Refine
Has Fulltext
- yes (14)
Is part of the Bibliography
- yes (14)
Document Type
- Journal article (13)
- Doctoral Thesis (1)
Keywords
- osteoarthritis (4)
- knee (3)
- AMADEUS (2)
- COVID-19 (2)
- Germany (2)
- MSCs (2)
- cartilage (2)
- chondrocytes (2)
- Anatomic reattachment (1)
- Bone marrow (1)
Institute
Sonstige beteiligte Institutionen
The topical application of tranexamic acid (TXA) helps to prevent post-operative blood loss in total joint replacements. Despite these findings, the effects on articular and periarticular tissues remain unclear. Therefore, this in vitro study examined the effects of varying exposure times and concentrations of TXA on proliferation rates, gene expression and differentiation capacity of chondrocytes and human mesenchymal stromal cells (hMSCs), which underwent osteogenic differentiation. Chondrocytes and hMSCs were isolated and multiplied in monolayer cell cultures. Osteogenic differentiation of hMSCs was induced for 21 days using a differentiation medium containing specific growth factors. Cell proliferation was analyzed using ATP assays. Effects of TXA on cell morphology were examined via light microscopy and histological staining, while expression levels of tissue-specific genes were measured using semiquantitative RT-PCR. After treatment with 50 mg/mL of TXA, a decrease in cell proliferation rates was observed. Furthermore, treatment with concentrations of 20 mg/mL of TXA for at least 48 h led to a visible detachment of chondrocytes. TXA treatment with 50 mg/mL for at least 24 h led to a decrease in the expression of specific marker genes in chondrocytes and osteogenically differentiated hMSCs. No significant effects were observed for concentrations beyond 20 mg/mL of TXA combined with exposure times of less than 24 h. This might therefore represent a safe limit for topical application in vivo. Further research regarding in vivo conditions and effects on hMSC functionality are necessary to fully determine the effects of TXA on articular and periarticular tissues.
Purpose
Despite much improved preoperative planning techniques accurate intraoperative assessment of the high tibial valgus osteotomy (HTO) remains challenging and often results in coronal over- and under-corrections as well as unintended changes of the posterior tibial slope. Noyes et al. reported a novel method for accurate intraoperative coronal and sagittal alignment correction based on a three-dimensional mathematical model. This is the first study examining preliminary data via the proposed Noyes approach for accurate intraoperative coronal and sagittal alignment correction during HTO.
Methods
From 2016 to 2020 a total of 24 patients (27 knees) underwent HTO applying the proposed Noyes method (Noyes-Group). Radiographic data was analyzed retrospectively and matched to patients that underwent HTO using the conventional method, i.e., gradual medial opening using a bone spreader under fluoroscopic control (Conventional-Group). All operative procedures were performed by an experienced surgeon at a single orthopaedic university center.
Results
From the preoperative to the postoperative visit no statistically significant changes of the posterior tibial slope were noted in the Noyes-Group compared to a significant increase in the Conventional-Group (p = 0.01). Regarding the axial alignment no significant differences between both groups were observed pre- and postoperatively. The number of over- and under-corrections did not differ significantly between both groups. Linear regression analysis showed a significant correlation of the postoperative medial proximal tibial angle (MPTA) with the position of the weightbearing line on the tibial plateau.
Conclusion
The 3-triangle method by Noyes seems to be a promising approach for preservation of the posterior tibial slope during HTO.
