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ZusammenfassungMit der steigenden Anzahl der Primärprothetik nehmen die Revisionen der anatomischen Prothese einen immer höheren Stellenwert ein. Die häufigsten Revisionsgründe sind Glenoidlockerung, einschließlich Protrusion, Insuffizienz der Rotatorenmanschette, einschließlich Instabilität, und Früh‑/Spätinfekt. Der glenoidale Defektaufbau kann mit einem Autograft oder Allograft erfolgen. Er wird je nach Größe und Situation ein- oder zweizeitig durchgeführt. Die in den letzten Jahren immer häufiger eingesetzten metaphysär verankerten Prothesen und Kurzschaftprothesen haben die humerale Revision deutlich vereinfacht. Einen anderen Weg beschreiten die Plattformsysteme mit der Möglichkeit der Konversion ohne höhergradige Eingriffe am Glenoid oder Wechsel des Schaftes. Intraoperative Komplikationen treten vor allem humeral auf. Postoperative Komplikationen sind neben der Luxation die Komponentenlockerung und der Infekt. Der Wechsel einer anatomischen Prothese auf eine inverse Prothese zeigt bessere klinische Ergebnisse, sowie niedrigere Komplikationsraten als der Wechsel auf nochmals eine anatomische Prothese.

Purpose: To evaluate the classification performance of a new method to individualize reference ranges for biomarkers of muscle recovery in elite handball. Methods: In a longitudinal observational study, creatine kinase (CK) and urea levels were assessed in 16 male elite handball players during the 2019–20 preseason. Blood samples were collected at prespecified time points when players were considered either recovered or nonrecovered. Initially, linear mixed-effects models were calculated, as outlined in the study design, to examine the effect of recovery status on CK and urea levels. Finally, a fixed-effect model was calculated for urea based on the law of parsimony. Individualized reference ranges were calculated using a recently published algorithm. To investigate whether the individualized approach resulted in a more accurate classification of recovery status (recovered or nonrecovered), it was compared with a group-based approach derived from the same data set, utilizing predefined error rates. Results: Linear mixed-effects models showed a large effect of recovery status on CK (P d = 3.49) and a small effect on urea (P = .018, d = 0.382). In contrast to CK (P = .017), urea had no significant interindividual variation. Hence, individualization was examined only for CK. The numerical decrease in both CK error rates by the individualized approach was significant for the test-pass error rate (P = .0196, ϕ = .19). Conclusions: Our findings underscore the critical role of CK for monitoring in team sports such as handball. The observed improvement in CK error rates suggests a promising opportunity to individualize biochemical monitoring, although further studies encompassing larger sample sizes are warranted.

Since the introduction of stemless anatomic shoulder arthroplasty, few midterm functional and radiographic results have been published. This article presents results of the Arthrex Eclipse prosthesis with a mean follow-up of 70 months.We prospectively evaluated the outcome of 53 arthroplasties in 51 patients with a mean age of 65 years at the time of implantation with a minimum follow-up of 48 months. All patients were physically and radiologically examined, and the results documented by Constant-Murley and Disabilities of the Arm, Shoulder, and Hand (DASH) scores.Significant improvements from preoperative to last follow-up were documented in the Constant-Murley score (53.8%-83.5%, P.001) and active range of motion (abduction 84°-108°, flexion 98°-125°, and external rotation 19°-41°). There was no significant difference between total and hemiarthroplasty. The mean DASH score was 28.3 points (95% confidence interval 20.1-35.2). Lowering of bone mineral density was observed in anteroposterior radiographs at the humeral component in 24.5% and at the glenoid component in 33.3%. The rate of complications was 15.7%.This study finds improvements in functional, radiographic, and subjective midterm results comparable to other accessible data for stemless and stemmed arthroplasty.

Purpose Among juvenile apophyseal avulsion injuries of the pelvis in adolescents, fractures of the ischial tuberosity are rare but sustainably debilitating. Also because informations on surgical repair options are very sparse and so far limited to general reviews, reports of individual cases or heterogeous small case series, practitioners, patients and their parental environment still feel a comprehensible hesitation regarding operative treatment. Therefore we intended to investigate patient related outcome measurements and return to sports rates after different types of surgical intervention in an own case series, so far unprecendented in its size. Methods Patient data of adolescents that underwent surgical intervention for a displaced apophyseal avulsion fracture of the ischial tuberosity between 01/2015 and 12/2019 in our institution were gathered. Patients were then evaluated using the hamstring injury specific Perth Hamstring Assessment Tool (PHAT). Furthermore the return to sports level in comparison to the particular pre-injury level was rated. Results Eleven adolescents with an acute or chronic mean fragment dislocation of 3.3 cm (SD ± 1.7) underwent surgical intervention in the assigned period. The mean post-operative PHAT score was 86.9 (0–100, SD ± 11.9) and thus good to excellent. The majority of adolescents (10/11) was able to return to their pre-injury sports, whereas 63.6% achieved full or nearly full level. Conclusions Surgical refixation or restoration of aphoyseal avulsion fractures of the ischial tuberosity result in good to excellent outcomes and return to sport rates, irrespective of the type of intervention. Here prompt diagnosis with a timely intervention seems more promising than delayed interventions in chronic cases. Beyond 1.5 cm of fragment displacement affected patients should be counselled for surgical intervention.

The arthroscopic Bankart procedure is the most performed surgery for shoulder stabilization. Short to midterm results are well studied, however long-term results over 10 years are rare.This study evaluates the long-term results and MRI findings in athletes at a mean follow-up of 14 years after an arthroscopic Bankart stabilization as well as risk factors for osteoarthritis.63 athletes had an arthroscopic Bankart repair between 2001-2008, out of which 46 patients (73.0%) participated in the final follow-up. The Constant, Rowe and Western Ontario Shoulder Instability Index Score (WOSI) and the rate of return to sports were evaluated. Glenohumeral osteoarthritis was assessed using the Samilson Prieto classification. Known risk factors for osteoarthritis were analyzed. MRI findings (bone marrow edema, cysts, and joint effusion) were analyzed.The average follow-up was 14 years. Assessment was performed on 46 athletes with an average age of 21.6 at the time of surgery. The overall redislocation rate was 21.7%. Constant Score was 96.7, Rowe Score was 83.4, and WOSI Score was 90.7 out of 100. 84.8% of the athletes returned to their initial sports level. Glenohumeral osteoarthritis occurred in 28.1%. Known risk factors for osteoarthritis could be confirmed. Further MRI findings were rare.Arthroscopic Bankart Repair in athletes shows good long-term clinical results. However, this has to be restricted to patients with osteoarthritis. Osteoarthritis was very rare and known risk factor could be confirmed. We assume that resorption of anchors differs in patients. If it does have an impact on developing arthrosis, this should be confirmed in further studies.

