Hip-spine syndrome refers to the coexistence of hip and spinal pathologies, complicating diagnosis and surgical decision-making. This study investigated how German hip and spine surgeons prioritize surgical sequence in hip-spine syndrome and compared these patterns with those previously reported among U.S. surgeons. A cross-sectional survey containing five standardized case scenarios of concurrent hip osteoarthritis and typical degenerative spinal disorders was distributed to members of the German Society for Joint Replacement and the German Spine Society. Respondents included orthopaedic hip surgeons, orthopaedic spine surgeons (OSS), and neurosurgical spine surgeons (NSS). Quantitative data were analyzed using descriptive statistics and chi-square tests, and qualitative comments were examined using text-mining and thematic synthesis. Findings were compared on a point-by-point basis with the published results of the original U.S. study. In general, German surgeons recommended spine-first treatment when neurological deficits such as myelopathy or neurogenic claudication were present, and hip-first treatment in cases without neurological deficits. Preferences differed significantly among specialties, especially between NSS and OSS. Compared with U.S. respondents, German surgeons were more likely to prioritize spine-first procedures in scenarios involving neurogenic claudication. Decision-making was primarily driven by symptom severity, spine-pelvis-hip biomechanics, and perceived procedural risk, rather than by surgeons’ years of experience. The preferred order of surgery for patients with hip-spine syndrome varies with neurological status, surgeon specialty, and geographic context. These results underscore the importance of interdisciplinary communication and individualized, patient-centered strategies when formal treatment guidelines are lacking. Not applicable.

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.

OBJECTIVES:To determine the influence of obesity on revision rates and mortality after primary elective hip and knee arthroplasty in Germany. MATERIALS AND METHODS:In the German Arthroplasty Registry (EPRD) there were 403,073 elective total hip arthroplasties (THA), 320,913 bicondylar total knee arthroplasties (TKA) and 48,480 unicondylar knee arthroplasties (UKA) with valid BMI available for analysis. Cumulative revision rates and 1‑year mortality was calculated for BMI groups. RESULTS:There were increased revision rates with increasing BMI, most distinctive for septic revisions in THA during the first year after surgery (non-obese 0.7%, obesity grade 1 1.3%, grade 2 2.1%, grade 3 4.2%). In TKA and UKA this increase was generally less pronounced. Age- and gender-standardized mortality was lower than expected in most groups, but also increasing with increasing BMI. CONCLUSION:The risk for revisions in obese patients is more distinctive in hip arthroplasty than in knee arthroplasty and is especially high in morbidly obese patients (BMI ≥ 40 kg/m2). Nonetheless, this risk may be acceptable for affected patients. Therefore, the possible benefits and risks of an arthroplasty should be weighed against each other and individually discussed with the patient.

Das Endoprothesenregister Deutschland (EPRD) hat sich nach seiner Gründung 2010 durch die Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC) und dem Aufbau gemeinsam mit der Vertretung der Industrie (Bundesverband Medizintechnologie e. V. [BVMed]) und der Krankenkassen (AOK-Bundesverband eGbR, Verband der Ersatzkassen e. V. [vdek]) rasant bezüglich Größe und Qualität der Ergebnisse weiterentwickelt. Inzwischen ist es mit über 3 Mio. erfassten Datensätzen von Hüft- und Knieprothesen das weltweit drittgrößte Register für Endoprothetik. Die Produktdatenbank des EPRD und National Joint Registry (NJR) wird zum weltweiten Standard. 2023 war ein Rekordjahr bezüglich erfasster Operationen und wissenschaftlicher Publikationen. Die Ergebnisse des EPRD analysieren und beeinflussen zunehmend den klinischen Alltag in der Hüft- und Knieendoprothetik in Deutschland. Ab 2025 können alle EPRD-Kliniken den Oxford Hip und Oxford Knee Score kostenfrei für ihre Patienten als „patient reported outcome measures“ (PROM) nutzen. 2025 werden die Erfassungsparameter um die operativen Zugänge an der Hüfte, die Navigation und Robotik am Kniegelenk sowie ein optionales Infektionsmodul erweitert. 2026 wird die freiwillige Erfassung des Operateurs möglich sein. Das EPRD und das Implantateregister Deutschland (IRD) werden ab 2025 voraussichtlich parallel bestehen, eine Kooperation wird unverändert angestrebt. Die Datenerfassung soll möglichst schlank ohne doppelte Dateneingabe ermöglicht werden. Das EPRD wird jedoch unabhängig vom IRD mit seiner über 12-jährigen Erfahrung und über 3 Mio. Datensätzen weiterarbeiten und die Kliniken und Fachkreise auch zukünftig mit seinen Analysen und Publikationen versorgen.

