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Arthrofibrosis is a frequent complication after total knee arthroplasty (TKA). Recently, arthrofibrosis could be successfully verified histologically after primary total hip arthroplasty (THA) and the clinical presentation on the hip could be described for the first time. Possible diagnostic and therapeutic approaches have not yet been published. The diagnostic work-up differs only slightly from that for the knee joint. Other causes, such as aseptic loosening, malalignment or periprosthetic joint infection should be excluded. The gold standard is still invasive diagnostics with histological evidence of arthrofibrosis according to the synovia-like interface membrane (SLIM) criteria. Conservative treatment approaches include mobilization under anesthesia and medication according to Traut, analogous to the knee joint. Surgical treatment should be carried out under strict interpretation of the indications and after detailed clarification for the patient. In contrast to the knee joint, open arthrolysis should be preferred to arthroscopic arthrolysis of the hip joint. It must be taken into consideration that the evidence for conservative as well as surgical treatment, including possible revision arthroplasty, cannot be assessed due to the absence of clinical data. Studies under controlled conditions on the possible treatment approaches in the presence of arthrofibrosis are desirable and necessary in order to be able to assess the significance of the symptoms. In addition to treatment, great importance should also be attached to the diagnostics. Histological confirmation of the diagnosis of arthrofibrosis should only be considered to a limited extent in the case of an assumed, only moderately successful surgical intervention., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Joint surgery is one of the most important and successful disciplines in surgery; nevertheless, complications still occur, especially in total knee arthroplasty and surgery of the anterior cruciate ligament. A significant disease in this context is arthrofibrosis. This review article presents the cellular and molecular pathogenetic concept of arthrofibrosis, the spectrum of histopathological diagnostics and differential diagnostics and a classification into joint endoprosthesis-associated and non-joint endoprosthesis-associated arthrofibrosis is proposed. The basis of the histopathological diagnostics is the standardized tissue removal with subsequent fixation in formalin. In the case of joint implant failure and the problem of endoprosthesis-associated arthrofibrosis, the histopathological diagnostics can be carried out according to the consensus classification of synovia-like interface membrane (SLIM). Arthrofibrosis is characterized by fibrosis, a high fibroblast cellularity with immunohistochemical detection of cytoplasmic beta catenin expression. The presence of endoprosthesis-associated arthrofibrosis is probable above a threshold of 20 beta catenin positive fibroblasts per high-power field (HPF). The diagnosis of a non-endoprosthesis-associated arthrofibrosis can be classified according to the joint pathology algorithm. Diffuse non-endoprosthesis-associated arthrofibrosis is characterized by generalized proliferation of connective tissue in the whole joint and localized circumscribed arthrofibrosis is characterized by a nodose cyclops-like fibrosis. The clarification of the cause of arthrofibrosis is based on an interdisciplinary cooperation. In addition to the histopathological diagnostics, this includes clinical, surgical, biomechanical, arthroscopic, microbiological, laboratory parameter and radiological findings., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Arthrofibrosis (AF) is one of the most frequent complications of injuries and surgical interventions on joints, particularly after total knee replacement and anterior cruciate ligament reconstruction. Even though all joints can be affected, most cases involve the knee joint. Patients feel a painful impairment of the range of motion caused by fibrotic tissue formation within and sometimes also outside the joint. The normal healing process is disturbed by mechanical and emotional stressors and severe pain. In 90% of the cases AF occurs even within the first few days after the injury or surgery, so that the quality standards cannot be achieved. Physiotherapy and rehabilitation often do not result in a substantial amelioration of symptoms, so that the activities of daily living (ADL) are severely limited. The clinical diagnostics, differential diagnostics and a novel pathogenesis and stage model of the primary AF with the treatment principles derived from this are presented in this article., (© 2022. The Author(s).)

One important field of manual medicine is the special diagnosis and treatment of the extremities. Biomechanical and neurophysiologic knowledge allows identification and treatment of so-called kinetic chain syndromes. The manual diagnosis of the extremities follows clear criteria and enables the diagnosis of myofascial or joint dysfunction. The manual approach to the extremities has many parallels with spinal treatment, although in certain cases, it follows a distinct algorithm. This article addresses the manual diagnosis and treatment of the joints of the extremities. Three case reports demonstrate how symptoms and manual findings guide manipulative treatment and what impact this can have., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

This review article elucidates the differential diagnostics of malignant and benign joint tumors, pseudotumors of the joints and the peri-implant tissue, which are rare but important entities in rheumatology and orthopedic rheumatology. The tissue of origin includes the synovium, peri-implant tissue, peri-articular fibrous tissue and peri-articular osseous tissue. Pseudotumors can be viewed as independent but heterogeneous entities. These are essentially manifested as tumor-like depositions of crystals, calcareous deposits, vascular malformations, ectasia of the synovia and joint capsule tissue and pseudocysts. Other causes for pseudotumors are focal destructive inflammation (e.g. induced by foreign bodies), high grade synovitis and focal fibrinoid necrosis (i.e. rheumatoid nodules). Methodologically, these diagnostics are based on conventional standard staining methods, immunohistochemical analyses of formalin-fixed and paraffin-embedded materials and on molecular diagnostic procedures. The latter are of great importance in cases of benign and malignant joint tumors. The most important immunohistochemical markers with respect to joint tumors are S100, SM-actin, CD68, CD34, STAT6, clusterin, Muc‑4, beta-catenin and MDM2-FISH. The following markers are recommended for the differential diagnostics and typing of periarticular tumor metastases in the pathology of rheumatic diseases: AE1/AE3, CK8, p63, TTF‑1, TGB, PSA, androgen receptor, GATA, CD56, chromogranin, CDX‑2, SAT-B2, SALL4, estrogen and progesterone receptors, CD45LCA, CD30, CD79a and S100. Necrosis, inflammatory infiltrations and reparative inflammatory changes may complicate the histopathological classification. Therefore, a correlation with clinical, microbiological and radiological data in the sense of interdisciplinary synergistic diagnostics may be required.