PURPOSE Local infiltration analgesia (LIA) has attracted growing interest in recent years. To prolong the positive effects of LIA, a continuous intraarticular perfusion has been introduced in total knee arthroplasty with good clinical results. The purpose of the present study was to evaluate if similar results can be obtained with the use of a continuous periarticular perfusion in unicondylar knee arthroplasty (UKA). METHODS 50 consecutively selected patients undergoing UKA received either a single-shot LIA (control group; n = 25) or single-shot LIA combined with a continuous postoperative periarticular perfusion for 2 postoperative days (intervention group, n = 25). VAS (visual analogue scale) for pain, pain medication consumption and range of flexion were recorded postoperatively for 6 days. The catheter was removed after 2 days. RESULTS Only minor advantages of using a continuous periarticular catheter could be shown. Patients in the intervention group showed significant lower VAS scores on day 1 and required significant less pain medication on day 6. Further, there was a significant difference in the range of flexion on day 3, on which patients of the intervention group were able to bend the knee joint on average by 12° more than patients of the control group. On the other days, any significant differences between the two groups were not observed. CONCLUSION In summary, the present study could not identify any superiority of a periarticular catheter over single-shot LIA in UKA. Because of additional costs and the potential risk of infection, the conclusion of this study is to not recommend adding a periarticular catheter to the single-shot LIA in UKA. LEVEL OF EVIDENCE II.

In the rare case of complete proximal adductor longus avulsion injuries, scientific recommendations of surgical or conservative injury management are limited to small case series and reviews of small cohorts about treatment examples. A clear consensus regarding optimal management so far has not been made. Thus, the aim of our study was to investigate patient-related outcome measurements (PROM) after either operatively or conservatively treated patients in order to evaluate and display own decision criteria for one of the two treatment options. In this retrospective case control study, two cohorts after MRI-confirmed, isolated, acute proximal adductor longus avulsion injury without concomitant injuries was investigated. Depending on stump retraction (less or more than 2 cm), patients of the particular cohorts had either been treated conservatively or by surgical refixation with suture anchors. All patients were asked to complete different PROM forms (Hip Osteoarthritis Outcome Score (HOS), Modified Harris Hip Score (MHHS)) in order to evaluate the particular procedures outcome. Between July 2015 and July 2018, eighteen avulsion injuries met our inclusion criteria, of which 14 were treated conservatively and operatively in equal parts and could be included into the study. The mean stump retraction of the conservative group was 1.3 cm (SD ± 0.5); patients in the surgical group had a mean stump retraction of 3.0 cm (± 1.5). Irrespective of the treatment option, all patients achieved a maximum score using the MHHS. Also in the HOS subscale respecting all day activities, almost all patients (13/14) achieved a maximum score. Instead, using the HOS subscale respecting sportive activities, one surgically and one conservatively treated patient described little restrictions compared with their pre-injury level. Conservative as well as operative treatment leads to very good patient-related outcome measurements if the decision for either of the two treatment options is made upon a stump retraction above or below 2 cm. Smaller restrictions regarding pre-injury level could rather be seen in the conservative instead of the operative group, favouring a more generous perspective for surgical refixation.

Background: Although debilitating, proximal hamstring tendon avulsion injuries are rare and often overlooked or misdiagnosed. Consequently, delayed diagnosis and surgical treatment may result in poor outcomes. Studies investigating a correlation between postoperative functional outcomes and this delay in surgical treatment or other concomitant factors in large cohorts have not yet been performed to our knowledge. Purpose/Hypothesis: The purpose of this study was to conduct an investigation in a large patient group regarding factors that could influence a patient’s functional outcome after hamstring surgery. We hypothesized that this outcome would significantly correlate to the time between trauma and surgery. Study Design: Case series; Level of evidence, 4. Methods: Patients who received surgical treatment of proximal hamstring tendon avulsion injuries in our institution between the years 2010 and 2020 were asked to complete a validated, injury-specific outcome measurement, the Perth Hamstring Assessment Tool (PHAT; 0-100 points). In addition to calculating these outcomes, we evaluated the association of the obtained results with possible predictive factors such as age, sex, stump retraction shown on magnetic resonance imaging (MRI), and timing and duration of surgery. Results: A total of 226 patients (227 operations) were eligible for the study, and 204 cases of hamstring tendon avulsion injury met our inclusion criteria. The return rate for the PHAT questionnaire was 85.3%. The mean PHAT score revealed good results (79.8 ± 19.1). Irrespective of concomitant factors, the scores of male patients were significantly higher compared with those of female patients (83.8 ± 16.9 vs 75.8 ± 20.6 respectively; P = .004). The mean time to surgery was 5.7 weeks after trauma, and more delayed surgery correlated significantly with lower PHAT scores ( P = .003; r = –0.228). The mean degree of stump retraction on MRI (5 cm) did not significantly influence PHAT scores ( P = .525; r = –0.06). Conclusion: Delay of surgery and female sex were disadvantageous in terms of a good functional outcome measure (PHAT score) after hamstring tendon refixation surgery. By contrast, patient age as well as the retraction of the tendon stump on preoperative MRI did not influence PHAT scores in the present study.

PURPOSE Local infiltration analgesia (LIA) has been proven to be efficient in total knee arthroplasty (TKA). However, the effect of single-shot LIA is temporarily limited. The objective of this prospective trial was to investigate if the potential benefits resulting from LIA can be prolonged by a continuous intra-articular perfusion of LIA. The hypothesis of the present study was that the use of an additional continuous intra-articular perfusion delivering LIA would result in less pain and better function compared to single-shot LIA in the immediate post-operative period. METHODS 50 consecutively selected patients undergoing TKA received either a single-shot LIA (S-LIA group, 25 knees) or single-shot LIA combined with a continuous post-operative intra-articular perfusion for three post-operative days (CP-LIA group, 25 knees). VAS (visual analogue scale) for pain, pain medication consumption and flexion ability were recorded postoperatively for 6 days. All patients had the same implant, surgeon and intra- as well as post-operative setting. RESULTS The VAS score was significantly better for CP-LIA 6 h after surgery and on post-operative day 1, 2 and 6. There was no significant difference with regard to additional opioid consumption or flexion ability of the knee. However, there was a trend of the CP-LIA group requiring less additional opioids over the complete post-operative period compared to the S-LIA group. There were no complications or revisions. CONCLUSION LIA combined with an additional intra-articular catheter provides better short-term pain control compared to single-shot LIA. However, no significant differences in terms of knee flexion were observed. This limited benefit should be balanced against the additional costs and the possible higher risk of infection. LEVEL OF EVIDENCE Level II.