In total knee arthroplasty (TKA), functional knee phenotypes are of interest regarding surgical alignment strategies. Functional knee phenotypes were introduced in 2019 and consist of limb, femoral, and tibial phenotypes. The hypothesis of this study was that mechanically aligned (MA) TKA changes preoperative functional phenotypes, which decreases the 1-year Forgotten Joint (FJS) and Oxford Knee Score (OKS) and increases the 1-year WOMAC. All patients included in this study had end-stage osteoarthritis and were treated with a primary MA TKA, which was supervised by four academic knee arthroplasty specialists. To determine the limb, femoral, and tibial phenotype, a long-leg radiograph (LLR) was imaged preoperatively and two to three days after TKA. FJS, OKS, and WOMAC were obtained 1 year after TKA. Patients were categorized using the change in functional limb, femoral, and tibial phenotype measured on LLR, and the scores were compared between the different categories. A complete dataset of preoperative and postoperative scores and radiographic images could be obtained for 59 patients. 42% of these patients had a change of limb phenotype, 41% a change of femoral phenotype, and 24% a change of tibial phenotype of more than ±1 relative to the preoperative phenotype. Patients with more than ±1 change of limb phenotype had significantly lower median FJS (27 points) and OKS (31 points) and higher WOMAC scores (30 points) relative to the 59-, 41-, and 4-point scores of those with a 0 ± 1 change (p < 0.0001 to 0.0048). Patients with a more than ±1 change of femoral phenotype had significantly lower median FJS (28 points) and OKS (32 points) and higher WOMAC scores (24 points) relative to the 69-, 40-, and 8-point scores of those with a 0 ± 1 change (p < 0.0001). A change in tibial phenotype had no effect on the FJS, OKS, and WOMAC scores. Surgeons performing MA TKA could consider limiting coronal alignment corrections of the limb and femoral joint line to within one phenotype to reduce the risk of low patient-reported satisfaction and function at 1-year.
Background
Surgical reattachment of the tendon is still the gold standard for ruptures of the distal biceps brachii tendon. Several fixation techniques have been described in the literature, with suture anchors being one of the most common fixation techniques. Currently, there is no data available on how many anchors are required for a safe and stable refixation. In this case report clinical data of a patient with non-simultaneous bilateral distal biceps tendon ruptures treated with a different number of suture anchors for each side (one vs. two) are demonstrated.
Case presentation
A 47-year-old factory worker suffered a rupture of the distal biceps tendon on both arms following two different occasions. The left side was fixed using a single suture anchor, while refixation on the right side was performed with two anchors. The patient was prospectively followed for one year. Functional outcome was assessed using the Andrews Carson Score (ACS), the Oxford Elbow Score (OES), and the Disabilities of Arm, Shoulder and Hand (DASH) Score after six, twelve, 24 and 48 weeks. Furthermore, an isokinetic strength measurement for flexion strength was performed after 24 and 48 weeks. After 48 weeks the patient presented with excellent functional outcome scores and no follow-up complications. During the follow-up period, no differences in the functional scores nor in the isokinetic flexion strength measurement could be detected. Furthermore, no radiological complications (like heterotopic ossifications) could be detected in the postoperative radiographs after one year.
Conclusions
Anatomic reattachment of the distal biceps tendon is a successful operative treatment option for distal biceps tendon ruptures. Suture anchor fixation remains one of the most common techniques, as it allows fast surgery and provides good results with respect to range of motion (ROM) and functional scoring according to the current literature. However, the number of anchors required for a stable fixation remains unclear. As indicated by our presented case, we hypothesize, that there are no significant differences between a one-point or a two-point fixation. In the presented case report, no intraindividual differences between the usage of one versus two suture anchors were evident in the short-term follow-up.
The AMADEUS score is not a sufficient predictor for functional outcome after high tibial osteotomy
(2023)
Purpose
The Area Measurement And Depth Underlying Structures (AMADEUS) classification system has been proposed as a valuable tool for magnetic resonance (MR)-based grading of preoperatively encountered chondral defects of the knee joint. However, the potential relationship of this novel score with clinical data was yet to determine. It was the primary intention of this study to assess the correlative relationship of the AMADEUS with patient reported outcome scores in patients undergoing medial open-wedge high tibial valgus osteotomy (HTO). Furthermore, the arthroscopic ICRS (International Cartilage Repair Society) grade evaluation was tested for correlation with the AMADEUS classification system.
Methods
This retrospective, monocentric study found a total of 70 individuals that were indicated for HTO due to degenerative chondral defects of the medial compartment between 2008 and 2019. A preoperative MR image as well as a pre-osteotomy diagnostic arthroscopy for ICRS grade evaluation was mandatory for all patients. The Knee Osteoarthritis Outcome Score (KOOS) including its five subscale scores (KOOS-ADL, KOOS-QOL, KOOS-Sports, KOOS-Pain, KOOS-Symptoms) was obtained preoperatively and at a mean follow-up of 41.2 ± 26.3 months. Preoperative chondral defects were evaluated using the AMADEUS classification system and the final AMADEUS scores were correlated with the pre- and postoperative KOOS subscale sores. Furthermore, arthroscopic ICRS defect severity was correlated with the AMADEUS classification system.