Shoulder stiffness is characterized by restriction of the active and passive movement of the glenohumeral joint. The stiffness is ultimately caused by fibrosis and the resulting contracture of the glenohumeral joint capsule and its ligaments; however, the term stiff shoulder is only a descriptive umbrella term that must be further defined as the course of the disease and the recommended treatment are decisively influenced by the cause of the shoulder stiffness. Primary shoulder stiffness, also known as idiopathic shoulder stiffness or "frozen shoulder", must be distinguished from various forms of secondary shoulder stiffness and often occurs in three stages, which can all last for several months to years: the initial "freezing phase", followed by a "frozen phase" and finally a "thawing phase". Although primary shoulder stiffness is a frequent pathological alteration with an prevalence of 2-5% in the general population, the exact etiology remains largely unknown; however, there is consensus throughout the literature that certain systemic pathologies, such as diabetes mellitus are associated with a higher incidence of primary shoulder stiffness.

Even though the diagnostics of rheumatic joint diseases are mostly based on clinical, immunoserological and imaging criteria, histopathology can also make a significant contribution. This is particularly true for clinically unclear monoarticular and periarticular diseases. The contribution of histopathology to the diagnosis of rheumatic diseases is manifold since the histopathological differential diagnosis includes the complete spectrum of synovial diseases. This heterogeneous pathogenetic spectrum is described in the joint pathology algorithm, which includes inflammatory and non-inflammatory diseases. To the latter group belong certain benign tumors such as the diffuse variant of the tenosynovial giant cell tumor, lipoma, hemangioma, vascular malformations and synovial chondromatosis. Additionally, the rare group of storage diseases should be kept in mind. Inflammatory diseases can be discriminated into crystal-induced arthropathies mainly such as gout and pseudogout, into granulomatous diseases such as tuberculosis and foreign-body inoculations, and finally into the large group of non-granulomatous, non-infectious synovitis. This large group is by far the most common, and it often causes difficulties in assigning the histopathological findings to a concrete rheumatologic diagnosis. In this context the synovitis score should be applied as a diagnostic device in these cases, leading to the diagnosis of a low-grade synovitis (which is associated with degenerative arthropathies) or of a high-grade synovitis (associated with rheumatic diseases). Identification of crystals and crystal-like deposits should be carried out with the application of the joint particle algorithm which addresses the identification of endogenous and non-endogenous particle deposits in the synovial tissues. Additionally, the synovitis-score may be used for evaluation of arthritis-progresssion and for the evaluation of inflammation-regression as a consequence of therapy with biologicals.

Objective: Successful treatment of shoulder disease requires an accurate diagnosis. In addition to differentiated history taking, clinical examination is the most important component in the diagnosis of shoulder diseases., Method: The present video explains the common provocation tests and functional tests that are used in the basic clinical examination of the shoulder. In addition to general inspection and palpation, the focus is on different diagnostic tests and clinical signs that improve diagnostic accuracy., Conclusion: The present basic clinical examination methods allow a structured approach to clinical issues and can be a good basis, if supplemented by further specific and individual tests., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Arthropathy is the most common and often the earliest clinical manifestation of hereditary hemochromatosis (HH). It is difficult to treat and there is a high risk for early endoprosthetic joint replacement. Research done during the last decade shows that it is a joint disease in its own right. Clinically, there are degenerative articular changes with an atypical pattern of distribution, a crystal arthropathy (CPPD) with congenital joint swelling and synovitis like in RA. The X-ray image shows typical but not exclusive findings. In MRI, groundbreaking subchondral findings are found, especially in the large joints, and ultrasound shows inflammatory lesions in non-arthropathy patients as well. In animal experiments and pathomorphological studies of the synovial membrane, the arthropathy can be differentiated from osteoarthrits and RA. The pathophysiological significance of iron overload can be distinguished from immunohistochemical and cytogenetic investigations in chronic degenerative HH arthropathy and inflammatory-destructive arthropathy in hemophilia. By elucidating the pathophysiology, new therapeutic approaches can be formulated. In addition to colchicine, the IL-1 receptor antagonist anakinra is available for activation of the NLRP3 inflammasome by CPPD crystals and subsequent induction of IL-1β overproduction. Other manifestations include symptomatic pain therapy and intensive physiotherapy and occupational therapy. To promote further research into hemochromatosis arthropathy, the Hemochromatosis Arthropathy Research Initiative (HARI) was established in 2016., Competing Interests: Mitglied des wissenschaftlichen Beirates der HVD (Hämochromatose Vereiningung Deutschland e.V.)Erhalt von Reisekostenunterstützung bei wissenschaftlichen Vorträgen durch HVDGründungsmitglied der internationalen Hemochromatosis Arthropathy Research Initiative (HARI)Erhalt von Reisekostenunterstützung bei HARI-Meetings durch europäische Patienten-Selbsthilfe-Organisation (EFAPH), (© Georg Thieme Verlag KG Stuttgart · New York.)

