedics, the Association of the Scientific Medical Societies in Germany focuses on modifiable risk factors including obesity, diabetes mellitus and smoking.

Obesity: In the case of obesity in particular, the guidelines for knee and hip arthroplasty recommend a weight loss attempt for patients with a BMI > 30 kg/m². A BMI ≥ 40 kg/m² is considered a "relative contraindication" in the guidelines. Shared decision making is emphasized in both guidelines. Ultimately, the particularly critical individual assessment of risk and benefit for each obese patient remains crucial for the final decision.

Background: The increasing prevalence of obesity represents a significant and growing challenge in orthopaedic surgery. This is particularly true for patients with morbid obesity, who have a significantly increased risk of postoperative complications. The newer incretin-based therapies (such as semaglutide and tirzepatide), these so-called "weight loss injections", offer promising potential for preoperative weight reduction and minimisation of peri- and postoperative complications.

Study situation: However, the evidence regarding their influence on postoperative outcomes is inconsistent. Retrospective studies suggest that rapid weight loss immediately prior to orthopaedic surgery may increase the risk of complications, including septic shock and revision surgery. Meta-analyses, on the other hand, indicate potential protective effects in surgical outcomes with prior long-term weight reduction.

Conclusion: There are currently no sufficiently qualitative studies on the safety and efficacy of these new drugs in the orthopaedic surgery sector. An individualised and multidisciplinary approach, therefore, remains relevant in order to achieve an optimal surgical outcome for the individual patient.