Results
There was a statistically significant correlation between the AMADEUS BME (bone marrow edema) subscore and the KOOS Symptoms subscore at the preoperative visit (r = 0.25, p = 0.04). No statistically significant monotonic association between the AMADEUS total score and the AMADEUS grade with pre- and postoperative KOOS subscale scores were found. Intraoperatively obtained ICRS grade did reveal a moderate correlative relation with the AMADEUS total score and the AMADEUS grade (r = 0.28, p = 0.02).
Conclusions
The novel AMADEUS classification system largely lacks correlative capacity with patient reported outcome measures in patients undergoing HTO. The MR tomographic appearance of bone marrow edema is the only parameter predictive of the clinical outcome at the preoperative visit.
Medical tourism is a rapidly growing sector of economic growth and diversification. However, data on the demographics and characteristics of the traveling patients are sparse. In this study, we analyzed the common demographic properties and characteristics of the inbound medical tourists seeking orthopedic medical care in Germany for the years 2010 to 2019 compared to a domestic group. At the same time, we examined how the COVID-19 pandemic outbreak of 2020 changed the field of medical tourism in Germany. Calculations were performed using administrative hospital data provided by the Federal Statistical Department of Germany. Data were analyzed from the years 2010 to 2020. A total of six elective orthopedic surgery codes (bone biopsy, knee arthroplasty, foot surgery, osteotomy, hardware removal, and arthrodesis) were identified as key service indicators for medical tourism and further analyzed. Factors including residence, sex, year, and type of elective surgery were modeled using linear regression analysis. Age and sex distributions were compared between patients living inside Germany (DE) or outside Germany (non-DE). Between 2010 and 2020, 6,261,801 orthopedic procedures were coded for the DE group and 27,420 key procedures were identified for the non-DE group. Medical tourists were predominantly male and significantly younger than the domestic population. The linear regression analysis of the OPS codes over the past years showed a significantly different slope between the DE and non-DE groups only for the OPS code “hardware removal”. With the COVID-19 pandemic, an overall decline in performed orthopedic procedures was observed for the non-DE and the DE group. A significant reduction below the 95% prediction bands for the year 2020 could be shown for hardware removal and foot surgery (for DE), and for hardware removal, knee arthroplasty, foot surgery, and osteotomy (for non-DE). This study is the first to quantify inbound medical tourism in elective orthopedic surgery in Germany. The COVID-19 pandemic negatively affected many — but not all — areas of orthopedic surgery. It has to be seen how this negative trend will develop in the future.
Alignment strategies for primary total knee arthroplasty (TKA) have changed significantly over time with a shift towards a more individualized alignment goal. At the same time, computer-assisted surgery (CAS) has gained interest for intraoperative control and accuracy in implant positioning and limb alignment. Despite the often discussed benefits and drawbacks of robotics and navigation for TKA, the routine use of these new devices on a day-to-day basis remains obscure. Therefore, nationwide hospital billing data based on the Operation Procedure Classification System (OPS) were retrieved from the Federal Statistical Office of Germany for the period from 2010 to 2021. OPS codes for primary total knee arthroplasty (OPS code: 5-822*) were further analyzed regarding the usage of computer navigation (additional OPS code: 5-988) or robotic devices (additional OPS code: 5-987). Gender and age at the time of surgery were also assessed. The results show a total of 2,226,559 primary TKAs were implanted between 2010 and 2021, of which 2,044,914 were performed conventionally (91.84% of all TKAs). A total of 170,276 TKAs were performed using navigation technique (7.65% of all TKAs) and another 11,369 TKAs were performed using robotics (0.51% of all TKAs). For the period from 2018 to 2021, a substantial increase in robot-assisted TKA (R-TKA) was observed, with an average increase rate of 84.74% per year, while the number of navigated TKAs declined (−3.67% per year). Computer-assisted surgery, and particularly robotics for TKA, are seeing growing popularity and stepwise translation into routine clinical use in Germany, with a steep increase rate of more than 80% per year since 2018. Nevertheless, the majority of TKAs are still performed using manual instrumentation, rendering conventional TKA the currently unchanged gold standard.
