The minimally invasive direct anterior approach for total hip arthroplasty (THA) was first published in 1985. Since then the technique has been further improved and the indications have been extended. The approach utilizes the muscle gap between the tensor fasciae latae muscle on the lateral side and the sartorius muscle on the medial side. This muscle gap allows a direct and quick approach to the hip joint with good muscle preservation. During preparation of the femur the tensor fasciae latae muscle is at risk of being damaged. The lateral cutaneous nerve of the thigh (NCFL) and its branches are also in danger of being damaged during skin incision and dissection of the subcutaneous tissue. In this article the technique, risks and current clinical results of THA using the minimally invasive direct anterior approach are described. The results from the literature, as well as own results are compared to the traditional transgluteal lateral Bauer approach and discussed. Reviewing the literature, special attention has been given to the incidence of NCFL lesions, damage of the tensor fasciae latae muscle and positioning of the cup. Especially for the latter, the general view is hindered in the minimally invasive technique.

BACKGROUND:The painless clinic and postoperative pain therapy are currently major issues in the management of surgical procedures. The aim of this study was to evaluate the benefit of a standardized pain therapy on the postoperative pain level after orthopaedic procedures. PATIENTS AND METHODS:We investigated two different groups of patients who underwent an orthopaedic surgical procedure. Group 1 (n = 249) received a pain therapy which was based on an individual and surgery-dependent concept whereas group 2 (n = 243) was treated with a standardized pain therapy concept. The effect of the treatment was monitored with a VAS-based protocol. RESULTS:Up to day 9 after surgery there was a significant difference between the two groups in regard to the postoperative pain. The patients of group 2 had less pain but had more unwanted side effects caused by the pain therapy during the first 3 days after surgery. Mobility and mental disposition were positively affected. CONCLUSION:The implementation of a standardized pain therapy is successful in reducing postoperative pain. Mobility and mental disposition are also influenced positively. As a consequence the incidence of unwanted side effects is rising.

Die „schmerzfreie Klinik“ sowie die postoperative Schmerztherapie sind ein zentrales Thema in der heutigen Zeit. Ziel dieser Studie war es, die Auswirkung der Implementierung einer standardisierten Schmerztherapie auf den postoperativen Schmerzverlauf nach orthopädischen Operationen zu untersuchen.

A promising approach for the repair of osteochondral defects is the use of a scaffold with a well-defined cartilage-bone interface. In this study, we used a multiphasic composite scaffold with an upper collagen I fibre layer for articular cartilage repair, separated by a hydrophobic interface from a lower polylactic acid (PLA) part for bone repair. Focusing initially on the engineering of cartilage, the upper layer was seeded with human mesenchymal stem cells (hMSCs) suspended in a collagen I hydrogel for homogeneous cell distribution. The constructs were cultured in a defined chondrogenic differentiation medium supplemented with 10 ng/ml transforming growth factor-beta 1 (TGF beta 1) or in DMEM with 10% fetal bovine serum as a control. After 3 weeks a slight contraction of the collagen I fibre layer was seen in the TGF beta 1-treated group. Furthermore, a homogeneous cell distribution and chondrogenic differentiation was achieved in the upper third of the collagen I fibre layer. In the TGF beta 1-treated group cells showed a chondrocyte-like appearance and were surrounded by a proteoglycan and collagen type II-rich extracellular matrix. Also, a high deposition of glycosaminoglycans could be measured in this group and RT-PCR analyses confirmed the induction of chondrogenesis, with the expression of cartilage-specific marker genes, such as aggrecan and collagen types II and X. This multiphasic composite scaffold with the cartilage layer on top might be a promising construct for the repair of osteochondral defects. Copyright (C) 2009 John Wiley & Sons, Ltd.

The osteogenic differentiation of bone marrow-derived human mesenchymal stem cells (MSCs) in a collagen I hydrogel was investigated. Collagen hydrogels with 7.5 x 10(5) MSCs ml(-1) were fabricated and cultured for 6 weeks in a defined, osteogenic differentiation medium. Histochemistry revealed morphologically distinct, chondrocyte-like cells, surrounded by a sulfated proteoglycan-rich extracellular matrix in the group treated with bone morphogenetic protein 2 (BMP-2), while cells cultured with dexamethasone, ascorbate-2-phosphate, and beta-glycerophosphate displayed a spindle-shaped morphology and deposited a mineralized matrix. Real-time polymerase chain reaction (RT-PCR) analyses revealed a specific chondrogenic differentiation with the expression of cartilage-specific markers in the BMP-2-treated group and a distinct expression pattern of the osteogenic markers alkaline phosphatase (ALP), type I collagen, osteocalcin (OC), and cbfa-1 in the group treated with an osteogenic standard medium. The collagen gels were used to engineer a cell laden medical grade epsilon-polycaprolactone (PCL)-hydrogel construct for segmental bone repair showing good bonding at the scaffold hydrogel interface and even cell distribution. The results show that MSCs cultured in a collagen I hydrogel are able to undergo a distinct osteogenic differentiation pathway when stimulated with specific differentiation factors and suggest that collagen I hydrogels are a suitable means to facilitate cell seeding of scaffolds for bone tissue engineering applications.