Triiodothyronine (T3) is a key regulator of bone, muscle and articular cartilage. Musculoskeletal symptoms of hyperthyroidism include loss of bone mass finally leading to osteoporosis and weakness of the skeletal musculature. Hypothyroidism on the other side frequently leads to muscle stiffness and cramping and, occasionally, results in rhabdomyolysis. To prevent terminal differentiation of chondrocytes with consecutive cartilage degeneration, cartilage probably depends on exact regulation of local T3 availability by the intracellular deiodinase system. Recent findings underline the importance of local T3 generation by deiodinase type 2 and support the existence of local hypo- or hyperthyroidism.In the review, the implications of the recent literature for current understanding of osteoarthritis, myopathies and diabetic osteoarthropathy will be discussed. Further emphasis will be placed on the association of autoimmune thyroiditis with musculoskeletal diseases and fibromyalgia., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Successful treatment of knee joint disease requires an accurate diagnosis. In addition to a differentiated history, clinical examination is the most important component in the diagnosis of knee joint diseases., Method: The present video explains the common provocation and functional tests that are used in the basic clinical examination of the knee joint. In addition to general inspection and palpation, the focus here is on the individual region's patella, menisci, cruciate ligaments and collateral ligaments., Conclusion: The present methods of basic clinical examination allow a structured approach to clinical issues and can be a good basis for the diagnosis of knee joint diseases, if supplemented by further specific and individual tests., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Intraarticular benign tumors are rare lesions in many cases seen as incidental findings. One of the typical lesions is the diffuse or nodular form of pigmented villonodular synovitis, which needs a complete surgical removal. Magnetic Resonance Imaging (MRI) is diagnostic in most of the cases because of the intracellular iron content which shows an at least in some parts dark T2-sequence. Adjuvant therapies as radiosynoviorthesis should be considered in diffuse or recurrent lesions. Synovial Chondromatosis represents a metaplastic disorder of the synovial membrane resulting in the production of loose cartilage bodies. Also in this dissease synovectomy or, in late cases, removal of the loose bodies only, is recommended. Synovial hemangiomas are hamartomas which may lead to pain or restriction of movement. In these cases total or partial resection is justified. Alternative treatment options such as laserablation may be possible. Lipoma arborescens represents a proliferative lipoid lesion of the subsynovial region leading to villonodular synovial proliferation. If clinically symptomatic, resection by arthroscopic or open synovectomy is recommented.

Carpal bone fusions for secondary reconstruction are still indispensable despite state of the art diagnostic tools and modern treatment techniques for wrist lesions. The former fusions stabilize the wrist and enable sufficient residual carpal mobility. Pain can be reduced significantly by arthrodesis of destroyed joints and the progress of osteoarthritis may be stopped or delayed. This review presents commonly used fusions with their inherent indications, contraindications and complications.

Background: Approximately 10-50% of chest pains are caused by musculoskeletal disorders. The association is twice as frequent in primary care as in emergency admissions., Aim: This article provides an overview of the most important musculoskeletal causes of chest pain and on the diagnostics and therapy., Methods: A selective search and analysis of the literature related to the topic of musculoskeletal causes of chest pain were carried out., Results and Conclusion: Non-inflammatory diseases, such as costochondritis and fibromyalgia are frequent causes of chest pain. Inflammatory diseases, such as rheumatoid arthritis, spondyloarthritis and systemic lupus erythematosus are much less common but are more severe conditions and therefore have to be diagnosed and treated. The diagnostics and treatment often necessitate interdisciplinary approaches. Chest pain caused by musculoskeletal diseases always represents a diagnosis by exclusion of other severe diseases of the heart, lungs and stomach. Physiotherapeutic and physical treatment measures are particularly important, including manual therapy, transcutaneous electrical stimulation and stabilization exercises, especially for functional myofascial disorders.

The wrist and hand form a highly complex organ that is of great importance in almost all daily activities. The hand serves as a tool and an organ of sense. Injuries of the hand and wrist as well as mechanical, neurological or systemic inflammatory changes are common. Taking a detailed history can already lead to a diagnosis. Almost all structures of the hand are easily accessible for clinical examination, i. e. inspection, palpation and clinical tests, including dynamic testing. Diagnostic imaging completes the examination procedure.

Background: Elbow complaints are complex problems leading to severe consequences for affected people and the healthcare system. The German version of the Oxford Elbow Score (OES) is the first German-speaking instrument that specifically measures elbow complaints from the patient's perspective and changes of their health status., Objective: The aim of this study is the validation of the German version of the OES. In this context the internal consistency and the construct validity were investigated., Materials and Methods: 59 patients with elbow complaints completed the German version of the OES, the DASH and the SF-36 in a cross-sectional study. The internal consistency was calculated with Cronbach's alpha coefficients. Spearman's correlation coefficients were used to confirm construct validity., Results: Cronbach's alpha for pain, function and psychological subscales was 0.88, 0.81 and 0.90, respectively. The whole questionnaire presents a Cronbach's alpha value of 0.93. Convergent construct validity was confirmed with correlation coefficients containing values of -0.84, -0.77 and -0.82 compared to DASH and values ranging from 0.41 to 0.80 compared with the physical domains of the SF-36. The divergent construct validity presented values ranging from 0.07 to 0.20 with the SF-36 domains of "general health perception" and "mental health"., Conclusion: The German OES is an internal consistent instrument with good convergent and divergent construct validity. Other aspects of the validity, the reliability and the responsiveness should be confirmed through further studies.