(1) Background: The mesenchymal stromal cells (MSCs) of different tissue origins are applied in cell-based chondrogenic regeneration. However, there is a lack of comparability determining the most suitable cell source for the tissue engineering (TE) of cartilage. The purpose of this study was to compare the in vitro chondrogenic potential of MSC-like cells from different tissue sources (bone marrow, meniscus, anterior cruciate ligament, synovial membrane, and the infrapatellar fat pad removed during total knee arthroplasty (TKA)) and define which cell source is best suited for cartilage regeneration. (2) Methods: MSC-like cells were isolated from five donors and expanded using adherent monolayer cultures. Differentiation was induced by culture media containing specific growth factors. Transforming growth factor (TGF)-ß1 was used as the growth factor for chondrogenic differentiation. Osteogenesis and adipogenesis were induced in monolayer cultures for 27 days, while pellet cell cultures were used for chondrogenesis for 21 days. Control cultures were maintained under the same conditions. After, the differentiation period samples were analyzed, using histological and immunohistochemical staining, as well as molecularbiological analysis by RT-PCR, to assess the expression of specific marker genes. (3) Results: Plastic-adherent growth and in vitro trilineage differentiation capacity of all isolated cells were proven. Flow cytometry revealed the clear co-expression of surface markers CD44, CD73, CD90, and CD105 on all isolated cells. Adipogenesis was validated through the formation of lipid droplets, while osteogenesis was proven by the formation of calcium deposits within differentiated cell cultures. The formation of proteoglycans was observed during chondrogenesis in pellet cultures, with immunohistochemical staining revealing an increased relative gene expression of collagen type II. RT-PCR proved an elevated expression of specific marker genes after successful differentiation, with no significant differences regarding different cell source of native tissue. (4) Conclusions: Irrespective of the cell source of native tissue, all MSC-like cells showed multipotent differentiation potential in vitro. The multipotent differentiation capacity did not differ significantly, and chondrogenic differentiation was proven in all pellet cultures. Therefore, cell suitability for cell-based cartilage therapies and tissue engineering is given for various tissue origins that are routinely removed during total knee arthroplasty (TKA). This study might provide essential information for the clinical tool of cell harvesting, leading to more flexibility in cell availability.
Objective
As native cartilage consists of different phenotypical zones, this study aims to fabricate different types of neocartilage constructs from collagen hydrogels and human mesenchymal stromal cells (MSCs) genetically modified to express different chondrogenic factors.
Design
Human MSCs derived from bone-marrow of osteoarthritis (OA) hips were genetically modified using adenoviral vectors encoding sex-determining region Y-type high-mobility-group-box (SOX)9,transforming growth factor beta (TGFB) 1or bone morphogenetic protein (BMP) 2cDNA, placed in type I collagen hydrogels and maintained in serum-free chondrogenic media for three weeks. Control constructs contained unmodified MSCs or MSCs expressing GFP. The respective constructs were analyzed histologically, immunohistochemically, biochemically, and by qRT-PCR for chondrogenesis and hypertrophy.
Results
Chondrogenesis in MSCs was consistently and strongly induced in collagen I hydrogels by the transgenesSOX9,TGFB1andBMP2as evidenced by positive staining for proteoglycans, chondroitin-4-sulfate (CS4) and collagen (COL) type II, increased levels of glycosaminoglycan (GAG) synthesis, and expression of mRNAs associated with chondrogenesis. The control groups were entirely non-chondrogenic. The levels of hypertrophy, as judged by expression of alkaline phosphatase (ALP) and COL X on both the protein and mRNA levels revealed different stages of hypertrophy within the chondrogenic groups (BMP2>TGFB1>SOX9).
Conclusions
Different types of neocartilage with varying levels of hypertrophy could be generated from human MSCs in collagen hydrogels by transfer of genes encoding the chondrogenic factorsSOX9,TGFB1andBMP2. This technology may be harnessed for regeneration of specific zones of native cartilage upon damage.