Für die Osteointegration von orthopädischen Implantaten sind eine ausreichende Anzahl von Knochenzellen und eine hohe biologische Aktivität zur Produktion extrazellulärer Matrix notwendig.

Freeman-Sheldon syndrome (FSS) or craniocarpotarsal dysplasia is characterized by a triad of symptoms: 1. Masklike, whistling facial expression (whistling face syndrome), 2. Ulnar deviation of digits II to V and adduction contracture of the thumb and 3. Foot deformities. The pathogenesis of this malformation is unknown. Heredity is autosomal dominant and not sex-linked. Genetic counseling of affected individuals is imperative. The differential diagnosis should exclude the possibility of arthrogryposis multiplex congenita and particularly congenital windmill deformity of the fingers, which can also be accompanied by foot deformities. The foot and hand deformities associated with FSS are resistant to treatment and require consistent conservative and operative measures. Multiple, extensive operative interventions were unavoidable in both cases described.

Five cases of hereditary onycho-osteodysplasie are reported. All of the family members presented dysplastic nails. Hypoplastic patella, elbow dysplasia or iliac horns were shown in variable expression. We've seen no other anomalies especially nephropathy did not occur.

The aminobisphosphonate zoledronic acid (ZA) is a bone seeking specific inhibitor of protein farnesylation and geranylgeranylation, which causes inhibition of osteoclast function and apoptosis. It is widely used as an osteoclast targeted antiresorptive treatment of metastatic bone disease, Paget's disease and osteoporosis. Mesenchymal stein cells (MSC) and osteoblast precursors can also be targets of bisphosphonates, but the clinical relevance of these effects is under debate. We show here that ZA in vitro causes inhibition of proliferation and induction of apoptosis in hMSC, when applied in concentrations of 20 and 50 mu M for more than 24 h which can be rescued by treatment with 10 mu M geranylgeranyl pyrophosphate (GGPP). However, pulse Stimulation for 3 and 6 h with these concentrations and subsequent culture for LIP to 2 weeks under osteogenic conditions exerts Sustained regulation of osteogenic marker genes in hMSC. The effect on gene regulation translates into marked enhancement of mineralization, as shown by alizarin red and alkaline phosphatase staining after 4 weeks of osteogenic culture. ZA, when applied as a pulse stimulus, might therefore also stimulate osteogenic differentiation in vivo, since mu M plasma concentrations can be achieved by intravenous application of 5 mg in patients. These data set the stage for the future dissection of the effects of ZA and other aminobisphosphonates on cells beyond osteoclasts, with respect to cell differentiation in benign metabolic and to antitumor efficacy in metastatic bone diseases, as well as adverse events due to Putative Substance accumulation in bone during long-term treatment. (C) 2009 Elsevier Inc. All rights reserved.

Introduction: Without primary facture of femoral cortex in femoral head necrosis, 85% of cases have a collapse of the femoral head without treatment after 2 years. It was the aim of this retrospective study to examine the long term outcome of patients having undergone femoral head decompression.Methode: The clinical evaluation was done by the Harris Score. A.p. pictures of the pelvis as well as Lauenstein X-rays were taken as radiographic evaluation. These were compared to the preoperative radiographs, computer-tomographies, szintigrams and MRIs according to the classification of Ficat et al. (1980) and to that of Steinberg et al. (1984).Results: 62 cases of femoral head necrosis in 52 patients were followed. 12 cases received a varic osteotomy in addition to the decompression of the femoral head. The average follow up period was 90 months postoperatively. 11 cases had received a total hip arthroplasty (THA) and in three cases there was an indication for a THA after follow up examination. The mean intervell between femoral head decompression and THA was 7.1 years. 40 cases (65%) ha a Harris Score over 75 points corresponding to a good to excellent clinical result.Conclusion: Femoral head decompression remains an important operation to preserve the structural integrity. It is indicated in cases without subchondral.

Purpose: Thromboprophylaxies with heparins after total hip arthroplasty (THP) and total knee arthroplasty (TKA) is well accepted. The aim of this study was to compare the low molecular weight heparin (Enoxaparin) with PTT adjusted unfractioned heparin (Na-heparin).Methods: In a prospective study of 226 patients after THA and TKA, we performed physical examination and ultrasound in compression and duplex technique one day before surgery and at the 7th and 14th day after surgery. 120 patients received Enoxaparin 1 x 40 mg per day in fixed dosage. 106 patients received Na-heparin 3 x 5000 IE. Since PTT did not reach 40 seconds, Na-heparin dosage was increased to 3 x 7500 IE. Results: The overall thrombosis rate was 4% (n=9), in the Enoxaparin group 2.9% for the 70 THA and 10% for the 50 TKA. Thrombosis occured in the group of unfractioned heparin (PTT adjusted) in 1.8% after THA and in 2% after TKA. In TKA, there is statistical difference between the two heparin groups. Conclusion: In the thromboprophylaxis of TKA, PTTadjusted unfractioned heparin is superior to low molecular weight heparin in fixed dosage.