A precise medical history and specific symptom-oriented clinical tests of the wrist joint should always precede any radiological, computed tomography (CT) or magnetic resonance imaging (MRI) diagnostics. In many cases, specific clinical tests of the wrist joint allow at least a preliminary diagnosis, which can be supported by standard radiography using correct projections. A systematic approach is recommended covering the radiocarpal, midcarpal, ulnocarpal and distal radioulnar joints. Exact identification of the palpable anatomic landmarks is mandatory for correct application and interpretation of the various clinical tests. The results of the clinical tests in combination with radiological imaging can often detect precisely ruptures of distinct wrist joint ligaments and localized arthritis.

Injections at tendon insertions, in muscles and in joints are an important instrument in the conservative treatment of musculoskeletal diseases, for acute injuries as well as for chronic degenerative diseases. Local anesthetic agents and glucocorticoids are well-established medications; however, severe side effects, such as chondrolysis have sometimes been reported, particularly for local anesthetic agents. In addition platelet rich plasma (PRP) and hyaluronic acid are also widely used; however, the clinical effectiveness has not always been proven. This article gives an overview on the most commonly used medications for injections and the mechanisms of action. The indications for treatment and the evidence for the clinical adminstration of muscle, tendon and joint injections are described based on the currently available literature.

Ankle impingement syndromes are one of the most frequent chronic and posttraumatic pathologies of the ankle joint. Anterior and posterior impingement result from the abutting of anatomical structures leading to pain and limitation in the range of motion of the ankle joint. Ankle impingement can be classified based on the localization or the underlying cause. Besides chronic ankle pain, further symptoms are movement and load-dependent swelling of the ankle joint and limitations in dorsiflexion and plantar flexion. The clinical symptoms and physical examination play an essential role in diagnosing soft tissue impingement, whereas various imaging techniques are important for the diagnostics of bony impingement. From a therapeutic perspective, conservative treatment should be initially attempted. If non-operative treatment fails, arthroscopic resection and debridement of the underlying cause is nowadays the standard method of surgical treatment. With a current complication rate of approximately 3 % ankle arthroscopy is a safe operative method, which is associated with a high postoperative rate of patient satisfaction and significant relief of symptoms.

Elderly patients may be different from the average population in regard to the treatment of shoulder disorders. Challenges are the decreased quality of bone, tendons and cartilage, decreased blood perfusion and a generally aged biology. The advantages however are the often more realistic expectations and more cautious use of the extremity, and the limited life expectancy of prosthetic implants is a less pressing issue. Local pathologies such as in the AC-joint or long head of the biceps may also in the aged patient be treated with infiltration or arthroscopic means. If however large rotator cuff tears and osteoarthritis are present, (reverse) total shoulder implants are the treatment of choice due to the high reliability and uncomplicated rehabilitation.

Background: Today, knee arthroscopy is one of the standard interventions performed by an orthopaedist and usually has a low potential for complications., Purpose: The surgeon should still be aware of possible problems, and be able to control and explain them to the patient in detail before surgery., Materials and Methods: The possible relevant peri-, intra- and postoperative complications of knee arthroscopy are discussed., Results: Evaluation of the patient's medical history and comorbidities is crucial to successful treatment, in addition to a correct diagnosis and indications with the assistance of appropriate imaging procedures. Nervous and vascular injuries, malplacement of arthroscopy portals, thrombosis, air embolism, material breakage and a possible compartment syndrome constitute the peri-and intraoperative complications. Postoperatively, the most frequent negative events are haemarthrosis, thrombosis, embolism and infection, and the appearance of synovial fistulas. In the case of a joint infection, consistent and immediate diagnosis and therapy are vital for joint preservation. Late complications after arthroscopic interventions include Ahlback's disease, arthrofibrosis and complex regional pain syndrome (CRPS)., Discussion: Nowadays, the systematic education of arthroscopic surgeons using simulators, models, and cadavers, in addition to shadowing experienced arthroscopists, is required to offer patients the best therapeutic options.

Sarcoidosis is a systemic, inflammatory, granulomatous disease of unknown origin that can involve any organ. More than 90% of patients have thoracic sarcoidosis, which most frequently presents with bilateral hilar lymphadenopathy. In approximately 20% of patients with thoracic sarcoidosis there is involvement of the lung parenchyma as well as mostly asymptomatic cardiac sarcoidosis in up to 55% of patients. Most patients are asymptomatic and the diagnosis is an incidental finding on chest X-ray or during clarification of unspecific symptoms, such as fatigue or cough. In approximately two thirds of patients the disease undergoes spontaneous remission and in one third the disease follows a chronic or even progressive course. Furthermore, sarcoidosis can also be manifested in the abdominal organs, the central nervous system (CNS) and the musculoskeletal system. These manifestations are frequently subclinical and require targeted diagnostics when sarcoidosis is clinically suspected.