In March 2020, Germany imposed a nationwide lockdown to curb the spread of COVID-19, prompting questions about the impact on the incidence of common fractures. This study examined 15 fracture types in pre-outbreak (2010–2019) and post-outbreak (2020–2021) periods, using data categorized by age (18–64 years, 65 years) and sex (male, female). Linear regression assessed annual growth rates, and mean fracture numbers were compared across periods for significant differences. Results indicated a positive correlation between fracture incidence rates and time for various types, such as cervical, thoracic, lumbar, and pelvic spine fractures, rib fractures, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures. Frequencies of proximal humerus, distal radius, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures in 2020 and 2021 were within predicted ranges from previous years. However, rib fractures and spinal fractures (cervical, thoracic, lumbar, and pelvic spine) occurred less frequently during this time. Notably, this study found a consistent decline in most fracture types for individuals aged 18–64 after the pandemic’s onset, while the fracture incidence of hip fractures, often referred to as fragility fractures, for those over 65 remained unchanged. Fibula fractures showed the most considerable decrease in both age groups. In conclusion, the COVID-19 pandemic substantially impacted fracture incidence, with lower rates among individuals under 65 and unchanged fragility fractures in the elderly population.
Background and objectives: Cartilage surgery constitutes a standard intervention in foot and ankle procedures. Currently, there is a lack of epidemiological data on its frequency, age distribution, and surgical options for cartilage surgery. This study aimed to investigate the current landscape of cartilage surgery in Germany and identify the most common procedures from an epidemiological standpoint. Materials and methods: Medical billing and reporting data from the Federal Statistical Office of Germany, encompassing the period 2006–2020, was examined, including all foot and ankle cartilage surgical procedures (summarized under OPS codes 5-812 and 5-801). The dataset incorporated information on the affected joint, patient age and sex, and surgery type. Each surgical procedure was categorized as “debridement”, “regeneration” or “refixation”. Linear and nonlinear regression analyses were employed, with a statistical significance threshold of 0.05. Results: From the total of 136,501 procedures conducted during the study period, the most frequently performed interventions were microfracture (58,252) and chondroplasty (56,135), and thus, debridement procedures were in the leading position. The use of acellular membranes was the most used regenerative technique (n = 11,414). At the ankle joint, interventions were mostly arthroscopic and in men, while foot cartilage surgeries were preferably performed via open surgery and mostly in women. Age distribution analysis revealed two primary peaks: the first in the 20–25-year-old group (ankle and foot) and the second in the 45–50-year-old group (ankle) and 55–60-year-old group (foot). Refixation and regenerative procedures were more frequent among younger individuals, while debriding procedures were more frequent among older individuals. Regenerative procedures, particularly in the ankle, significantly increased over time. Conclusions: Cartilage surgery of the foot and ankle was common, with two primary age groups predominantly affected. Notably, recent years have witnessed a considerable rise in cartilage regenerative procedures.
Background
While multiple in vitro studies examined mesenchymal stromal cells (MSCs) derived from bone marrow or hyaline cartilage, there is little to no data about the presence of MSCs in the joint capsule or the ligamentum capitis femoris (LCF) of the hip joint. Therefore, this in vitro study examined the presence and differentiation potential of MSCs isolated from the bone marrow, arthritic hyaline cartilage, the LCF and full-thickness samples of the anterior joint capsule of the hip joint.
Methods
MSCs were isolated and multiplied in adherent monolayer cell cultures. Osteogenesis and adipogenesis were induced in monolayer cell cultures for 21 days using a differentiation medium containing specific growth factors, while chondrogenesis in the presence of TGF-ss1 was performed using pellet-culture for 27 days. Control cultures were maintained for comparison over the same duration of time. The differentiation process was analyzed using histological and immunohistochemical stainings as well as semiquantitative RT-PCR for measuring the mean expression levels of tissue-specific genes.
Results
This in vitro research showed that the isolated cells from all four donor tissues grew plastic-adherent and showed similar adipogenic and osteogenic differentiation capacity as proven by the histological detection of lipid droplets or deposits of extracellular calcium and collagen type I. After 27 days of chondrogenesis proteoglycans accumulated in the differentiated MSC-pellets from all donor tissues. Immunohistochemical staining revealed vast amounts of collagen type II in all differentiated MSC-pellets, except for those from the LCF. Interestingly, all differentiated MSCs still showed a clear increase in mean expression of adipogenic, osteogenic and chondrogenic marker genes. In addition, the examination of an exemplary selected donor sample revealed that cells from all four donor tissues were clearly positive for the surface markers CD44, CD73, CD90 and CD105 by flow cytometric analysis.