Purpose: To follow the radiographic parameters of prosthetic loosening of the Knee Society Roentgenographic Evaluation and Scoring System (KSRESS) and to test their clinical relevance.Methods: This prospective study documents the use of the KSRESS and clinical rating system in 333 primary posterior cruciate retaining PFC total knee arthroplasties preoperatively, at 3 month and at yearly intervals postoperatively. The average follow-up period was 3.2 years (range 2-5.5 y).Results: The average component position and alignment angles remained unchanged at biomechanically correct angles during the follow-up period. Radiolucent lines were observed regularly at the edges of the tibial and femoral components. The average total radiolucent lines score decreased for the tibial component. Patellar and femoral lucencies remained unchanged. The total radiolucent lines scores did not correlate with postoperative pain, body-mass-index, alignment, stability, knee and function score. Four revisions, one with relevant radiolucent lines, had to be performed.Conclusions: The KSRESS is a useful tool. Standardisation of roentgenograms is mandatory. The PFC arthroplasty, the operative technique and the instruments ensure a biomechanically correct implantation.

Das Ziel bei der Therapie der Femurkopfnekrose des Erwachsenen ist es, den Hüftkopf zu erhalten und einen künstlichen Gelenkersatz zu vermeiden. Die Core-Dekompression bietet neben der intraossären Druckentlastung zusätzlich die Möglichkeit, bioaktive Materialien, Substanzen und Zellen in den Bohrkanal einzubringen. Hierzu zählen vaskularisierte und nichtvaskularisierte Knochentransplantate, allogene und synthetische Knochenersatzmaterialien, osteogen und angiogen wirkende Wachstumsfaktoren sowie unterschiedliche Vorläuferzellen. Insbesondere der Einsatz neuer zellbasierter Verfahren hat ein großes therapeutisches Potenzial und könnte zukünftig einen entscheidenden Fortschritt bei der Behandlung der Femurkopfnekrose bedeuten. In diesem Beitrag werden die bisherigen klinischen Erfahrungen der zellbasierten Strategien zur Therapie der Femurkopfnekrose des Erwachsenen zusammenfasst und ein eigener neu entwickelter Therapieansatz unter der Verwendung von Knochenmarkstammzellen (TRCs: „tissue repair cells“) in Kombination mit einer β-TCP-Matrix vorgestellt.

Die bildgebende Diagnostik der aseptischen Femurkopfnekrose hat das Ziel, den Patienten einer stadiengerechten Therapie zuzuführen. Hierfür ist eine differenzierte Diagnostik erforderlich. Das Röntgenbild des Hüftgelenks in 2 Ebenen ist nach wie vor der erste Schritt der Diagnostik. In den vergangenen Jahren hat sich die Bildgebung durch die Anwendung der Magnetresonanztomographie (MRT) und der Computertomographie (CT) enorm verbessert. Durch diese Entwicklung kann bereits frühzeitig die korrekte Stadieneinteilung vorgenommen und die adäquate Therapie eingeleitet werden. Das sensitivste bildgebende Verfahren ist heute die MRT. Die CT hat insbesondere für den Ausschluss einer subchondralen Fraktur ihre Berechtigung. Die Szintigraphie wird nur in Ausnahmefällen eingesetzt.

The goal of the therapy for necrosis of the femoral head in adults is the preservation of the femoral head and, therefore, avoidance of total joint replacement. Core decompression is known to reduce the intraosseous pressure and additionally provides the opportunity to introduce bioactive materials, substances and cells into the core tract. These include vascularized and non-vascularized bone grafts, allogenic and synthetic bone substitutes, osteogenic and angiogenic growth factors, as well as different progenitor cells. In particular, the use of cell-based strategies has great therapeutic potential and could play an important role in the treatment of femoral head necrosis in adults in the future. In this article, we summarize the existing clinical experience of current cell-based strategies for the treatment of femoral head necrosis in adults, and present a therapeutic approach using bone marrow stem cells (TRCs: tissue repair cells). in combination with a beta-TCP matrix.

The aim of diagnostic imaging procedures in avascular femoral head necrosis is to provide the patient with a stage-adapted therapy. Therefore, a differentiated diagnostic work-up is needed. Native radiography of the hip in two planes is still the first step. Over the past years, the diagnosis of femoral head necrosis has experienced tremendous improvement due to the use of MRI and CT scans. Because of these improvements the correct stage can be diagnosed early and the appropriate therapy can be initiated immediately. Today, MRI is the most sensitive diagnostic imaging procedure. CT scans can be particularly useful to exclude subchondral fractures.The use of bone scintigraphy is restricted to exceptional cases. In Europe, the ARCO classification of avascular femoral head necrosis has been widely accepted. It is essential here to define subtypes according to the localisation and the extent of the necrosis, because both have major influence on the prognosis of the disease and therefore also for the therapeutic strategy. In this overview, we describe the specific characteristics of the different diagnostic imaging procedures and illustrate them with appropriate imaging material. At the end of the article an algorithm for diagnostic imaging procedures in avascular femoral head necrosis for daily orthopaedic practice is proposed.