Downhill mountain biking is a rapidly growing sport. In our case we want to present an isolated medial clavicular fracture following a mountain bike accident with a critical review on the used protection device. A 35 year old healthy patient presented to our hospital after bike accident during downhill mountain biking in Austria with pain over his right medial clavicle. The imaging showed a multifragmentary medial clavicle fracture with an intact SC-joint. Surgical intervention was recommended. Postoperative x-rays showed an anatomic reposition and correct plate positioning. The implant was removed after 18 months without any complications. A full-face helmet with a chin bar is used to achieve better protection of the maxilla, mandible and the teeth. In a hyperflexion situation of the cervical spine, a direct contact of the chin bar with the sternum, sc-joint and the medial clavicle can occur. This impact sets the mentioned structures on a high risk of dislocation and fracture as seen in our case. This risk can be significantly reduced by the combined use of a full face helmet and a neck brace. If the injury is properly identified, positive results can be achieved by surgery.Downhill-Mountainbiking ist eine zunehmend beliebte Sportart. Wir möchten einen Fall mit isolierter Fraktur der medialen Klavikula nach einem Mountainbike-Unfall vorstellen und hierbei die verwendete Schutzausrüstung kritisch hinterfragen. Ein 35-jähriger gesunder Patient stellte sich nach einem Fahrradunfall beim Downhill-Mountainbiking in Österreich mit Schmerzen über der rechten medialen Klavikula vor. Die Bildgebung zeigte eine multifragmentäre mediale Klavikulafraktur mit intaktem Sternoklavikulargelenk. Es wurde ein chirurgischer Eingriff empfohlen. Die postoperative Röntgenkontrolle zeigte eine anatomische Reposition und eine korrekt einliegende Platte. Nach 18 Monaten wurde das Implantat komplikationslos entfernt. Full-Face-Helme mit Kinnbügel werden zum besseren Schutz der Maxilla, der Mandibula und der Zähne verwendet. Bei Hyperflexion der Halswirbelsäule kann es zu direktem Kontakt zwischen Kinnbügel und Sternum, Sternoklavikulargelenk und der medialen Klavikula kommen. Aufgrund dieses Aufpralls werden die genannten Strukturen einem hohen Luxations- und Frakturrisiko ausgesetzt, wie unser Fall zeigt. Dieses Risiko kann durch gleichzeitiges Tragen eines Full-Face-Helms und einer Neck Brace signifikant verringert werden. Bei gesicherter Diagnose der Verletzung lassen sich durch eine Operation positive Ergebnisse erzielen.

Zusammenfassung Hintergrund Komplette Rupturen der proximalen Hamstringsehnen sind selten, im Falle einer solchen stellt die operative Refixation die therapeutische Methode der Wahl dar. Bislang ist das postoperative Outcome sehr heterogen und wenig vergleichbar untersucht, sodass Aussagen bezüglich einer Korrelation des Outcomes zu OP-Methoden und Zeitpunkt der OP nach Trauma nur begrenzt möglich sind. Ziel Es soll anhand des neuen, validierten und verletzungsspezifischen Perth Hamstring Assessment Tools (PHAT) das postoperative Outcome eines eigenen Kollektivs untersucht und dies in Korrelation zum Abstand zwischen Trauma und Operation dargestellt werden. Methode In dieser retrospektiven Fallkontrollstudie wurden alle operierten Patienten zwischen 1/2011 und 3/2016 und einer zurückliegenden OP-Zeitpunkt von mindestens 6 Monaten gebeten, ihr subjektives funktionelles Outcome anhand des PHAT – Fragebogens zu dokumentieren. Je nach Zeitraum zwischen Trauma und OP wurden die Patienten und deren Fragebogenergebnisse dabei einer akut (3 Monate) versorgten Gruppe zugeordnet. Ergebnisse Von 64 operierten Patienten im genannten Zeitraum konnten 57 in die Studie eingeschlossen werden, von denen wiederum 39 (68 %) den PHAT-Score vollständig komplettierten. Der mittlere PHAT-Score (0 – 100 Pkt.) aller Patienten betrug 72,4 Punkte (SD ± 21,0). Es ergab sich kein signifikanter Unterschied zwischen der akut und der verzögert versorgten Gruppe (77,0 Punkte ± 22,0 vs. 63,4 Punkte ± 16,2; p: 0,067), jedoch ein deutlich signifikanter Unterschied zwischen der akut und der verspätetet operierten Gruppe (77,0 Punkte ± 22,0 vs. 58,3 Punkte ± 20,2; p: 0,021). Schlussfolgerung In der vorliegenden Studie kann gezeigt werden, dass eine schnelle Indikationsstellung einer proximalen Hamstringverletzung mit einer operativen Versorgung innerhalb von 4 Wochen zu einem signifikant besseren, funktionellen Outcome führt als verspätet versorgte Rupturen.

Revision ACL reconstruction is becoming more frequent because of a 10% rate of re-ruptures and insufficiencies. Currently, computed tomography (CT) represents the gold standard in detecting and measuring the tunnels of the initial ACL reconstruction. The purpose of this study was to compare measurement results of CT and thin-sliced MRI sequences, which were modified to a high soft tissue-bone contrast. Prior to an ACL revision surgery, 16 consecutive patients had an MRI in addition to the standard CT scan. A dedicated 0.25-T Esaote G-Scan (Esaote Biomedica, Cologne, Germany) with a Turbo 3D T1 sequence was used for MRI. Tunnel diameters were measured at 11 defined points of interest. For the statistical evaluation, the Mann-Whitney U test for connected samples was used. Inter- and intraobserver reliability was additionally calculated. All measured diameters showed significant to highly significant correlations between both diagnostic tools (r = 0.7–0.98). In addition, there was no significant difference (p > 0.5) between the two techniques. Almost all diameters showed nearly perfect intraobserver reliability (ICC 0.8–0.97). Interobserver reliability showed an ICC of 0.91/0.92 for only one diameter in MRI and CT. Prior to ACL revision surgery, bone tunnel measurements can be done using a 3D T1-MRI sequence in low-field MRI. MRI measurements show the same accuracy as CT scans. Preoperative radiation exposure in mainly young patients could be reduced. Also the costs of an additional CT scan could be saved.