Conclusions
This study proved the presence of MSC-like cells in all four examined donor tissues of the hip joint. No significant differences were observed during osteogenic or adipogenic differentiation depending on the source of MSCs used. Further research is necessary to fully determine the tripotent differentiation potential of cells isolated from the LCF and capsule tissue of the hip joint.
Die stark limitierte intrinsische Regenerationsfähigkeit des hyalinen Gelenkknorpels stellt auch in der modernen Medizin eine große Herausforderung dar. Während eine Vielzahl von knorpelchirurgischen Techniken am Kniegelenk koexistieren, bleibt die Selektion des am besten geeigneten Therapieverfahrens eine zentrale Herausforderung des orthopädischen Chirurgen. Hierzu bieten in Zeiten evidenzbasierter Medizin medizinische Register die Möglichkeit, klinische Behandlungsdaten systematisch in einem breiten Patientenkollektiv zu erfassen, die klinische Versorgungsrealität adäquat abzubilden sowie neue Behandlungsstrategien und Hypothesen zu generieren. Das Knorpelregister der DGOU bietet als webbasierte Registerform eine besonders moderne, effiziente und unbürokratische Form der Patientennachverfolgung über subjektiv bewertete und validierte Funktionsscores. Für das gesamte Registerkollektiv von 100 Patienten an der Orthopädischen Klinik-König-Ludwig Haus ergaben sich bereits sechs Monate nach dem knorpelchirurgischen Eingriff signifikant höhere Funktionsscores im IKDC und KOOS, welche sich auch im mittelfristigen Verlauf von zwölf Monaten noch signifikant erhöht gegenüber ihren präoperativen Werten zeigten. Die mediale Femurkondyle und knorpelige Patellarückfläche waren im Registerkollektiv am häufigsten von Defekten betroffen. Meist handelte es sich hierbei um drittgradige Defekte nach ICRS degenerativer Genese.
Während das mechanische Débridement bei großflächigem, arthrotischem Gelenkknorpelverschleiß keine suffiziente Therapieoption bietet, ist zum Nutzen und Effektivität des Débridements bei fokalen, umschriebenen Gelenkknorpeldefekten bisher nur wenig bekannt. Im Registerkollektiv zeigte sich für das isoliert mechanische Débridement von Gelenkknorpeldefekten eine signifikante Verbesserung der subjektiven Funktionsscores. Im Falle begleitend durchgeführter meniskuschirurgischer Eingriffe zeigt sich die Datenlage deutlich heterogener und bietet Anlass für weiteren wissenschaftlichen Diskurs.
Purpose
The AMADEUS (Area Measurement And DEpth and Underlying Structures) scoring and grading system has been proposed for the MRI based evaluation of untreated focal chondral defects around the knee. The clinical practicability, its correlation with arthroscopically assessed grading systems (ICRS – International Cartilage Repair Society) and thereby its clinical value in terms of decision making and guiding prognosis was yet to determine.
Methods
From 2008 to 2019 a total of 89 individuals were indicated for high tibial valgus osteotomy (HTO) due to tibial varus deformity and concomitant chondral defects of the medial compartment of the knee. All patients received a preoperative MRI (1.5 Tesla or 3.0 Tesla) and pre-osteotomy diagnostic arthroscopy. Chondral defects of the medial compartment were scored and graded with the MRI based AMADEUS by three independent raters and compared to arthroscopic defect grading by the ICRS system. Interrater and intrarater reliability as well as correlation analysis with the ICRS classification system were assessed.
Results
Intraclass correlation coefficients for the various subscores of the AMADEUS showed an overall good to excellent interrater agreement (min: 0.26, max: 0.80). Intrarater agreement turned out to be substantially inferior (min: 0.08, max: 0.53). Spearman correlation revealed an overall moderate correlative association of the AMADEUS subscores with the ICRS classification system, apart from the defect area subscore. Sensitivity of the AMADEUS to accurately identify defect severity according to the ICRS was 0.7 (0.69 for 3.0 Tesla MRI, 0.67 for 1.5 Tesla MRI). The mean AMADEUS grade was 2.60 ± 0.81 and the mean ICRS score 2.90 ± 0.63.
Conclusions
Overall, the AMADEUS with all its subscores shows moderate correlation with the arthroscopic chondral grading system according to ICRS. This suggests that chondral defect grading by means of the MRI based AMADEUS is well capable of influencing and guiding treatment decisions. Interrater reliability shows overall good agreement.