Background: Corrective osteotomies around the knee are a cost-efficient and joint-preserving treatment option for primary leg deformities. Incorrect indications, technical errors, and insufficient postoperative management may lead to severe complications., Objectives: This review discusses potential complications of corrective osteotomies around the knee and treatment and prevention strategies., Materials and Methods: A selective review of the literature and a discussion of the authors' strategies for avoiding complications are presented., Results: Major risk factors for complications are the indication for and the planning of an osteotomy. The indication should take into consideration the difference between primary (constitutional) and secondary deformity. Planning must be based on a long-leg X-ray with correct rotation of the leg. Joint space opening of the non-involved compartment must be considered to avoid over-correction. Intraoperative fractures can be avoided by the use of an optimized technique. The neurovascular structures must be protected during osteotomy of the posterior cortex. Delayed bone healing/pseudarthrosis may occur in open-wedge and in closed-wedge procedures. High-energy shock wave therapy or autologous cancellous bone grafts can be used to enable bone healing. Infection is usually associated with the implant. Early infection may be treated by debridement and antibiotics. Late infection requires removal of the implant and placement of an external fixator if the osteotomy is still unstable., Conclusions: Corrective osteotomies around the knee represent a safe treatment option if there is a proper indication and patient selection. Intra- and postoperative complications need to be identified quickly to maintain satisfactory postoperative results.

Background: Tibial plateau fractures requiring surgery are severe injuries of the lower extremity. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment. In the last decade we have had a tremendous development, might it be the angular stable anatomical plates as well as new approaches to the proximal tibia. Nevertheless in the recent literature there are still many complications reported. Not only for sports professionals, recreational athletes or heavy load workers tibial plateau fractures affect leisure, all day activity and professional life. This article reports the treatment algorithm showing different cases, outlines the pitfalls and explains treatment strategies with a detailed x-ray follow-up., Conclusion: After a tibial plateau fracture patients are affected in their sporting activity due to an impaired knee function. Despite a long rehabilitation time and programs, physical activity changes to lower impact sports. Among the usual perioperative complications there are the specific complications of postoperative malalignment, implant infections, osteitis of the tibial head, compartment syndrome, secondary loss of reduction, avascular tibial head necrosis, secondary varus or valgus deformity, post-traumatic arthrosis and lesions of the peroneal nerve. In the literature in up to 43% of the cases complications have been noted. Despite surgery the majority of patients cannot return to their previous level of activity. However, overall about 70% of the patients return to sports after a tibial plateau fracture. For a beneficial outcome a detailed fracture analysis with CT scan and precise planning of the surgical strategies and approaches is mandatory.

Background: Fractures of the distal femur are rare injuries that are mainly treated operatively. Complication rates remain high., Objectives: This study aimed to analyse complications following the operative treatment of these fractures and to identify predictive factors that have the potential to identify patients who are at risk for a complicated course of treatment., Materials and Methods: We retrospectively analysed all fractures of the distal femur that were treated operatively at our institution between 2005 and 2015. Besides patient and fracture-specific data, surgical details and the types of complications that occurred were recorded and analysed., Results: Open soft tissue damage, the polytraumatised patient and the timing of surgery (i.e. emergency surgery) are significant risk factors for the development of a nonunion. A risk factor that predicts a postoperative infection is open soft tissue damage. Type C fractures, stabilisation as emergency surgery and an accompanying polytrauma are risk factors for a postoperative pneumonia., Conclusions: The complication rate is significantly determined by surgical factors. To reduce the rate of nonunion, infection and pneumonia, the optimisation of the patient's general condition before surgery and optimal surgical care is more important than an immediate emergency surgery.

Complaints in the region of the hips and pelvis are often difficult to classify. This is due to the fact that pain projection and overlapping can occur; therefore, the complete region of the lumbar spine, pelvis and hips must be considered as a single entity in which alterations can result in radiation throughout the whole region. There are many different anatomical structures within the pelvic region so that the function of various muscle components can be impaired and cause pathological alterations to positional relationships of bony structures or even alterations to other soft tissues, such as ligaments, tendons and labra. In terms of differential diagnostics the groin must be seen as the weak point of the peritoneum and vascular system and taken into consideration. Therefore, a detailed and targeted medical history, functional testing and specific examinations and tests are necessary to narrow down the pathology in question and reach a definitive diagnosis. Orthopedic surgeons must know which conspicuous features can lead to which problems and which anatomical structures are likely to be affected by irritation. The results of the clinical examination are the basis for targeted imaging diagnostics and subsequent therapy.

The Rasch-based, computerized adaptive assessment procedure RehaCAT allows to assess the ICF-oriented dimensions "activities in daily living", "functionality upper extremities" and "functionality lower extremities" as well as "depression" economically and reliably in orthopaedic rehabilitation patients. This validation study aimed at analyzing the multivariate association of the RehaCAT dimensions with the commonly applied ODI, SF-12 and HADS-D assessment scales in a sample of rehabilitation patient suffering from musculoskeletal diseases (spine disease: 58,7%). By means of structural equation modeling high convergent and divergent validity of the RehaCAT dimensions could be proven in a sample of N=184 rehabilitation patients (71,2% inpatient and 28,8% outpatient). In the resulting model between 41% (functionality upper extremities) and 76% (activities in daily living) of the RehaCAT dimensions could be explained mainly by the theoretical assumed predictor constructs. Because of its psychometric foundation, economy and validity, the RehaCAT provides an optimal basis to assess central ICF-oriented constructs in orthopaedic rehabilitation., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The prevalence of the post-polio syndrome (PPS) is in estimated 50 % of persons with established poliomyelitis with a subsequently stable phase of at least 15 years. The basic mechanism is a loss of motoneuron cells in the spinal cord resulting in muscle weakness and fatigue. In addition pain, cold intolerance and a loss of stamina are frequently reported. There are few studies focusing on the orthopaedic symptoms in the PPS. This study should support the health-care professionals to the address the needs of PPS patients., Methods: A questionnaire was developed to collect data on patients who have been diagnosed by a neurologist as fulfilling the criteria of a PPS. It consists of two parts. In the first part, general patient data are collected. In the second part, details of health, pain, and activities of daily living are collected at two points in time: the time of the stable phase immediately after the acute phase of the disease and the phase after the PPS diagnosis. The questionnaires were sent to patients with a diagnosis of PPS. A total of 124 questionnaires were analysed (male: 45, female: 79). Parts of the data were used to calculate a score. It was hypothesised that the score would demonstrate a higher load of orthopaedic symptoms in the PPS phase., Results: The results show that the phase after poliomyelitis (stable phase vs. PPS phase) was associated with significantly different sum score relating to the orthopaedic impairments. The score in the stable phase is on average 18.6 units lower than that in the post-PPS diagnosis phase (p < 0.001). The hypothesis that in the PPS phase the load of orthopaedic symptoms is increased is confirmed by our data. The "loss of functioning in the upper extremity" is also significantly associated with the score (p = 0.004)., Conclusions: At the time the survey was taken, patients reveal a high level of musculoskeletal impairments and disabilities after PPS than during the stable phase with regard to general health as well as pain status and performance of daily activities. Age has no significant impact. Many of the patients are severely limited, especially with regard to activities such as walking, climbing stairs, and performing simple household tasks. Since there is no causal therapy for the underlying degeneration of the anterior horn cell pools, treatment is focused on the compensation of the functional limitations., (Georg Thieme Verlag KG Stuttgart · New York.)