BACKGROUND:The burden of osteoarthritis (OA) in multiple joints is high. For patients with bilateral knee OA there is no clear recommendation when to time the second surgery. The purpose of this study was therefore to compare revision and mortality rate in bilateral unicondylar and bicondylar knee arthroplasties after different strategies of surgical timing in bilateral knee OA from the German Arthroplasty Registry (EPRD). METHODS:Data from the German Arthroplasty Registry (EPRD) was used. Since 2012 a total of 15,154 patients had bilateral knee arthroplasty within one year. Patellofemoral arthroplasties and constraint total knee arthroplasties (TKA) were excluded. 1,144 TKA and 682 unicondylar arthroplasties (UKA) were simultaneously performed, 772 TKA and 292 UKA between 1 and 90 days (short interval) and 24,496 TKA and 2,922 UKA between 91 and 365 days (intermediate interval). Revision and mortality rates were analyzed up to 7 years after surgery. Cox regression was performed to evaluate the influence of different patient characteristics on these outcomes. RESULTS:The highest cumulative revision rate for any of the bilateral TKA was found for simultaneous surgery with 3.4% (95% CI 2.1-5.5). Lower risk for revision was seen in two-staged surgery in short interval (HR 0.42; 95% CI 0.20-0.90) and intermediate interval (HR 0.58; 95% CI 0.39-0.85). The cumulative one year mortality rate for TKA was comparable in all three groups with 0.8% for simultaneous TKA, 1.3% for short interval two-staged and 0.7% for intermediate interval. In UKA there were no differences between the groups regarding cumulative revision rate and mortality rate. CONCLUSION:TKA should be performed simultaneously in selected patients only, the two-staged procedure demonstrated lower revision risks. For UKA we found no differences in timing, simultaneous surgery seems to be a safe option. TRIAL REGISTRATION:Clinical trial number not applicable. LEVEL OF EVIDENCE:III.

Welchen Einfluss hat die Adipositas und deren Ausprägung auf Revisionsraten und Mortalität in der primären Hüft- und Knieendoprothetik in Deutschland? Im Endoprothesenregister Deutschland (EPRD) waren 403.073 elektive Hüft-TEP, 320.913 Standard-Knie-TEP und 48.480 unikondyläre Knieendoprothesen mit BMI verfügbar. Es erfolgte der Vergleich von Revisionen und 1‑Jahres-Mortalität über BMI-Gruppen. Mit steigendem BMI zeigten sich zunehmende Revisionsraten, in der Hüftendoprothetik insbesondere septische Revisionen innerhalb des 1. Jahres (nichtadipös 0,7

Background and purpose: Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes. Patients and methods: 21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015–2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan–Meier analysis. The mean follow-up (FU) was 1.5 (0–4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score. Results: The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0–50] vs. 46 [11–80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group. Conclusion: Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.

Background: We studied whether an individualized digital decision aid can improve decision-making quality for or against knee arthroplasty. Methods: An app-based decision aid (EKIT tool) was developed and studied in a stepped-wedge, cluster-randomized trial. Consecutive patients with knee osteoarthritis who were candidates for knee replacement were included in 10 centers in Germany. All subjects were asked via app on a tablet about their symptoms, prior treatments, and preferences and goals for treatment. For the subjects in the intervention group, the EKIT tool was used in the doctor-patient discussion to visualize the individual disease burden and degree of fulfillment of the indication criteria, and structured information on knee arthroplasty was provided. In the control group, the discussion was conducted without the EKIT tool in accordance with the local standard in each participating center. The primary endpoint was the quality of the patient's decision on the basis of the discussion of indications, as measured with the Hip and Knee Quality Decision Instrument (HK-DQI). (Registration number: ClinicalTrials.gov:NCT04837053). Results: 1092 patients were included, and data from 1055 patients were analyzed (616 in the intervention group and 439 in the control group). Good decision quality, as rated by the HKDQI, was achieved by 86.0% of patients in the intervention group and 67.4% of patients in the control group (relative risk, 1.24; 95 % confidence interval, [1.15; 1.33]). Conclusion: A digital decision aid significantly improved the quality of decision-making for or against knee replacement surgery. The widespread use of this instrument may have an even larger effect, as this trial was conducted mainly in hospitals with high case numbers.