Rotational alignment of prosthetic components after total knee arthroplasty (TKA) is predominantly monitored with computer tomography (CT), for example by relating the anatomical transepicondylar axis (a-TEA) of the native femur to the posterior bicondylar axis of the prosthetic component (PBCA). The purpose of the present study was to portray a reliable, novel plain radiographic method that likewise enables the evaluation of rotational positioning of prosthetic components in TKA. Furthermore, it was intended to evaluate the prosthetic femoro-tibial functional behavior under loaded conditions. Modified plain axial radiographs under partial weight bearing (20 kg) were performed in 63 patients (63 knees) after TKA. On the obtained radiographs, all established, relevant anatomic, and prosthetic axis and angles reflecting the rotational position of the femoral (i.e., a-TEA/PBCA angle) and tibial component were detected twice by two independent examiners with an interval of one month. Additionally, in 14 cases with anterior knee pain after surgery, radiographic results were compared to obtained computer tomography images; intraclass coefficients (ICC’s) for intra- and inter-rater reliability were calculated. All pre-assigned axis and angles could be identified doubtlessly by both examiners in all investigated knees. For all measurements, ICC’s for intra-rater and inter-rater reliability ranged from 0.75 to 0.96. The comparison of the radiographic measurements with corresponding CT results (n = 14) revealed no significant differences (p > 0.05). Rotational alignment of the tibial tray in relation to the native tibial bone was not measurable due to display overlaying. Femoro-tibial behaviour of the prosthetic components under partial loading showed a high variability. We were able to establish a new reliable radiographic technique that is able to show the most established and relevant anatomic landmarks and prosthetic axis after TKA to assess the rotational alignment of the prosthetic components in TKA in relation to the distal femur. The evaluation of the femoro-tibal behaviour instead shows a high variability and so far does not allow valid explanatory conclusions.

Correct femoral rotational alignment in total knee arthroplasty (TKA) is important for femoropatellar knee kinematics as well as for the overall clinical success. The goal of the present study was to evaluate how accurately standard instruments of various manufacturers with specific rotational settings in posterior referencing restore the posterior femoral condylar anatomy and allow a rotational alignment which matches a particular anatomic rotational landmark on CT. The anatomical transepicondylar axis (aTEA) and the posterior condylar line (PCL) were identified and the angle formed by these two axes was measured on 100 consecutive CT scans of knees. A virtual posterior condylar resection was performed relative to the aTEA for femoral sizers of various manufacturers in different external rotations ranging from 3° to 7°. The resections of medial and lateral posterior condyle were calculated as well as the condylar twist angle (CTA) between PCL and aTEA. The posterior condylar resection varied between 9 mm and 14 mm on the medial side and between 4 mm and 10.5 mm on the lateral side. The mean CTA was 5.5° of internal rotation (SD ± 1.9°). External femoral rotation resulted in increased resection of the medial posterior condyle and decreased resection of the lateral posterior condyle. Femoral sizers using a posterior referencing technique increase, with rising external rotation, medial posterior condylar resection to an extent that may exceed the implant thickness in the majority of systems. Surgeons should be aware that current standard instruments do not restore the anatomy of the posterior medial and lateral condyle and do not align the femoral component parallel to the aTEA, which may result in internal rotation of a symmetric femoral component.

Combined femoral and sciatic nerve blocks for post-operative pain management following total knee arthroplasty (TKA) improve patient satisfaction, decrease narcotic consumption and improve pain. However, accompanying motoric weakness can cause falls and related complications. We wonder whether peri-capsular injections in combination with intra-articular perfusion of local anaesthetics would result in equal or less pain without the related complications of nerve blocks. The objective of the study was to verify these aspects in a prospective randomized trial comparing both treatments. Fifty TKA patients randomly received either a femoral (continuous) and a sciatic (single-shot) nerve block (CFNB group, 25 knees) or periarticular infiltrations and a continuous post-operative intra-articular infusion (PIAC group, 25 knees). VAS for pain, pain medication consumption, functional assessment, straight leg raising as well as KSS were recorded post-operatively for 6 days. VAS (p

With the growing interest in resurfacing procedures, several new implants have been recently introduced for isolated patello-femoral joint arthroplasty (PFA). However, not much data are available for these new techniques or about the right indications for each type of implant. Out of a retrospective cohort of 20 inlay PFA, 11 PFA with an elevated Insall–Salvati index and an increased patello-femoral congruence angle showed an initial satisfactory result, but presented thereafter with recurrent pain and “clunk” phenomena. They were all revised after a median time of 25 months (range 8–28 months) into an onlay technique PFA and analyzed for their failure mode and revision technique. Clinical symptoms such as clunking, as well as abraded areas craniolateral of the inlay implant found intraoperatively, were the main observations of this study. The modified Insall–Salvati index (mISI) was significantly higher in the revised knees compared to the unrevised (median 1.8 versus 1.6; p = 0.041). VAS and KSS significantly improved after revision (median VAS reduction in pain of 4.0 points, median KSS improvement of 20.0 points; p

In recalcitrant epicondylitis innumerable operative techniques have been published, nevertheless a certain percentage of patients remains symptomatic after operative treatment. We developed an individual, systematic diagnostic pathway including arthroscopic assessment of elbow stability to identify the optimal and respectively less invasive therapy. We so far included 40 patients with recalcitrant lateral epicondylitis (mean age 46 ± 11). 5 patients had previous surgery. In all patients, we did an elbow arthroscopy and a systematic arthroscopic stability testing. 25 patients were treated exclusively arthroscopically once instability was excluded. In 13 patients with slight instability, we did an open debridement of the lateral tendon complex and local refixation. Two patients with severe instability were treated with open debridement and additional stabilization of the LUCL with a trizeps graft. With a minimum follow-up of 1 year, we assessed the DASH score and subjective patient satisfaction. Mean follow-up was 24 ± 12 months, mean duration of symptoms before surgery was 19 ± 18 months. The mean DASH score at follow-up was 22 ± 19.36 patients reported symptoms improvement, 34 patients would repeat surgery given the same situation; in 30 cases, patients expectations had been fulfilled. We did not observe any intraoperative complications or infections. One patient developed joint stiffness requiring reoperation. Using a systematic diagnostic pathway including assessment of elbow stability and consecutive individualized, respectively, less invasive surgical procedure we acquired high patients satisfaction and good clinical outcome with a low complication rate. Level III.