A systematic clinical examination of the shoulder joint, including a structured medical history, is essential for the diagnosis of shoulder pathologies. Complex clinical situations that are accompanied by pain, restriction of movement, loss of strength, or instability have to be considered in accordance with the functional interaction between the cervical spine, the shoulder girdle, and the glenohumeral joint. Only accurate diagnosis allows us to apply successful therapeutic interventions. In order to achieve this, the physician needs to use standardized clinical tests and signs combined with a profound knowledge of the anatomy and the possible underlying pathologies. To ensure a structured approach as well as a complete documentation of results, a shoulder assessment form should be used. The information obtained from the history, examination, and collected data form the basis for further diagnostic imaging.

Cranial cruciate ligament rupture is the most common cause of hindlimb disease in dogs and is often associated with an additional lesion of the medial meniscus. The exact aetiopathogenesis of this condition in dogs is unknown. Normally, the degeneration of the ligament first leads to a partial rupture which progresses to a complete rupture following an unspectacular trauma. The positive cranial drawer test confirms the cranial cruciate ligament rupture, however, in some cases, particularly in partial ligament lesions, the diagnosis is not obvious. Therefore, the reexamination of the sedated patient is recommended to generally increase the sensitivity of clinical tests. Magnetic resonance imaging and stifle joint arthroscopy are useful methods to evaluate the cruciate ligaments in indistinct cases or to assess the joint for secondary changes. The therapy of cranial cruciate ligament ruptures can be divided into extra- and intracapsular as well as tibial osteotomies. The principle of the different tibial osteotomies is the muscular compensation of stifle joint instability. The results are successful but not uncritical. This article presents a short review on the substantial problems associated with cranial cruciate ligament rupture in dogs. A more detailed description of secondary problems and complications would exceed the scope of this article and should be considered in another study.

In Germany there is a clear deficit in the non-operative treatment of chronic and complex diseases and pain disorders in acute care hospitals. Only about 20 % of the treatments are carried out in orthopedic hospitals. Hospitals specialized in manual medicine have therefore formed a working group on non-operative orthopedic manual medicine acute care clinics (ANOA). The ANOA has developed a multimodal assessment procedure called the OPS 8-977 which describes the structure and process quality of multimodal and interdisciplinary diagnosis and treatment of the musculoskeletal system. Patients are treated according to clinical pathways oriented on the clinical findings. The increased duration of treatment in the German diagnosis-related groups (DRG) system is compensated for with a supplemental remuneration. Thus, complex and multifactorial orthopedic diseases and pain disorders are conservatively and appropriately treated as inpatient departments of acute care hospitals.

Manual medicine (MM) is a manual medical technique to identify and treat reversible dysfunction especially of the musculoskeletal system. The origins of MM were derived from empirical observations but MM is nowadays based on anatomy, biomechanics and neurophysiology. Besides special training in palpation according to precise topographic anatomic knowledge, the diagnostics of segmental or articular dysfunction are also based on knowledge about afferent convergence of multiceptive neurons located in proprioceptive and nociceptive layers of the brain stem and spinal cord. This leads to activation of motor and sympathetic reactions with the consequence of segmental or regional dysfunction. Manual therapy aims to eliminate noci-afferents as well as to activate inhibitory receptive fields. This can be achieved either by a single high velocity manipulative impulse or by slow-soft rhythmic repetitive mobilization. The special medical education and training in MM is outlined in relation to the Bologna postgraduate concept. As MM is basically used in relation to the musculoskeletal system it should definitely be incorporated into the specialization for orthopedics and traumatology and become part of the examination. In outpatient medicine an orthopedic and trauma surgeon without MM expertise will be inferior to a general practitioner with this expertise.