Background Knee arthroplasty is one of the most frequently performed operations in Germany, with approximately 170000 procedures per year. It is therefore essential that physicians should adhere to an appropriate, and patient-centered indication process. The updated guideline indication criteria for knee arthroplasty (EKIT-Knee) contain recommendations, which are based on current evidence and agreed upon by a broad consensus panel. For practical use, the checklist has also been updated. Methods For this guideline update, a systematic literature research was conducted in order to analyse (inter-)national guidelines and systematic reviews focusing on osteoarthritis of the knee and knee arthroplasty, to answer clinically relevant questions on diagnostic, predictors of outcome, risk factors and contraindications. Results Knee arthroplasty should solely be performed in patients with radiologically proven moderate or severe osteoarthritis of the knee (Kellgren-Lawrence grade 3 or 4), after previous non-surgical treatment for at least three months, in patients with high subjective burden with regard to knee-related complaints and after exclusion of possible contraindications (infection, comorbidities, BMI >= 40 kg/m(2)). Modifiable risk factors (such as smoking, diabetes mellitus, anaemia) should be addressed and optimised in advance. After meeting current guideline indications, a shared decision-making process between patients and surgeons is recommended, in order to maintain high quality surgical management of patients with osteoarthritis of the knee. Conclusions The update of the S2k-guideline was expanded to include unicondylar knee arthroplasty, the preoperative optimisation of modifiable risk factors was added and the main indication criteria were specified.

Zusammenfassung Die Implantation einer Knieendoprothese zählt mit ca. 170000 Eingriffen pro Jahr zu den am häufigsten stationär durchgeführten Operationen in Deutschland. Eine einheitliche, angemessene und patientenorientierte ärztliche Indikationsstellung ist bei einem solchen Eingriff unerlässlich. Das Update der S2k-Leitlinie „Indikation Knieendoprothese“ beinhaltet auf aktueller Evidenz basierende und im breiten Konsens abgestimmte Empfehlungen und eine Checkliste im praxistauglichen Format. Für dieses Leitlinien-Update wurde eine systematische Literaturrecherche nach (inter-)nationalen Leitlinien und systematischen Übersichtsarbeiten zur Gonarthrose und Knieendoprothetik durchgeführt, um klinisch relevante Fragestellungen zu Diagnostik, Prädiktoren für das Outcome, Risikofaktoren und Kontraindikatoren zu beantworten. Eine Knieendoprothese soll nur bei radiologisch nachgewiesener fortgeschrittener Gonarthrose (Kellgren-Lawrence-Grad 3 oder 4), nach vorangegangener konservativer Therapie über mindestens 3 Monate sowie bei hohem subjektivem Leidensdruck hinsichtlich der kniebezogenen Beschwerden und nach Ausschluss möglicher Kontraindikationen (Infektionen, Begleiterkrankungen, BMI ≥ 40 kg/m2) erfolgen. Modifizierbare Risikofaktoren (wie Rauchen, Diabetes mellitus, Anämie) sollen zuvor adressiert und ggf. optimiert werden. Die Ziele der Patient*innen sollen erfragt und deren Eintrittswahrscheinlichkeit gemeinsam besprochen werden. Schließlich ist die Entscheidung zur Knieendoprothese von Patient*in und Operateur*in gemeinsam zu treffen, wenn der zu erwartende Nutzen die möglichen Risiken überwiegt. Das Update der S2k-Leitlinie wurde um die unikondyläre Knieendoprothese erweitert, die präoperative Optimierung modifizierbarer Risikofaktoren ergänzt sowie Konkretisierungen der Hauptindikationskriterien vorgenommen.

BACKGROUND:Large acetabular bone defects present a serious challenge in revision total hip arthroplasty. The off-label use of antiprotrusio cages in combination with tantalum augments is a promising treatment option in these difficult situations.METHODS:Between 2008 and 2013, 100 consecutive patients underwent acetabular cup revision with a cage-augment combination in Paprosky 2 and 3 defect types (including pelvic discontinuities). There were 59 patients available for follow-up. The primary endpoint was the explantation of the cage-and-augment construct. The secondary endpoint was acetabular cup revision for any reason. Also, radiographic and functional outcomes (Western Ontario and McMaster Universities Osteoarthritis Index, Harris Hip Score) were evaluated. Implant survival rates were determined using a Kaplan-Meier analysis. The significance level was set at P < .05.RESULTS:Explantation-free survivorship of the "Cage-and-Augment" system was 91.9% after a mean follow-up of 6.2 years (range, 0 to 12.8). All 6 explantations were due to periprosthetic joint infection (PJI). The overall revision-free implant survival rate was 85.7%, including 6 additional liner revisions due to instability. In addition, 6 early PJI occurred, which were successfully treated with debridement, irrigation, and implant retention. We did observe one patient who had radiographic loosening of the construct without necessity for treatment.CONCLUSION:The combination of an antiprotrusio cage with tantalum augments is a promising technique in treating large acetabular defects. A major risk of PJI and instability due to large bone and soft tissue defects needs special attention.