Initial graft tension in anterior cruciate ligament (ACL) reconstruction affects stability and tension loss at follow-up. This study investigated the influence of hybrid tibial fixation in 3-tunnel double-bundle ACL reconstruction on initial graft tension and tension change and stability under anterior and combined rotatory loads. Eleven fresh-frozen cadaveric knees were reconstructed with an ACL double bundle using a 3-tunnel technique. Grafts were tightened to 80 N in 60° (AM bundle) and 15° (PL bundle) of flexion. Anterior tibial translation under 134 N of anterior shear load and translation under combined rotatory and valgus loads (10 Nm valgus stress, 4 Nm internal tibial torque) were determined at 0°, 30°, 60°, and 90° flexion. In addition, graft tension under continuous passive motion was determined. Intact, ACL-resected and ACL-reconstructed joints with either tibial extracortical graft fixation or extracortical plus supplemental aperture graft fixation (hybrid fixation) were tested. Hybrid fixation did not increase graft tension in either bundle during fixation or in motion without additional load. AM-bundle tension increased (p

Rotator cuff reconstruction using arthroscopic double-row technique enables a better repair of the anatomical footprint at the tendon insertion. Objective of this serial study was to illustrate structural and functional results during recovery following double-row reconstruction.Forty-five patients with mid-sized ruptures of the supraspinatus tendon were assessed prospectively and underwent arthroscopic surgery using the double-row technique. Rupture localization, size, form, and extent of retraction were recorded intraoperatively. Clinical and MRI follow-up examinations were carried out for all patients after 6, 12, 26, and 52 weeks. A A standard protocol was used during the follow-up examinations to determine tendon integration, signal changes in the tendon, extent of bone marrow edema near the enclosed absorbable suture anchors, muscle changes. The clinical results were correlated with the MRI appearance.After 26 weeks, the Constant score (CS) showed a highly significant increase for the first time with a value of 78 (p 0.001). Tendon integration according to Sugaya showed a left shift over time, with higher CS-values for lower Sugaya classifications. Significant improvements in strength were first measured between the 26-week and 52-week follow-ups (9-19/p 0.001). Highly significant improvement (p 0.001) of the tendon signal and the fatty infiltration was found in the same time interval. The hypotrophy showed slight improvement, while a highly significant reduction of the bone marrow edema was found between weeks 12 and 26 (p 0.001). There were no re-ruptures after week 26.The present serial study showed that it took 26 weeks to reach a significant clinical improvement concerning CS. With regard to tendon healing, no further deterioration of the structural results occurred between week 26 and week 52 postoperative. There were slightly but not significant better clinical results according to the the Sugaya classification. However, parameter "strength" was significantly increased between weeks 26 and 52. This was consistent with a significant decrease in the signal intensity at the repaired tendon site, an additional improvement in the fatty infiltration, and the atrophy according to Thomazeau in the same time interval.I.

Arthroskopische Rotatorenmanschettenrekonstruktionen werden heutzutage haufig durchgefuhrt. Aber auch nach technisch korrekt durchgefuhrter Operation klagen einige Patienten postoperativ uber Beschwerden. Eine prospektive serielle Studie wurde durchgefuhrt. Insgesamt 40 Patienten mit mittelgrosen Rupturen wurden in arthroskopischer Double-Row-Technik operiert. Nachuntersuchungen erfolgten nach 6, 12, 26 und 52 Wochen. Klinisch wurde der Constant-Murley-Score erfasst, und es erfolgte jeweils eine MRT-Kontrolle. Alle Patienten zeigten eine signifikante Verbesserung bei den klinischen Ergebnissen. Der Schmerz war bereits ab der 6. Woche signifikant rucklaufig. Dies korrelierte jedoch nicht mit einer Abnahme der Grose des Knochenmarkodems. Die signifikante Normalisierung des Sehnensignals trat erst ab der 26. Woche ein, was mit einer signifikanten Kraftzunahme einherging.

Patellofemoral instability is influenced by ligamentous, boney and neuromuscular factors. The most important variables are trochlea geometry, medial patellofemoral ligament (MPFL), patella height, tibial tuberosity–trochlea groove distance (TT–TG) and the extensor muscles. Treatment is complicated by these multifactorial conditions. This prospective study examined the influence of risk factors on clinical results and athletic activities where treatment was confined to ligamentous procedures only. Fifty patients with chronic patellofemoral instability were treated with MPFL reconstruction using an autologous gracilis tendon. Clinical data, radiographs and magnetic resonance imaging (MRI) were prospectively evaluated pre- and postoperative (minimum follow-up 12 month) to detect existing risk factors for patellofemoral instability and to evaluate clinical and sport ability scores (Kujala, Valderrabano). There was a low rate of redislocation (2 %) and an average Kujala score of 87 ± 13 points postoperative. The MRI showed good integration of the reconstructed MPFL and a positive effect regarding the decrease of patella tilt (16.1° to 11.2°). A negative relationship was found between the degree of trochlear dysplasia and outcomes. 80 % of all patients returned to the same or higher level of physical activity. Addressing only ligamentous factors through MPFL reconstruction leads to satisfying clinical results and low redislocation rates in most patients. In cases with a high degree of trochlear dysplasia and enlarged TT–TG, additional procedures such as trochleaplasty and tibial tuberosity transfer should be considered as well. IV.