Objectives: Restoration of extension in the metacarpophalangeal joints of the fingers as well as in the interphalangeal joint of the thumb by transfer of the superficial flexor tendons of the long and ring fingers (flexor digitorum superficialis III and IV)., Indications: The indications for surgery are substantial loss and palsy of muscles innervated by the radial nerve and its roots., Contraindications: The procedure is contraindicated by reversible radial palsy, palsy or substantial loss of flexors, limited passive mobility due to contracture, ankylosis or instability of the affected joints, instability of the wrist joint, palsy of the wrist flexors, ankylosis of the wrist joint in an unfavorable position, adhesions of flexor or extensor tendons, insufficient soft tissue coverage or soft tissue defects and passage of transposed tendons through scarred tissue., Surgical Technique: The surgical technique involves division of the superficialis tendons of the long and ring fingers proximal to Camper's chiasm and routing of the tendons to the dorsum of the hand through separate fenestrations of the interosseus membrane. The flexor digitorum superficialis tendon III is interwoven into the tendons of the extensor pollicis longus und extensor indicis and the flexor digitorum superficialis IV is interwoven into the extensor digitorum tendons., Postoperative Management: Forearm splinting in 20° wrist extension including the metacarpophalangeal joints of the fingers in extension and the thumb in the automatic stop position for 4 weeks leaving the proximal and distal interphalangeal joints free., Results: From March 1999 to January 2010 a Boyes' transfer was performed in 13 patients (8 female and 5 male) and the right side was affected in 8, the left side in 5 and the dominant hand in 7 cases. The patient age at the time of surgery was an average of 47 ± 17 (13-73) years. The interval between radial palsy and tendon transfer was an average of 79 ± 144 (4-543) months. The final follow-up was performed at an average of 82 ± 35 (32-165) months. According to the Haas scoring system finger extension was excellent in 5, good in 5, fair in 3 and unfavorable in 4 cases and thumb extension was excellent in 5, good in 3, fair in 1 and unfavorable in 5 patients. The mean disabilities of the arm, shoulder and hand (DASH) score was 36 ± 24 (11-85) points. Although disability of varying degrees persisted in all patients, Boyes' transfer is considered to be a safe procedure to restore finger and thumb extension with excellent and good functional results, a high degree of patient satisfaction and few complications.

The revised classification of the periprosthetic membrane (synovial-like interface membrane SLIM) encompasses all pathological alterations which can occur as a result of endoprosthetic replacement of major joints and lead to a reduction in durability of prostheses. This also includes the established consensus classification of SLIM by which aseptic and septic prosthetic loosening can be subdivided into four histological types and histopathological criteria for additional pathologies: endoprosthesis-associated arthrofibrosis, immunological/allergic alterations and osseous pathologies. This revision represents the foundation for the histopathological diagnostics of the total spectrum of diseases associated with joint prostheses, is a suitable basis for a standardized diagnostic procedure and etiological clarification of endoprosthesis failure and also as a data standard for endprosthesis registers, in particular for registers based on routine data (e.g. German endoprosthesis register).

Although complications following release of elbow contracture are rare, among these the neurological complications are the most common. Fortunately the majority of complications are transient, however, major complications including complete nerve transection at the level of the elbow have been reported especially after arthroscopic release. The ulnar nerve is mostly involved, rarely the radial nerve and very rarely the median nerve. This article describes the risk of nerve lesions in contracture release of the elbow and provides guidelines on how to avoid them.

Carpal instability can be understood as a disturbed anatomical alignment between bones articulating in the carpus. This disturbed balance occurs either only dynamically (with movement) under the effect of physiological force or even statically at rest. The most common cause of carpal instability is wrist trauma with rupture of the stabilizing ligaments and adaptive misalignment following fractures of the radius or carpus. Carpal collapse plays a special role in this mechanism due to non-healed fracture of the scaphoid bone. In addition degenerative inflammatory alterations, such as chondrocalcinosis or gout, more rarely aseptic bone necrosis of the lunate or scaphoid bones or misalignment due to deposition (Madelung deformity) can lead to wrist instability. Under increased pressure the misaligned joint surfaces lead to bone arrosion with secondary arthritis of the wrist. In order to arrest or slow down this irreversible process, diagnosis must occur as early as possible. Many surgical methods have been thought out to regain stability ranging from direct reconstruction of the damaged ligaments, through ligament replacement to partial stiffening of the wrist joint.

Magnetic resonance (MR) imaging is a well established, non-invasive method in the evaluation of joint pathologies. Basically four different MR imaging techniques are used in the clinical routine: (1) conventional MR imaging of joints, (2) intravenously contrast-enhanced MR imaging of joints, (3) direct MR arthrography with intraarticular injection of contrast medium and (4) indirect MR arthrography after intravenous application of contrast medium. Additionally, a variety of new MR imaging techniques are available and currently used for clinical research. These techniques have a great potential for clinical use in the future.

Lateral pain of the elbow is frequently reported. Impingement of the humeroradial fold or a synovial fringe is a seldom evoked cause, sometimes ignored. Nonetheless, this etiology should be remembered in young adults performing sport activities and in heavy workers. Pain can be acute and inflammatory. Elective pain is usually elicited by the pressure on the humeroradial joint space, beneath the lateral epicondyle. Snapping, locking and restricted mobility can be observed. MRI-arthrogram is the best radiological examination to perform. Symptoms can be improved by conservative treatment but may warrant an arthroscopical resection.