Die stabil zentrierte Stellung des Hüftkopfes in einem gut ausgeformten Pfannendach gilt als Grundvoraussetzung für die physiologische Entwicklung mit langfristig guter Hüftfunktion [1]. Bei Erkrankungen der Hüfte im Kindesalter, die mit einer Dezentrierung des Hüftkopfes einhergehen (z. B. Hüftdysplasie oder Morbus Perthes), lässt sich unter Beachtung der altersabhängigen Entwicklung der Schenkelhalsachse und der knöchernen Formgebung des Pfannendaches durch gezielte Osteotomien am proximalen Femur und Azetabulum eine Rezentrierung erreichen. Auch im Jugend- und Erwachsenenalter können Störungen dieses komplexen Zusammenspiels zwischen der räumlichen Ausrichtung des Schenkelhalses und dem Azetabulum Anlass für Hüftbeschwerden darstellen bzw. in schweren Fällen zum frühzeitigen Gelenkverschleiß führen. Viele Deformitäten sind mit hüftnahen Osteotomien korrigierbar und bei der richtigen Indikationsstellung kann u. U. auch langfristig die Konversion in einen künstlichen Hüftgelenksersatz vermieden werden [2] [3].

Polymethylmethacrylate (PMMA) removal during septic total joint arthroplasty revision is associated with a high fracture and perforation risk. Ultrasonic cement removal is considered a bone-preserving technique. Currently, there is still a lack of sound data on efficacy as it is difficult to detect smaller residues with reasonable technical effort. However, incomplete removal is associated with the risk of biofilm coverage of the residue. Therefore, the study aimed to investigate the efficiency of ultrasonic-based PMMA removal in a human cadaver model. The femoral components of a total hip and a total knee prosthesis were implanted in two cadaver femoral canals by 3rd generation cement fixation technique. Implants were then removed. Cement mantle extraction was performed with the OSCAR-3-System ultrasonic system (Orthofix (R)). Quantitative analysis of cement residues was carried out with dual-energy and microcomputer tomography. With a 20 mu m resolution, in vitro microcomputer tomography visualized tiniest PMMA residues. For clinical use, dual-energy computer tomography tissue decomposition with 0.75 mm resolution is suitable. With ultrasound, more than 99% of PMMA was removed. Seven hundred thirty-four residues with a mean volume of 0.40 +/- 4.95 mm(3) were identified with only 4 exceeding 1 cm in length in at least one axis. Ultrasonic cement removal of PMMA was almost complete and can therefore be considered a highly effective technique. For the first time, PMMA residues in the sub-millimetre range were detected by computer tomography. Clinical implications of the small remaining PMMA fraction on the eradication rate of periprosthetic joint infection warrants further investigations.

Pelvic osteotomies are an established treatment for symptomatic adult hip dysplasia with a promising long-term outcome. Results depend not only on the achieved acetabular reorientation but also on patient-factors like preoperative joint condition (degree of osteoarthritis and joint congruency) and age. Additionally, the diagnosis and appropriate therapy of impingement-associated hip deformities is essential in order to achieve good mid- and long-term outcomes. The influence of chondrolabral pathology on the outcome of pelvic osteotomies is not yet defined. Symptomatic patients with residual dysplasia after previous pelvic or acetabular osteotomies can benefit from an additional osteotomy, although results can be worse in comparison to prior unoperated joints. Obesity can make surgery more demanding and increases the complication profile of PAO, although it has no influence on the postoperative outcome. Regarding the overall prognosis after an osteotomy, the consideration of combined risk factors is superior to the concentration on individual factors alone.