Die arthroskopische Rekonstruktion von Rotatorenmanschetten (RM)-Rupturen in „Double-row“-Technik wird mit verbesserter anatomischer Rekonstruktion in Zusammenhang gebracht. Ziel dieser Studie war es, strukturelle und funktionelle Ergebnisse im Verlauf darzustellen. Es wurden 20 Patienten mit mittelgrosen Rupturen prospektiv erfasst. Intraoperativ wurden Rupturlokalisation, -grose, -form, sowie der Retraktionsgrad erhoben. Alle Patienten wurden nach 6, 12 und 26 Wochen nachuntersucht. Die magentresonanztomographische Kontrolle erfolgte nach einem Standardprotokoll im Niederfeld-System. Hier wurden die Sehnenintegration sowie Signalveranderungen der Sehne und der Bursae, Grose des Knochenmarkodems mit Ankerverhalten bzw. -lage, die Muskelatrophie und der Grad der Muskelverfettung bestimmt. Bei der 6-Wochen-Kontrolle fanden sich noch Restbeschwerden mit Schmerzen. Der Constant Murley Score (34 Punkte) zeigte niedrigere Werte als praoperativ (52 Punkte). Der Constant Murley Score nach 12 Wochen zeigte einen signifikanten Anstieg von 52 auf 61 Punkte. Ebenso konnte das praoperative Kraftniveau erreicht werden. Die Schmerzen reduzierten sich bei allen Patienten. Signalveranderungen in der Sehne und den Bursae sowie das Knochenmarkodem waren deutlich rucklaufig und eine Sehnenintegration war in 87% der Falle bestimmbar. Nach 26 Wochen stieg der Constant Murley Score auf 79 Punkte. Signalveranderungen in der Sehne und den Bursae sowie das Knochenmarkodem normalisierten sich. Die arthroskopische „Double-row“-Rekonstruktion bei mittelgrosen RM-Rupturen stellt eine sichere Behandlungsmethode dar. Die in der MRT-Untersuchung erhobenen Parameter korrelieren mit den klinischen Ergebnissen.

STUDY DESIGN Case-control observational study. OBJECTIVE Determination of dimensional changes in the lumbar spines of athletes between supine and stand-up position in MRI, concerning the lordosis, spinal canal cross-sectional area (SCCA), dural sac cross-sectional area (DSCA), sagittal dural sac diameter (SDSD), the lateral recess and the neural foramina. SUMMARY OF BACKGROUND DATA The development of positional MRI allows the examination of spine segments under a true weight-bearing situation. METHODS About 35 athletes (20m/15f, O: 28a) were examined using a 0.25 T open MRI-Scanner (G-Scan, ESAOTE, Italy). In all cases, axial and sagittal SE-T1 + SSE-T2 images were recorded in supine and true standing position. All measurements were performed using MEDIMAGE software (Vepro AG, Germany). The blinded measurements were performed 3 times by 2 independent examiners. Sagittal images were used to determine the lordosis and the narrowing of the left/right foramen at all levels between L1/2 and L5/S1. Axial images were used to determine the SDSD, the SCCA and the DSCA at L3/4, L4/5, L5/S1, and narrowing of the left/right recessus lateralis of L4, L5 and S1. RESULTS The lordosis showed a significant increase of 6.3 degrees (14%) from supine to true standing position (P < 0.001). The SDSD is significantly smaller in true standing position, than in supine position at the level of L3/4 and L4/5 (P < 0.001). Narrowing of the foramen occurred in true standing position in 13.4% at L4/L5 and in 26.7% at level L5/S1. No significant differences were observed at the recessus lateralis, the SCCA and the DSCA. CONCLUSION The measurement method in supine and true standing position is excellent for depicting the anatomical regions relevant for spinal canal stenosis in healthy individuals. Measuring the lumbar lordosis angle in both positions is an important requirement for interpreting the relevant anatomical regions. Of particular importance here is the DSCA and the SDSD.

The purpose of this study was to investigate whether an anterior cruciate ligament (ACL) double-bundle reconstruction with one tibial tunnel displays the same in vitro stability as a conventional double-bundle reconstruction with two tibial tunnels when using the same tensioning protocol. In 11 fresh-frozen cadaveric knees, ACL double-bundle reconstruction with one and two tibial tunnels was performed. The two grafts were tightened using 80 N in different flexion angles (anteromedial-bundle at 60° and posterolateral-bundle at 15°). Anterior tibial translation (134 N) and translation with combined rotatory and valgus loads (10 Nm valgus stress and 4 Nm internal tibial torque) were determined at 0°, 30°, 60° and 90° flexion. Measurements were taken in intact ACL, resected ACL, three-tunnel reconstruction and four-tunnel reconstruction. Additionally, the tension on the grafts was determined. Student’s t test was performed for statistical analysis of the related samples. Significance was set at p

Purpose of this study was to establish and validate an MRI-associated classification to graduate postoperative results of MPFL reconstructions. 30 autologous MPFL reconstructions of 28 patients were evaluated by two independent raters using MRI. All grafts were assigned to a novel graduation system respecting the graft’s anchoring insertions, its MRI signal appearance, continuity and tension and the differentiation relating to the surrounding soft tissue. All grafts could reliably be assigned to one of the subgroups by both raters. 86.6 % of the grafts could be classified A1 or B1, reflecting a correct positioning and a low to intermediate signal intensity. Only one graft had to be classified C3 (malpositioned, elongated). We were able to establish and validate an MRI-associated classification to graduate the postoperative outcome after MPFL reconstructions. Foresighted, the presented classification might support further decision making in case of unsatisfying postoperative results.

Medial transfer of the tibial tubercle has become a standard procedure in cases of patella instability caused by an increased tuberositas tibae-trochlear groove (TT-TG) distance. However, the TT-TG distance has always been assessed as an absolute value without taking individual joint size into consideration. It was assumed that the pathological influence of the TT-TG distance correlates with individual joint size. Aim of the current study therefore was to develop a method to express TT-TG distance in relation to these joint variables.Two hundred knee MRI scans of healthy individuals (69 females and 131 males) were evaluated retrospectively in a control group. First, the TT-TG distance was measured as described by Schoettle et al. To determine joint size, the proximal-distal distance between the entrance of the chondral trochlear groove (TE) and the onset of the patella tendon at the tibial tubercle (TT) was selected. Subsequently, the TT-TG/TT-TE ratio expresses the relationship between the TT-TG distance and the proximal-distal distance from the entrance of the chondral trochlear groove to the height of the tibial tubercle. The TT-TG Index can also be expressed as an angle (TT-TG angle). Likewise, in another patient group, 54 knee MRTs of patients with patellofemoral instability were evaluated.The average TT-TG distance of the control group was 7.5±3.5 mm (range 0-17.4 mm) with no significant differences between genders. The mean TT-TE distance was 63.9 mm (range 49-79 mm) with there being significant differences between genders. The resulting mean TT-TG Index was 0.12±0.05 (range 0-0.25). In the patient group, the average TT-TG distance was 13.5±4.1 mm and the average TT-TE distance was 61.3±6.8 mm. The resulting average TT-TG Index of 0.22±0.07 in the patient group (PFI) approximates the threshold determined by the 95% confidence interval in the healthy control group. A direct comparison between the control group and the patient group revealed a significant difference in the TT-TG distance (p=0.0001), in the TT-TE distance (p0.0042) and in the resulting TT-TG Index (p0.0001).The measurement of the TT-TG Index is a reliable and differentiated approach for determining the lateral displacement of the tibial tubercle in relation to the proximal trochlear groove. The pathological influence of the TT-TG distance in case of patella instability depends on individual joint size, confirming the initial hypothesis. We currently consider a TT-TG Index0.23 to be pathological based on our findings. Particularly, in case of a marginal TT-TG distance, the additional relative TT-TG Index facilitates a decision concerning an indication for a operative medial transfer of the tibial tubercle.II.