Hernitation pits (HPs) of the femoral neck were first described in 1982. The purpose of this paper is to summarize the information concerning HPs published since then and to show their association with the diagnosis of femoroacetabular impingement (FAI) which has occurred within the last years. HPs are predominantly located at the anterior-superior femoral neck with a typical radiological appearance, which makes it possible to differentiate them from the numerous differential diagnoses mentioned. In the early publications HPs were described as a separate entity, while recent studies increasingly assign them to intra-osseous ganglia. In contrast to the early publications depicting HPs as an incidental finding, they are currently mainly mentioned in association with FAI and at the same time are partly considered to be a radiological indicator of FAI. In summary, HPs should always be recognized and documented because they may contribute to the diagnosis of FAI which is essential for preventing or delaying osteoarthritis of the hip joint in the early stage., (Copyright (c) Georg Thieme Verlag KG Stuttgart-New York.)

Background: Free movement of the limbs is a prerequisite of mobility and autonomy in old age. The prevalence of contractures in international studies has been reported to range between 15% and 70%. The wide variation might be explained by different definitions and diagnostic criteria, settings, and participants' characteristics. Contractures lead to additional nursing demands. In Germany, contracture risk assessment and prevention have been recently defined as a quality indicator of nursing home care that should be regularly monitored by expert raters of the statutory health insurance system. Therefore, it is necessary to have a clear definition of contracture. The goal of this literature review was to identify definitions of contractures used in controlled trials., Methods: A systematic literature search of controlled trials investigating contracture as primary, secondary, or adverse outcome was conducted using the databases PubMed, CINAHL, Embase, and the Cochrane Library. The search was limited to articles published after 1985 and written in English or German language. Publications were excluded, if animals, children, or congenital contracture were investigated. Two reviewers independently screened the abstracts and extracted data from full publications. Disagreement was solved by consensus involving a third reviewer., Results: Initially, 544 publications were identified; 37 controlled studies fulfilled the inclusion criteria and were included. A total of 33 studies investigated contracture as primary outcome, three as secondary outcome, and one as adverse outcome. Five studies clearly defined the term contracture. However, all these definitions are different. In 31 studies, only the diagnostic criteria were mentioned and one study mentioned neither a definition nor specific diagnostic criteria., Conclusion: The majority of clinical trials investigating contracture as outcome parameter do not provide a clear definition. However, the success of contracture prevention and treatment in clinical trials and practice can only be judged in the presence of a clear definition. Thus, it appears especially difficult to use contracture as a quality indicator for nursing homes.

The techniques of manual medicine provide the basis for the palpatory recognition of dysfunction, primarily in the musculoskeletal system. The essential criterion of manual medicine is inclusion of the segmental level of function. One criterion of evaluation is, most notably, segmental hypomobility. The purpose of manual diagnostics is to determine segmental blockage. Manual therapy techniques lead first to improved function of the segment and, consequently, to improved function of the whole organism. Manual medicine focuses on the (peri)articular and myofascial levels as well as on the nervous control level of the motion segment and may interact with therapeutic methods. For therapeutic purposes, the joint may be manipulated with impulse as well as without therapeutic impulse for soft techniques. Different muscle relaxation techniques are used on the myofascial system to achieve improved function of reflectory or structurally altered musculature and of the myofascial system.

The acromioclavicular (AC) joint cyst is a rare sequela of complete supraspinatus tendon rupture and arthritis of the AC joint. It appears as a swelling on the AC joint and must be distinguished from tumours of the shoulder and neck region. Besides physical examination, magnetic resonance imaging is the most useful tool for correct diagnosis. As reported in the literature, therapeutic procedures include observation, aspiration, excision of the cyst with or without resection of the AC joint, and repair of the underlying supraspinatus tendon rupture. All procedures should be based on consideration of the comorbidity and recurrence of the cyst. Combinations of cyst excision and rotator cuff repair or AC resection seem to be the most promising therapeutic options. We report on a 75-year-old patient with a painless swelling over the AC joint who had suffered shoulder trauma 15 years previously.

Objective: Reconstruction of active elbow flexion against gravity (strength grade > or =M(3)) by transfer of the latissimus dorsi muscle in order to improve the functionality of the upper extremity., Indications: Irreparable lesions of the musculocutaneous nerve (C(5)/6). Failure of regeneration after peripheral nerve reconstruction for the musculocutaneous nerve (neurolysis, suture, nerve grafting). Brachial plexus injury (lesions to the upper part, C(5)/6). Loss of biceps function due to trauma, ischemia, poliomyelitis or tumor., Contraindications: Possible recovery of biceps function by reinnervation, spontaneously or after nerve reconstruction. Weakness of the latissimus dorsi muscle (strength grade < M(4)). Insufficient passive range of motion of the elbow joint (osteoarthritis, contracture). Lack of motivation, reliability, and cooperation of the patient in postoperative rehabilitation program., Surgical Technique: The intact latissimus dorsi muscle is transferred with its origin and insertion ventrally and sutured with its thoracic aponeurosis into the insertion of the biceps tendon in order to act as an elbow flexor., Postoperative Management: Following postoperative immobilization in an upper-arm Gilchrist bandage at 100 degrees flexion and supination (or neutral position, but not pronation) of the forearm for 6 weeks, passive motion exercises of the elbow are started. Active flexion and extension exercises begin at 8-10 weeks postoperatively. To prevent the deleterious effect of muscle and tendon elongation, an orthosis is used during the night to keep the elbow flexed at 90 degrees for 6 months., Results: According to the authors' experience and the results reported in the literature, bipolar latissimus dorsi muscle transfer is a reliable method to restore functional elbow flexion regarding range of motion (> 90 degrees elbow flexion) and strength (at least antigravity strength, > or =M(3)) with acceptable donor morbidity and complication rate.