Die Beckenosteotomie ist eine etablierte Therapie der symptomatischen adulten Hüftdysplasie mit sehr guten Langzeitergebnissen. Neben der optimalen Reorientierung des Pfannendaches sind die Resultate auch durch patientenabhängige Faktoren, wie den präoperativen Gelenkzustand (v. a. Gelenkkongruenz und Ausmaß degenerativer Veränderungen) sowie das Alter, beeinflusst. Zusätzlich ist die Identifikation und Therapie von impingementassoziierten Hüftpathologien entscheidend, um den mittel- bis langfristigen Verlauf positiv zu beeinflussen. Die Auswirkung von Schäden des chondrolabralen Komplexes sind noch nicht ausreichend beleuchtet. Auch symptomatische Patient*innen mit Restdysplasie nach vorheriger Osteotomie am Becken oder Femur können von einer Beckenosteotomie profitieren, selbst wenn sich Voreingriffe nachteilig auf das Ergebnis auswirken können. Übergewicht kann das intraoperative Komplikationsrisiko erhöhen, zeigt bis jetzt aber keinen Einfluss auf den postoperativen Verlauf. Insgesamt sollten die eine Indikationsstellung beeinflussenden Faktoren nicht isoliert, sondern in Summe betrachtet werden.

Hip arthroplasty revision management can range from simple procedures using standard implants to complex surgical interventions requiring the combined use of revision cups, metal augments, bone grafts, and antiprotrusio cages. The adequate restoration of biomechanics and function of the hip joint with reconstruction of the original center of rotation can be challenging. We present an overview of various available techniques with the associated implant and anchoring strategies and the respective clinical results depending on the acetabular defect situation.

Purpose: Articular cartilage defects are a prevalent consequence of femoroacetabular impingement (FAI) in young active patients. In accordance with current guidelines, large chondral lesions of the hip joint over 2 cm2 are recommended to be treated with matrix-associated, autologous chondrocyte transplantation (MACT); however, the conditions in the hip joint are challenging for membrane-based MACT options. Injectable MACT products can solve this problem. The purpose of the trial was to assess clinical and radiological outcomes 24 months after injectable MACT of focal chondral lesions caused by FAI. Methods: We present data of 21 patients with focal cartilage defects of the hip [3.0 ± 1.4 cm2 (mean ± SD)], ICRS Grade III and IV caused by CAM-type impingement, who underwent arthroscopic MACT (NOVOCART® Inject) and FAI correction. The outcome was evaluated with the patient-reported outcome instruments iHOT33 and EQ-5D-5L (index value and VAS), whilst graft morphology was assessed based on the MOCART score over a follow-up period of 24 months. Results: The iHOT33 score increased significantly from 52.9 ± 21.1 (mean ± SD) preoperatively to 85.8 ± 14.8 (mean ± SD; p < 0.0001) 24 months postoperatively. The EQ-5D-5L index value (p = 0.0004) and EQ-5D VAS (p = 0.0006) showed a statistically significant improvement as well. MRI evaluation after 24 months showed successful integration of the implant in all patients with a complete defect filling in 11 of 14 patients. Conclusions: Injectable MACT for the treatment of full-thickness chondral lesions of the hip joint due to FAI in combination with FAI correction improved symptoms, function, and quality of life in the treated cohort. Alongside the treatment of the underlying pathology by the FAI correction, the developed cartilage defect can be successfully repaired by MACT, which is of considerable clinical relevance.

With the implementation of the new MDR 2017/745 by the European Parliament, more robust clinical and pre-clinical data will be required due to a more stringent approval process. The EFORT Implant and Patient Safety Initiative WG1 ‘Introduction of Innovation’, combined knowledge of orthopaedic surgeons, research institutes, orthopaedic device manufacturers, patient representatives and regulatory authorities to develop a comprehensive set of recommendations for the introduction of innovations in joint arthroplasty within the boundaries of MDR 2017/745. Recommendations have been developed to address key questions about pre-clinical and clinical requirements for the introduction of new implants and implant-related instrumentation with the participation of a steering group, invited by the EFORT Board in dialogue with representatives from European National Societies and Speciality Societies. Different degrees of novelty and innovation were described and agreed on in relation to when surgeons can start, using implants and implant-related instrumentation routinely. Before any clinical phase of a new implant, following the pre-market clinical investigation or the equivalent device PMCF pathway, it is a common understanding that all appropriate pre-clinical testing (regulatory mandatory and evident state of the art) – which has to be considered for a specific device – has been successfully completed. Once manufacturers receive the CE mark for a medical device, it can be used in patients routinely when a clinical investigation has been conducted to demonstrate the conformity of devices according to MDR Article 62 or full equivalence for the technical, biological and clinical characteristics has been demonstrated (MDR, Annex XIV, Part A, 3.) and a PMCF study has been initiated.