Objective To evaluate the presupposed preventive residual mechanical effectiveness of the widespread use of adhesive elastic ankle tape after a nonlaboratory, realistic soccer-specific outfield intervention reflecting a soccer halftime. Design A prospective nonrandomized test-retest design was used. Setting Laboratory. Participants Seventeen professional male outfield players (mean age, 25.5) without any signs of chronic ankle instability. Intervention Participants were investigated before and after a 45-minute soccer-specific field intervention. Main outcome measures The passive inversion range of motion (ROM) of the ankle was tested unloaded on a self-developed inversion device with and without a standardized ankle tape before and after the intervention. Additionally, electromyography signal was taken to assure the inactivity of the protective evertor muscles, and reliability tests for the inversion device (test-retest and trial to trial) were conducted in 12 healthy controls. Results Tape restricted the maximum passive inversion ROM of the uninjured ankle significantly to 50.3%. The protection declined nearly completely after 45 minutes of outfield soccer performance to a negligible nonsignificant ROM restriction of 9.7%. Pearson correlation coefficient for the reliability was 0.931 (P ≤ 0.001) for the test-retest and 0.983 (P ≤ 0.001) for the trial-to-trial test. Conclusions The initial significant protection of external ankle-tape support declines almost completely without relevant remaining residual mechanical effect after 45 minutes, reflecting a soccer halftime. The so far presupposed residual mechanical effectiveness of tape to prevent injury is increasingly irrelevant during soccer performance and consequently antidromic to the increasing injury risk toward the end of a soccer halftime.

Zusammenfassung Hintergrund Es wurde postuliert, dass die Neovaskularisation gemessen im Powerdopplerultraschall (PDU) eine Rolle in der Pathogenese der Midportion-Achillessehnentendinopathie spielt und als ursachlich fur die Schmerzsymptomatik gesehen wurde. Diese Studie soll die Entwicklung der Neogefase uber den Therapiezeitraum bei konservativen Therapieformen, insbesondere im Vergleich des exzentrischen Trainings mit der konventionellen Physiotherapie untersuchen. Studiendesign Prospektive randomisiert-kontrollierte Studie, Evidenzlevel Ib. Methoden 27 Patienten mit einer Midportion-Achillessehnentendinopathie wurden prospektiv randomisiert in eine Interventions- (Gruppe A) und Kontrollgruppe (Gruppe B) eingeschlossen. Gruppe A absolvierte ein 12-wochiges exzentrisches Training, Gruppe B erhielt physiotherapeutische Behandlung ohne Dehnubungen. Die Neovaskularisation wurde mittels PDU erfasst und anhand eines modifizierten Scores nach Ohberg eingeteilt. Es wurden anthropometrische Daten, die sportliche Aktivitat, der VISA-A Score und die visuelle Analogskala (VAS) erhoben und mit dem modifizierten Score nach Ohberg korreliert. Ergebnisse Der modifizierte Ohberg Score verbesserte sich von 2,4 auf 1,8. Es konnte keine Korrelation zwischen der Neovaskularisation und der VAS (n.s.) und VISA-A Score (n.s.) gezeigt werden. Eine signifikante Besserung der VAS konnte in beiden Gruppen gefunden werden. Der VISA-A Score zeigte in beiden Gruppen eine Zunahme nach 12 Wochen. Insgesamt fuhrte exzentrisches Training zu einer deutlicheren Besserung der VAS. Schlussfolgerung Dem Grad der Neovaskularisation kann anhand der in dieser Studie erhobenen Daten weder ein diagnostischer noch ein prognostischer Wert zugeordnet werden.

Fragestellung In Deutschland werden jahrlich ca. 25000 primare VKB-Ersatzplastiken durchgefuhrt. Hiervon sind literaturabhangig 8–25% revisionsbedurftig. In den letzten 10 Jahren wurden in der Sportklinik Stuttgart jahrlich ca. 600 VKB-Plastiken durchgefuhrt, wovon im Schnitt 30 Revisionseingriffe aufgrund erneuter Ruptur oder Instabilitat waren. In diesem Zeitraum gab es einen grosen Wechsel in der Wahl der Primartransplantate und der Verankerungstechniken. Es stellt sich die Frage, ob sich hierdurch auch die Versagensursachen und die Art der Revisionseingriffe verandert hat. Patienten und Methodik Es wurden aus den Jahren 1999–2003 105 (m:w=64:41) und aus den Jahren 2007–2009 108 (m:w=78:30) Revisionsfalle nach VKB-Ersatz erfasst. Untersucht wurden die Art der primaren und sekundaren Versorgung, die Standzeit bis zum Auftreten von erneuten Beschwerden nach primarem VKB-Ersatz und die Art der Beschwerden. Ebenfalls wurde eruiert, ob Begleitverletzungen bestanden sowie ob ein adaquates Retrauma vorlag. Abschliesend wurde die intraoperative Darstellung des Primartransplantates sowie der Notch in der Sekundaruntersuchung erfasst. Ergebnisse Im Zeitraum 1 zeigte sich eine mittlere Standzeit bzw. beschwerdefreie Zeit von 65 Mon. (Median 48 Mon.), in Zeitraum 2 von 61 Mon. (Median 28 Mon.). Hierbei zeigten sich in 50 bzw. 49 Fallen eine Reinstabilitat ohne erneutes adaquates Trauma. Im Vergleich adaquates Retrauma/kein adaquates Retrauma konnte im Zeitraum 1 kein signifikanter Unterschied zwischen gelenknaher (15:7) und gelenkferner (6:15) Verankerung festgestellt werden. Im Zeitraum 2 konnte ebenfalls kein Unterschied, 6:8 bei den Patienten mit gelenknaher Verankerung und 17:16 bei Patienten mit gelenkferner Verankerung, gezeigt werden. Die Revisionseingriffe erfolgten 1999–2003 ausnahmslos einzeitig mittels Patellarsehne oder Quadrizepssehne in pressfit-Technik. 2007–2009 wurden primar BTB's mittels Semitendinosussehne (single- oder double bundle) und primare Semitendinosusplastiken mittels BTB oder Semitendinosus von der Gegenseite versorgt. Schlussfolgerung Es konnte gezeigt werden, dass sich in den letzten 10 Jahren trotz Veranderungen in der Art der Verankerung und in der Wahl der Transplantate, keine Veranderung in der Haufigkeit der Insuffizienzen ohne Retrauma ergeben haben. Auch zwischen der gelenknahen oder-fernen Verankerung konnte diesbezuglich kein signifikanter Unterschied gefunden werden. Eine klare Ursache fur sekundare Insuffizienzen konnte in keiner der beiden Gruppen gefunden werden. Entscheidend fur eine erfolgreiche Revisionsoperation ist heute vornehmlich die genaue praoperative Planung bezuglich der primaren Bohrkanale zur Entscheidung ein- oder zweizeitiger Eingriff.

Fragestellung Die Bestimmung des Patellastandes und -tilts stellen wichtige Pfeiler im Rahmen der Diagnostik bei patellarer Instabilitat dar. Durch Vorliegen verschiedener Indizes (Insall-Salvati, Canton etc.) gestaltet sich eine einheitliche Bestimmung als problematisch. Daruber hinaus ist bisher ungeklart, inwieweit die einzelnen Indizes unter Belastung beeinflusst werden. Im Rahmen der vorliegenden Studie soll anhand MRT-Aufnahmen geklart werden, ob es beim gesunden Sportler zu einer Veranderung des Patellastands bzw. -tilts unter Belastung im Stehen gegenuber der Messung im Liegen kommt. Material & Methoden MRT-Untersuchungen von 14 Sportlern (13 m, 1 w, Durchschnittsalter 30 Jahre) wurden in Hinblick auf Patellastand (Patello-Trochlearer Index (PTI) und Insall-Salvati) und Patellatilt analysiert. Bei keinem der Probanden bestand anamnestisch oder klinisch eine patellofemorale Beschwerdesymptomatik. Die MRT-Untersuchungen wurden am gestreckten Bein unter Belastung im Stehen und Liegen an einem Niederfeld-MRT (Esaote/G-scan 0,25 Tesla) durchgefuhrt. Die Analyse erfolgte anhand von sagittalen und axialen SSE-T2-Sequenzen, 4 mm. Bestimmt wurde der Patellastand nach Insall-Salvati bzw. der PTI sowie der Patellatilt. Ergebnisse Gemessen an den Durchschnittswerten kam es zu keiner signifikanten Veranderungen der gemessenen Parameter im Kollektiv. Der Insall-Salvati-Index betrug im Liegen durchschnittlich 1,0 gegenuber 1,2 im Stand. Der durchschnittliche PTI betrug im Liegen 27 bzw. 28 im Stand. Der Patellatilt variierte von 10° im Stand auf 8° im Liegen. Diskussion/Ausblick Die Untersuchung der Patellastellung ist im Niederfeld-MRT im Stehen unter Belastung moglich. Bei grenzwertigen Risikofaktoren der Patellainstabilitat kann die MRT-Diagnostik im Stand ggf. einen lediglich unter Belastung bestehenden Fehlstand der Patella detektieren. Weitere MRT-Untersuchungen u.a. unter 20° Knieflexion bzw. bei Patienten mit bekannter Patellainstabilitat sind in Planung, um weitere Aufschlusse in Hinblick auf den Patellastand zu gewinnen.

Fragestellung Fuhrt die MPFL-Rekonstruktion mittels Gracilissehne zur dauerhaften Patellastabilitat unter Berucksichtigung des sportlichen Aktivitatsniveaus? Methodik Im Zeitraum von 03/2007 bis 06/2008 erfolgte bei einer Gruppe von 30 Patienten eine MPFL-Rekonstruktion mittels Gracilissehne. Im Rahmen einer prospektiven Studie wurden diese Patienten mindestens ein Jahr postoperativ klinisch und kernspintomografisch nachuntersucht. Die klinischen Untersuchungsbefunde wurden pra- und postoperativ mittels Kujala- und Lysholm-Score objektiviert. Die sportliche Leistungsfahigkeit wurde anhand des Valderrabano-Scores erfasst und ebenfalls mit den praoperativen Ergebnissen verglichen. Anhand pra- und postoperativer Bildgebung wurde das femuropatellare Alignement zur Bestimmung bestehender habitueller Pradispositionen erfasst (MRT: TTTG-Abstand, Patellatilt, lateraler trochlearer Slope, femuropatellare Knorpelverhaltnisse, konventionelles Rontgen: Trochleadysplasie nach Dejour, Patellastand nach Insall-Salvati, Sulcuswinkel). Ergebnisse Bei der Nachuntersuchung kam es bisher bei allen Patienten, auch bei bestehender anatomischer Pradisposition, zu einer signifikanten Verbesserung der Knieproblematik in den o.g. Scores. Die Sportfahigkeit wurde bei der Groszahl der Patienten wieder erlangt. Einmal kam es zu einer erneuten, durch adaquates Trauma ausgelosten, Rezidivluxation. Postoperativ traten in zwei Fallen revisionspflichtige Wundprobleme im Bereich des Tuberkulum adduktoriums auf. Schlussfolgerungen Die MPFL-Rekonstruktion mittels Gracilissehne stellt auch bei Ausubung von Risikosportarten ein geeignetes Verfahren zur Behandlung der chronischen Patellainstabilitat dar. Langzeitergebnisse mussen allerdings zeigen, inwieweit die MPFL-Rekonstruktion v.a. hinsichtlich auftretender Reluxationen, anderen, weniger invasiven Therapiemasnahmen (z.B. der Retinakulumraffung nach Yamamoto) uberlegen ist.